Outcomes Of Thoracic Endovascular Aortic Repair (TEVAR) In Patients With Concomitant Traumatic Brain Injury (TBI): Data from The Aortic Trauma Foundation Global Registry
Cassra N. Arbabi1, Joseph DuBose2, Ben Starnes3, Naveed Saqib4, Elina Quiroga3, Charles Miller4, Ali Azizzadeh1
1Cedars-Sinai Medical Center, Los Angeles, CA, 2University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, 3University of Washington, Seattle, WA, 4University of Texas Health Science Center, Houston, TX
INTRODUCTION: Blunt thoracic aortic injury (BTAI) is the second leading cause of death, after traumatic brain injury (TBI), in blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, as optimal hemodynamic parameters are conflicting between the two pathologies. Early TEVAR is often performed, even in minimal aortic injuries, to allow for the higher blood pressure parameters required in TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy.
METHODS: The Aortic Trauma Foundation (ATF) international prospective multicenter registry was utilized to identify all patients who underwent TEVAR for BTAI in the setting of TBI from 2015 to 2020. Primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality and aortic-related mortality. Outcomes were examined among patients who underwent TEVAR at emergent (< 6 vs. ≥ 6 hours) and urgent (< 24 vs. ≥ 24 hours) intervals.
RESULTS: A total of 100 patients (mean age 46, 79% male, mean ISS 40) with BTAI (SVS BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who underwent TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (< 6 hrs) to repairs conducted at ≥ 6 hrs, there was no difference in delayed cerebral ischemic events (2.0% vs. 4.1%, p = 0.614), in-hospital mortality (15.7% vs. 22.4%, p = 0.389) or aortic-related mortality (2.0% vs. 2.0%, p = 0.996) and no patients had delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (< 24 hours) fashion had no difference compared to those completed ≥ 24 hours, with regards to delayed ischemic stroke (2.6% vs. 4.3%, p = 0.548), in-hospital mortality (18.2% vs. 21.7%, p = 0.764) or aortic-related mortality (1.3% vs. 4.3%, p = 0.654) , with no patients having delayed hemorrhagic stroke.
CONCLUSIONS: In contrast to prior retrospective efforts, results from the ATF international prospective multicenter registry demonstrate that neither emergent or urgent TEVAR for patients with concomitant BTAI and TBI is associated with delayed stroke, in-hospital or aortic-related mortality. In these patients, early TEVAR is safe and may improve outcomes by facilitating the higher blood pressures required to maintain optimal cerebral perfusion and mitigate the risk for secondary brain injury.
Back to 2021 Abstracts