Treatment Strategies And Outcomes Of Thoracic Aortic Blunt Injuries In Adults: A Systematic Review
DOI:
https://doi.org/10.48729/pjctvs.402Abstract
Introduction: Blunt thoracic aortic injuries (BTAI) once had mortality rates up to 32%, but the advent of thoracic endovascular aortic repair (TEVAR) has significantly improved outcomes. However, concerns persist regarding long-term devicerelated complications, device integrity in aging aortas, and the criteria for selecting patients for endovascular repair. We aimed to assess BTAI treatment strategies based on injury grade and their associated outcomes.Methods: A systematic search of MedLine and Scopus databases was conducted to identify original articles published after 2013, which provided information on injury characteristics, outcomes, secondary effects, and reinterventions following BTAI. We classified aortic injuries following the SVS Clinical Practice Guidelines.
Results: We included 28 studies involving 1888 BTAI patients, including 5 prospective studies. Most patients were under 45 years old (86.4%), and grade III injuries were the most common (901 patients), followed by grades I and II (307 and 291 patients, respectively). TEVAR was performed in 1458 patients, mainly with grade III and IV injuries (1040 patients). Approximately half of the grade I injuries (153 of 307) were treated with TEVAR. Thirty-day mortality rate was 11.2%, primarily due to associated injuries. Aortic-related deaths were reported in 21 studies, with an overall rate of 2.2%, but none occurred beyond the first 30 days. Partial or complete coverage of the left subclavian artery was performed in 522 patients, with 27.9% requiring immediate or delayed revascularization. Aortic reintervention rates were relatively low (3.9%).
Conclusion: TEVAR effectively treats BTAI grades III and IV, with potential benefit for some grade II injuries with more aggressive early intervention. Despite SVS guidelines suggesting conservative management for grade I injuries, there is a substantial rate of intervention with positive outcomes and low mortality. Long-term follow-up data, extending up to almost 20 years, reveal the durability of grafts, aortic remodeling, and minimal reintervention and complications.
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MA F, KV K, N D, BW S, JS M, et al. Five-year Outcomes With Conformable GORE TAG Endoprosthesis Used in Traumatic Aortic Transections. The Annals of thoracic surgery. 2022;113(5):1536-42.
AC G, J Z, E S, JG Q, J G, et al. Natural History of Nonoperative Management of Grade II Blunt Thoracic Aortic Injury. Annals of vascular surgery. 2020;65:124-9.
SW C, SY W, CH L, YK H, KS L, et al. Timing of Intervention in Blunt Traumatic Aortic Injury Patients: Open Surgical versus Endovascular Repair. Netherlands2015 2015-11. 1559-66 p.
JS,MB,BS,TR,ND,etal.Editor'sChoice–Durabilityof Endovascular Repair in Blunt Traumatic Thoracic Aortic Injury: Long-Term Outcome from Four Tertiary Referral Centers. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2015;50(4):460-5.
Soong TK, Wee IJY, Tseng FS, Syn N, Choong A. A systematic review and meta-regression analysis of nonoperative management of blunt traumatic thoracic aortic injury in 2897 patients. J Vasc Surg. 2019;70(3):941-53.e13.
K D, A L, C N, T C, N Y, et al. Blunt thoracic aorta injuries, an Australian single centre's perspective. ANZ journal of surgery. 2021;91(4):662-7.
SM S, K S, CP S, ML C, IS B. Nonoperative management rather than endovascular repair may be safe for grade II blunt traumatic aortic injuries: An 11-year retrospective analysis. The journal of trauma and acute care surgery. 2018;84(1):133-8.
R S, S dF, R G, L B, P P, et al. Endovascular repair for acute traumatic transection of the descending thoracic aorta: experience of a single centre with a 12-years follow up. Journal of cardio-thoracic surgery. 2015;10:171.
Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-92.
CN A, J D, K C-O, BW S, N S, et al. Outcomes and practice patterns of medical management of blunt thoracic aortic injury from the Aortic Trauma Foundation global registry. Journal of vascular surgery. 2022;75(2):625-31.
SS G, JV B, S L, JF E, 3rd CC. Nonoperative management of grade III blunt thoracic aortic injuries. United States2016 2016-12. 1580-6 p.
CL M, RP D, Y H, W Y, GJ W, et al. Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury2018 2018-7. 64-73 p.
C M, F T, M R, P B, P L, et al. Long-term results following emergency stent graft repair for traumatic rupture of the aortic isthmus. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2017;51(4):767-72.
A K, CE D, A A, R W. One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). United States2015 2015-1. 155-61.e4 p.
AA,DC,BB,CM,AV,etal. Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience. Interactive cardiovascular and thoracic surgery. 2019;28(1):17-22.
Ye JB, Lee JY, Lee JS, Kim SH, Choi H, et al. Observational management of Grade II or higher blunt traumatic thoracic aortic injury: 15 years of experience at a single suburban institution. International Journal of Critical Illness and Injury Science. 2022;12(2):101-5.
