Invited commentary

Abstract

The authors are to be commended for collecting one of the larger series of endovascular repair of traumatic ruptures of the thoracic aorta. At the same time, the retrospective and case-selective nature of their study population limits the validity of this report. It is not unlikely that a number of patients with arch ruptures were never considered for endovascular repair early in the study period as endovascular repair was not introduced simultaneously in the four study centers. Unfortunately, the outcomes of these patients along with the ones unsuitable for endovascular repair as a result of anatomic restrictions or hemodynamic instability were not studied. Even in a retrospective setting, the study could have been much stronger if all traumatic ruptures in The Netherlands in this period were included and not just the ones that received an endovascular graft in a few trauma centers. Open surgical repair of traumatic arch ruptures is associated with high mortality and morbidity rates. Because of frequent major comorbidities, the timing of surgical repair is still controversial. Paraplegia, respiratory insufficiency, renal failure, and major bleeding are common complications after open surgical repair. Various studies have suggested better outcomes for patients who are treated in a delayed manner. The present study on endovascular repair seems to confirm endovascular repair to be a safe and highly effective procedure with fewer intraoperative and postoperative complications, even for high-risk patients. Although short-term results are encouraging, concerns have been raised regarding stent-graft failure due to the acute angle of the aortic arch in young patients and regarding stent-graft migration. Also, the issue of durability of endovascular repair is highly relevant in this patient category. With the low incidence of traumatic aortic ruptures, randomized trials are almost impossible to conduct. Prospective, population-based studies including all patients with aortic arch ruptures are probably the best attainable level of evidence on this issue. For the moment, this large retrospective study adds to the perception that immediate or early endovascular repair of traumatic ruptures of the thoracic aorta is feasible, safe, and effective in polytrauma patients even in the face of severe accompanying injuries.