Blunt Thoracic Aortic Injury: Open or Stent Graft Repair?

Abstract

Conclusion: There are no significant differences between endovascular and open repair of blunt aortic injury with respect to morbidity or mortality. Summary: Endovascular stent grafting has nearly become the standard of care for treatment of blunt thoracic aortic injury. This is despite the lack of any randomized data to support this paradigm change in the treatment of blunt aortic injury. The authors sought to determine whether the use of endovascular stent grafting has actually improved outcome of treatment of blunt thoracic aortic injury. This was a retrospective review of the patients from single institution that were treated for blunt thoracic aortic injury from October 1999 to May 2007. Patients were identified from the University of Wisconsin's level I trauma registry and included in this study if they had computed tomography scan or angiographic evidence of a thoracic aortic injury distal to the left subclavian artery after blunt trauma. Patients were separated into those who underwent open repair (OR) and those who underwent endovascular repair (ER). Patients were assessed for demographics, mechanism of injury, injury severity score (ISS), associated injuries, known comorbid conditions, intraoperative findings, postoperative complications, and hospital stay. Outcomes in patients treated with OR and ER were compared. During this 8-year period, 26 consecutive patients (20 men) were treated for blunt aortic injury, of which 12 were treated with OR and 14 with ER. The mean age was 36 years. There were no differences between the ER and OR groups with respect to mechanism of injury, ISS score, or number of associated injuries upon presentation. ER was technically successful in 100%, with no procedurally related mortality. One patient in the OR group had a presumed recurrent laryngeal nerve palsy postoperatively. There was no treatment-related paraplegia in either group. One-year survival for OR and ER patients was 93% and 92% respectively. At 1 year, 25% of patients in the OR group and 18% in the ER group required reintervention. Intraoperative blood product administration was greater in the OR group (P = .055). However, total blood products transfused in the initial hospital stay did not differ between the two groups. Duration of hospital stay was also similar, at 13 days for the OR group and 13.9 days for the ER group. Patients in the ER group tended to have delayed repair vs those in the OR group, with an average time from injury to repair of 0.3 days for the OR group and 12.2 days for the ER group. Comment: ER of thoracic aortic injury has its problems, but most articles on this subject have concluded ER of blunt thoracic injury has advantages over OR. This report will not significantly detract from the trend for ER of blunt thoracic aortic injury. The number of patients treated here was relatively small, averaging only about three patients per year. In addition, the patients treated with OR had a mean cross-clamp time of 27 minutes (these are quick surgeons), and half of the patients could be treated with primary repair (favorable injuries). Overall survival of the OR group was higher than is usually seen in reports of OR of thoracic aortic injury. This suggests a relatively favorable group of patients treated with OR for blunt thoracic injury at the University of Wisconsin. More data are clearly needed, but despite this report, the trend for ER of blunt thoracic aortic injury will continue.