Aortic and cardiovascular remodelling after thoracic endovascular aortic repair for blunt traumatic aortic injury in younger patients: A narrative review of physiological and clinical outcomes

Dear Editor, During the last decade, endovascular (EV) repair has replaced open surgical repair (OSR) as the preferred method of treatment of blunt traumatic thoracic aortic injuries (BTAIs) at many trauma centers. The thoracic endovascular aortic repair (TEVAR) means percutaneous replacement of a stent within the descending thoracic or thoracoabdominal aorta to treat aortic aneurysm (1). The thoracic endovascular aortic repair has the advantage of being a less invasive technique compared to the open surgical method of repairing, owing to the unique ability to insert the stent through a small incision. Because the incision is small, the patients who are operated by the TEVAR technique have minimal amounts of blood loss. Through the TEVAR method, prolonged cross clamping of aorta is not necessary. As a result, the incidence of renal, visceral and spinal ischemia is fewer than that in the standard open surgical repair technique (2). Studies show that the TEVAR reduces early mortality and paraplegia compared with the open surgical management. The risk of dependency to the mechanical respiratory ventilation is lower in the thoracic endovascular aortic repairmen. Unlike the traditional aortic repair, standard recovery after the TEVAR is remarkably straightforward. Patients, who have undergone the TEVAR, typically spend one night in hospital to be monitored although it has been suggested that the TEVAR can be performed as a same-day procedure. In 2005, the United States Foods and Drugs Administration (FDA) approved the pivotal trial of the TEVAR for treating the patients with thoracic aorta aneurysm (2). Certainly, blunt traumatic thoracic aortic injuries are among the most dangerous and fatal emergency situations. The typical mechanism causing these injuries is blunt deceleration, usually from motor vehicle collisions, falls, and crushes with significant amounts of force. So, the blunt traumatic thoracic aortic injuries occur in young patients with multiple traumas (3). Since the last decade, so important advancements have been developed in medical and surgical management of blunt traumatic thoracic aortic injuries. Endovascular stent graft technologies are employed increasingly as an off label emergency treatment of these kinds of aortic injuries (4, 5). Finally, as experiments, we present two cases of 23 and 25 year-old men, who were admitted to our hospital because of blunt traumatic thoracic aortic injuries from car accidents. They were operated by the TEVAR technique. The management of both patients was the same. First of all, a chest X-ray was performed. The widening of mediastinum was obvious on the X-ray (Figure 1). Figure 1. Preoperation CXR-widening of mediastinum is obvious in preoperation CXR. In the next step, Computed Tomography (CT) angiography and an aortography were done. This study confirms the dissection of descending thoracic aorta. The patients were underwent the repair of thoracic aorta by the EV stent insertion approach. At the end of surgery, after repairing the injured part of aorta, the patients were referred to Intensive Care Unit (ICU) in the surgery ward. They were closely observed for 3 days. After three days of hospitalization, they were discharged with acceptable conditions. As it is obvious, this minimally invasive EV approach results in several advantages for the patients compared with the open surgical repair. Therefore, it is highly recommended that the TEVAR be used instead of the open repair of blunt traumatic injury of the aorta.

The modern open surgical management of abdominal aortic aneurysm (AAA) has changed little since its inception in the 1950s. Endoaneurysmorrhaphy, first described by Rudolph Matas in 1888, involved ligating the branches of an aneurysm from within the aneurysm sac. Approximately 25 years later at the

Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.

Blunt traumatic aortic injury (BTAI) patients are severely ill, with high mortality and morbidity. As 60% of BTAIs occur in the distal arch, left subclavian artery (LSCA) management is determined without knowing posterior cerebral or left arm circulation in emergent cases. Because we perform thoracic endovascular aortic repair (TEVAR) + debranching technique for thoracic BTAI, we assessed efficacy and safety of debranching TEVAR in BTAI patients. We retrospectively reviewed vital signs on arrival, injury mechanism, characteristics, clinical time-series, concomitant injuries, injury description, operative procedures, and results from patient records. We excluded patients in cardiopulmonary arrest on arrival. From April 2014 to December 2018, nine of 25 patients admitted with BTAI underwent TEVAR. Median Injury Severity Score was 34 (29-34) and probability of survival was 0.82 (0.16-0.94). Society for Vascular Surgery BTAI injury grade was III or IV in all patients. Three patients underwent simple TEVAR and six underwent debranching TEVAR (LSCA occlusion + left common carotid artery to LSCA bypass). Median operation time was 108 (75-157) min for simple TEVAR and 177 (112-218) min for debranching TEVAR. Concomitant injuries included intracranial hemorrhage (N = 1), intra-abdominal injuries (N = 3), pneumo- or hemothoraxes (N = 4) and pelvic/extremities fractures (N = 7). Only one complication of left-hand claudication occurred postoperatively in a patient with simple TEVAR with LSCA occlusion. Despite debranching TEVAR taking approximately 60min longer than simple TEVAR, short-term results indicated it to be acceptable for BTAI in multiple trauma patients to avoid LSCA complications unless we fail to stop bleeding first.

Outcomes of routine surveillance of grade 1 blunt traumatic aortic injury.

The Society of Vascular Surgery (SVS) guidelines currently suggest thoracic endovascular aortic repair (TEVAR) for grade II-IV and nonoperative management (NOM) for grade I blunt traumatic aortic injury (BTAI). However, there is increasing evidence that grade II may also be observed safely. The purpose of this study was to compare the outcome of TEVAR and NOM for grade I-IV BTAI and determine if grade II can be safely observed with NOM. The records of patients with BTAI from 2004 to 2015 at a Level I trauma center were retrospectively reviewed. Patients were separated into two groups: TEVAR versus NOM. All BTAIs were graded according to the SVS guidelines. Minimal aortic injury (MAI) was defined as BTAI grade I and II. Failure of NOM was defined as aortic rupture after admission or progression on subsequent computed tomography (CT) imaging requiring TEVAR or open thoracotomy repair (OTR). Statistical analysis was performed using Mann-Whitney U and χ tests. A total of 105 adult patients (≥16 years) with BTAI were identified over the 11-year period. Of these, 17 patients who died soon after arrival and 17 who underwent OTR were excluded. Of the remaining 71 patients, 30 had MAI (14 TEVAR vs. 16 NOM). There were no failures in either group. No patients with MAI in either group died from complications of aortic lesions. Follow-up CT imaging was performed on all MAI patients. Follow-up CT scans for all TEVAR patients showed stable stents with no leak. Follow-up CT in the NOM group showed progression in two patients neither required subsequent OTR or TEVAR. Although the SVS guidelines suggest TEVAR for grade II-IV and NOM for grade I BTAI, NOM may be safely used in grade II BTAI. Therapeutic study, level IV.

Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

Recommendations on the Use of Open Surgical and Endovascular Aneurysm Repair for the Management of Unruptured Abdominal Aortic Aneurysm from the Guideline Development Committee Appointed by the UK National Institute for Health and Care Excellence

Impact of trauma center volume on treatment strategies and outcomes of blunt traumatic aortic injuries.

Between a rock and a hard place? Not when dealing with traumatic aortic injuries!

PC10. Selective Nonoperative and Delayed Operative Approaches for the Management of Grade III Blunt Traumatic Aortic Injury

Aim: Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery. Materials and Methods: Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period. Results: The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I. Conclusion: TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA. Clinical Impact Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.

Designed to treat degenerative aneurysms of the thoracic and abdominal aorta, endovascular stent-grafts have been increasingly employed as an off-label emergency treatment for blunt traumatic aortic injury (BTAI). In this review we explore the controversies associated with thoracic endovascular aortic repair (TEVAR) for BTAI. Early versus delayed treatment of aortic injuries is controversial, and stent-graft repair has further confused the issue of timing the repair. The diagnosis and management of minimal aortic injuries remains elusive. We analyze the available literature pertaining to BTAI, including the recent multicenter prospective trial from the American Association for the Surgery of Trauma. The strengths and weaknesses of the stent-grafts currently available for use in the US are examined to provide insight into which graft may be best suited for BTAI at the present time. Also of importance, we offer recommendations regarding clinical situations in which TEVAR should not be the first line therapy for BTAI. We conclude with a discussion of upcoming trials and new devices that will shape the future of endovascular treatment of BTAI.

Timing of Intervention in Blunt Traumatic Aortic Injury Patients: Open Surgical versus Endovascular Repair

We aimed to investigate the changes in aorta size, the factors affecting size changes in patients with acute blunt traumatic aortic injury and to evaluate the adequacy of the current 120% thoracic endovascular aortic repair graft oversizing policy. This retrospective review study was conducted using the prospectively collected medical records of 45 patients (mean age: 53.5years, male: 39 patients) with blunt traumatic aortic injury treated at a level 1 trauma center between 2012 and 2021. Aortic diameter was measured by computed tomography angiographic images at four different levels [ascending aorta (A), isthmus (B), descending thoracic aorta (C), and infrarenal aorta (D)] on arrival and follow-up (median time interval, 13days). Associated factors including patient characteristics and hemodynamic parameters on arrival and follow-up were collected to determine their influence on changes in the aorta. The mean diameter of all four aortic levels increased on follow-up computed tomography compared to initial computed tomography (A: + 11.77%, B: + 10.19%, C: + 7.71%, D: + 12.04%). Patient age and injury severity score influenced changes in the diameter of the ascending aorta (P < 0.05). Patient age and blunt traumatic aortic injury grade were significantly associated with changes in the infrarenal aortic diameter (P < 0.05). Three cases of type 1 endoleak were observed at follow-up but all were spontaneously resolved without further intervention at next computed tomography follow-up. In patients with acute blunt traumatic aortic injury, aortic diameter is significantly smaller by about 10% under shock and is not considered a basis for oversizing the currently implemented 120% thoracic endovascular aortic repair graft sizing. However, in young patients under the age of 40, the change is significantly large and subsequent computed tomography follow-up is required.