Medical Management Versus TEVAR in Grade 2 Blunt Thoracic Aortic Injury from The Aortic Trauma Foundation Global Registry
Cassra N Arbabi1, Joseph DuBose2, Benjamin W Starnes3, Naveed U Saqib4, Elina Quiroga3, Charles C Miller4, Ali Azizzadeh1
1Cedars-Sinai Medical Center, Los Angeles, CA;2University of Texas, Austin, TX;3University of Washington, Seattle, WA;4University of Texas Health Sciences Center, Houston, TX
INTRODUCTION: Blunt Thoracic Aortic Injury (BTAI) is the second leading cause of death from blunt force trauma. Current Society for Vascular Surgery (SVS) guidelines suggest urgent Thoracic Endovascular Aortic Repair (TEVAR) for patients with Grade 2 BTAI. This study aims to determine if medical management (MM) alone is a safe and effective alternative to TEVAR for Grade 2 BTAI.
METHODS: The Aortic Trauma Foundation (ATF) international prospective multicenter registry was utilized to identify all patients with Grade 2 BTAI from 2015 to 2023. Within this cohort we analyzed patient demographics, injury characteristics, management and outcomes of patients treated with definitive MM versus TEVAR. Primary outcomes included in-hospital and aortic-related mortality. Secondary outcomes included failure of MM and complications related to TEVAR.
RESULTS:A total of 105 patients (median age 52, 70% male, median ISS 34) with SVS Grade 2 BTAI were identified, 1 patient was treated with open surgical repair and was excluded, leaving 104 patients for this analysis. Definitive treatment selected for BTAI was MM in 55 patients (52.3%) and TEVAR in 49 patients (47.1%). The majority of patients were treated in a Level 1 trauma center (92.3%). The most common mechanism of injury was motor vehicle collision (52.3%), followed by auto vs pedestrian (15.2%), motorcycle accidents (12.4%) and falls (12.4%). The most common method of anti-impulse control in both groups was continuous titrated infusion of beta blocker, with treatments targeted to a goal systolic blood pressure < 120 mmHg. Intentional coverage of left subclavian artery (LSA) was noted in 12 patients (23.1%), 2 of which underwent additional procedure to maintain LSA perfusion (1 Snorkel/Chimney, 1 Branched graft). A total of 3 patients (5.5%) had failure of MM requiring TEVAR. Complications relating to TEVAR included type 1 endoleak in 2 patients (3.8%). Access artery injury occurred in 7 patients (13.5%), 1 of which required open arterial repair. One patient (1.9 %) in the TEVAR group required return to operating room for issues relating to index BTAI procedure. In-hospital mortality for patients in the MM group was 10.6% (11/104) and for TEVAR was 7.7% (8/104). Aortic-related mortality occurred in 1 patient (0.9%) in the TEVAR group and 2 patients (1.9%) in the MM group, however for 1 patient this was related to concomitant abdominal aortic pseudoaneurysm with hemorrhage. Follow up evaluation (range 1-24 months) was performed on 11 patients (10 TEVAR). There were no complications of TEVAR or MM patients who were seen in follow up.
CONCLUSIONS: When compared to TEVAR, MM as a definitive treatment for Grade 2 BTAI appears to be a safe and effective alternative, with no difference in aortic-related or in-hospital mortality. Management of Grade 2 BTAI with TEVAR does not appear to change the short-term natural history of these injuries. However, further studies with long term follow up are warranted to better analyze this difference and formulate changes in the current SVS guidelines for Grade 2 BTAI.
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