S I, C N, T H, S H, T M, et al. Retrospective study of thoracic endovascular aortic repair as a first-line treatment for traumatic blunt thoracic aortic injury. General thoracic and cardiovascular surgery. 2022;70(1):16-23.
MCM,AJL,NLL,RH,EH,etal.Outcomesofoperativeand nonoperative management of blunt thoracic aortic injury. Journal of vascular surgery. 2022;76(1):239-47.e1.
Awadalla KM, Singer M, Ahmed E, Wahba M. Our Experience with Endovascular Repair of Descending Thoracic Aortic Injury after Blunt Trauma. Egyptian Journal of Hospital Medicine. 2022;87(1):2228-33.
Al-Thani H, Hakim S, Asim M, Basharat K, El-Menyar A. Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital. European Journal of Trauma and Emergency Surgery. 2022.
CF P, J S, KD S, B R, N K, et al. Blunt traumatic thoracic aortic injuries: a retrospective cohort analysis of 2 decades of experience. Interactive cardiovascular and thoracic surgery. 2021;33(2):293-300.
Sarquis LM, Michaelis W, Filho ALS, Pinto CS, Yokoyama RA, et al. Endovascular treatment of traumatic dissection of the thoracic aorta – Series of 16 cases. Jornal Vascular Brasileiro. 2020;19:1-9.
HJ P, A A, AH M, OC V, JD R, et al. Five-Year Outcomes From the United States Pivotal Trial of Valiant Captivia Stent Graft for Blunt Aortic Injury. Netherlands2020 2020-9. 815-20 p.
A M, NL L, MS M, ML S, A F, et al. Risk factors for mortality after endovascular repair for blunt thoracic aortic injury. Journal of vascular surgery. 2020;71(3):768-73.
HM,GM,SH,SAC,KD,etal.TheeffectofTEVARforblunt traumatic thoracic aortic injury on maximal aortic diameter: Mid- and long-term outcome. Vascular. 2019;27(4):411-6.
Chinyepi N, Motsumi MJ, Naidoo N. Outcomes after thoracic endovascular aortic repair in patients with traumatic thoracic aortic injuries—a single-centre retrospective review. European Surgery - Acta Chirurgica Austriaca. 2019;51(2):53-60.
HK S, SD L, A P, NU S, 3rd MC, et al. Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries. Journal of vascular surgery. 2018;67(2):389-98.
T G, S M, C R, RT H, K W, et al. Experts' Results in Blunt Thoracic Aortic Injury are Reproducible in Lower Volume Tertiary Institutions. Early and Mid-term Results of an Observational Study. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2017;54(5):604-12.
MB,WT,MH,MH,JOC,etal.Long-termoutcomesofthoracic endovascular aortic repair: A single institution's 11-year experience. The journal of trauma and acute care surgery. 2017;82(4):687-93.
ST,SM,HM,MS,HN,etal.Bluntthoracicaorticinjury with small pseudoaneurysm may be managed by nonoperative treatment. Journal of vascular surgery. 2016;63(2):341-4.
OM,AM,BG,GB,LB,etal. Outcomes in the emergency endovascular repair of blunt thoracic aortic injuries. Journal of vascular surgery. 2013;58(3):832-5.
GP,FB,MM,MA,AT,etal. Outcomes of endovascular repair for blunt thoracic aortic injury. United States2013 2013-12. 1483-9 p.
Heneghan RE, Aarabi S, Quiroga E, Gunn ML, Singh N, et al. Call for a new classification system and treatment strategy in blunt aortic injury. J Vasc Surg. 2016;64(1):171-6.
Osgood MJ, Heck JM, Rellinger EJ, Doran SL, Garrard CL, 3rd, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-41.
Hartley MC, Langan EM, 3rd, Cull DL, Taylor SM, Carsten CG, 3rd, et al. Evaluation of the diameter of the proximal descending thoracic aorta with age: implications for thoracic aortic stent grafting. Ann Vasc Surg. 2009;23(5):639-44.
Canaud L, Marty-Ané C, Ziza V, Branchereau P, Alric P. Minimum 10-year follow-up of endovascular repair for acute traumatic transection of the thoracic aorta. J Thorac Cardiovasc Surg. 2015;149(3):825-9.
TM S, DV F, JJ D, M O, JV OC, et al. Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard. United States2019 2019-4. 605-10 p.
Dubose JJ, Azizzadeh A, Estrera AL, Safi HJ. Contemporary management of blunt aortic trauma. J Cardiovasc Surg (Torino). 2015;56(5):751-62.
Azizzadeh A, Charlton-Ouw KM, Chen Z, Rahbar MH, Estrera AL, et al. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. Journal of Vascular Surgery. 2013;57(1):108-15.
Azizzadeh A, Keyhani K, Miller Iii CC, Coogan SM, Safi HJ, et al. Blunt traumatic aortic injury: Initial experience with endovascular repair. Journal of Vascular Surgery. 2009;49(6):1403-8.
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