A Level 1 Trauma Center Experience: Is Endovascular Repair All Good for Blunt Traumatic Aortic Injury?

Abstract

Introduction: Since blunt traumatic aortic injury (BTAI) carries a high mortality rate up to 10-30% [1] especially when combining with brain injury and severe thoraco-abdominal visceral organ injuries, urgent endovascular or open aortic repair (AR) for Grade (Gr) II-IV BTAI is mandatory. Endovascular aortic repair (EAR) is the first-line choice for BTAI involving descending aorta in concern of coagulopathy. [2] In case of blunt traumatic ascending aorta injury (BTAAI), EAR would be challenging. [3] This study aims at analyzing accuracy of diagnosis on computed tomography (CT), surgical strategy and results of various kinds of BTAI, including traumatic type A aortic dissection (AD) and intramural hematoma (IMH) in our Level 1 Trauma Center. Methods: From Jan. 2015 to Jan. 2019, all BTAI patients undergoing surgery are retrospectively reviewed. BTAI grading is modified with Gr IIa as IMH, Gr IIb as AD and Gr X as periaortic hemorrhage. Mechanism of injury, grade of BTAI on CT, associated injuries, injury severity score (ISS), visit-to-operation time, operative procedures, post-operative complications and re-intervention, operation-to-mortality time, cause of mortality and aortic remodeling on series of follow-up CT were recorded. Results: Total 43 patients presented 5 Gr IIa (1 type A IMH, 4 type B IMH), 11 Gr IIb (4 type A AD, 7 type B AD), 15 Gr III, 8 Gr IV and 4 Gr X BTAI. The mean ISS was 31±9. 65.1% patients got associated injuries in lungs, 44.2% in thoracic cage, 41.9% in abdomen and 39.5% in brain. Mean visit-to-operation time was 2.85 hours. Patients received hybrid AR or EAR with proximally landing at 15 Zone 2, 3 Zone 1, 2 Zone 0 and 22 beyond Zone 3. Associated operations included 10 brain, 10 abdominal, 6 orthopedic and 2 ECMO operations. There were 3 circulatory collapses before or during EAR and all of which died. 6 out of 13 mortality were found exacerbating intra-cranial and intra-abdominal hemorrhage after AR. 24-hour mortality and inhospital mortality were 20.9% and 30.2% (procedure related 38.5%, brain injury 38.5%, abdomen injury 15.4%, lung injury 7.6%). 60% patients with BTAAI underwent EAR and hybrid AR with 100% and 50% mortality respectively. Early complication rate was 7.1% with aortic valve entrapment and acute kidney injury. Re-intervention rate was 2.3% with left subclavian artery steal syndrome. Aortic healing in Gr IIa, Gr III, Gr IV and Gr X BTAI were 100%. For Gr IIb BTAI, there were 66.7% FL thrombosis beyond the aortic graft and 16.7% aortic healing. Conclusion: Diagnosis for BTAI could be mimicked by disrupted intercostal arteries, azygos vein and inferior vena cava. Exacerbations of ongoing intracranial and thoraco-abdominal hemorrhage are main causes of death if EAR is routinely applied as priority. EAR for BTAAI possessed 100% mortality in our series due to unskilled graft deployment and preoperative spinal shock. However, early EAR before aortic exsanguination and circulatory collapse has promising salvage rate and aortic remodeling in other conditions.Figure 2Associated injuries, causes of mortality and surgical outcomes of BTAI.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose