Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life

Dennis Hundersmarck,Joost A Van Herwaarden,Constantijn E V B Hazenberg,Luke P H Leenen,Falco Hietbrink,Lotte M Winterink,Quirine M J Van Der Vliet

doi:10.1007/s00068-020-01432-y

Dennis Hundersmarck, Joost A Van Herwaarden + Show 5 more

Open Access

https://doi.org/10.1007/s00068-020-01432-y

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Abstract

PurposeTreatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL).MethodsRetrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population.ResultsThirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01).ConclusionThis study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.

Highlights

MethodsBlunt thoracic aortic injury (BTAI) is a potentially lethal consequence of high-energy blunt thoracic trauma
Due to this emergency setting that limits pre-operative planning and BTAI morphology that often requires left subclavian artery (LSCA) coverage for a sufficient proximal stent graft landing zone, outcomes may be different compared to other thoracic endovascular aortic repair (TEVAR) procedures
MVC Fall from height (> 2 m) Pedestrian collision Blast injury Train collision Systolic blood pressure ≤ 90 mmHg Pulse Hemodynamic instability Cardiac arrest upon arrival at the ED Hb Arterial pHa Lactatea Base deficita BTAI injury g radeb Grade I Grade II Grade III Grade IV Treatment Early TEVAR Delayed TEVAR Conservative Died before repair Additional treatmentc Craniotomy Thoracotomy Laparotomy Pelvic fracture surgery Spinal fracture surgery Extremity fracture surgery Hospital stay ICU stay Outcomes In-hospital mortality BTAI-related mortality Cause of in-hospital death Hemorrhage Multi-organ failure Traumatic brain injury Myocardial contusion Futility

Summary

Introduction

MethodsBlunt thoracic aortic injury (BTAI) is a potentially lethal consequence of high-energy blunt thoracic trauma. Due to the relative mobility of the aortic arch and a fixed descending aorta, injuries to the thoracic aorta are usually located around the isthmus, just distal to the left subclavian artery (LSCA) [3, 4]. The use of thoracic endovascular aortic repair (TEVAR) for BTAI is a relatively novel development and in polytrauma patients usually performed in an emergency setting. Due to this emergency setting that limits pre-operative planning and BTAI morphology that often requires LSCA coverage for a sufficient proximal stent graft landing zone, outcomes may be different compared to other TEVAR procedures

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