Thoracic Aortic Injury Research Articles

Blunt Thoracic and Abdominal Aortic Injury in Multiple Trauma: A Case Report.

Blunt abdominal aortic injury (BAAI) is rare among traumatic aortic injuries, and further complications of blunt thoracic aortic injury (BTAI) have never been reported. A man in his 80s presented to our hospital following a motor vehicle accident. Pan-scan contrast-enhanced CT showed a thoracic aortic isthmus injury (Grade III), an abdominal aortic injury (Grade IV) with extravasation of contrast media at the level of the fourth lumbar vertebra. Endovascular abdominal aortic repair was performed on the same day and a thoracic endovascular aortic repair for BTAI was performed 11 days after admission. The patient had a good postoperative course and was discharged without complications. This report presented a rare case of BTAI complicated with BAAI. The timing of intervention for aortic injury should be determined based on urgency and other organ damage.

Traumatic Aortic Disruption Index is Associated with Mortality and Urgency of Stent Grafting in Blunt Thoracic Aortic (Grade 3) Injuries

ObjectiveDelayed stent grafting for blunt thoracic aortic injuries (BTAI) is current standard of care. However, given the heterogeneity of pseudoaneurysm presentations, it is currently unclear which severe BTAIs require more urgent intervention. We hypothesize that a Traumatic Aortic Disruption Index (TADI) calculation based on sagittal computed tomography angiography (CTA) imaging measurements would correlate with urgency of stent grafting. MethodsAll patients at a level-1 trauma center with BTAIs over a 12-year period were identified. A TADI score was then calculated using the length of pseudoaneurysm (L), maximum width of pseudoaneurysm (W), and normal adjacent aortic diameter (NA) (Figure1). Patient presentation, injury characteristics, timing of stent grafting, and outcomes were then evaluated. ResultsForty-two patients were diagnosed with BTAIs. Mean age was 37.6 years, with a median injury severity score (ISS) of 29. Overall mortality was 11.9%. TADI scores ranged from 3.6 to 158.6. Compared to patients with a TADI<28, patients with TADI>28 had similar median ISS scores (34 vs 29, p=0.16), and rates of both traumatic brain injury (33.3% vs 42.0%, p=0.53) and non-aortic hemorrhage control procedures (44.4% vs 33.3%, p=0.3). TADI>28 patients had a lower initial mean systolic BP (98.5 vs 121.9, p=.003), more severe hypotension (lowest systolic 77.0 vs 91.2, p=.034), lower initial GCS (6 vs 13, p=.039), higher mean admission lactate (4.6 vs 3.3, p=.036), and higher overall mortality (23.8% vs 0%, p=.048). Patients with TADI>28 received stent grafting at significantly shorter median time intervals from injury identification (median 4 hrs vs 14 hrs, p=.001). Overall causes of mortality were aortic hemorrhage related (n=3, 60%) and traumatic brain injury (n=2, 40%). ConclusionThis simple-to-calculate index is independently correlated with mortality and urgency of stent grafting in blunt trauma patients with similar ISS. Patients with TADI scores >28 were more likely to undergo urgent stent grafting, thereby suggesting a trend in practice patterns with higher scores representing injuries that should be considered for expedited operative management. The TADI score should be validated in a larger sample of blunt trauma patients as an injury prioritization tool in the multi-system injured patient.

Case Report: Aspirated Airway Foreign Body Mimicking Endobronchial Mass: A Diagnostic Challenge

Abstract Introduction/Objective Despite advancements in imaging modalities, identifying retained foreign bodies within the lung remains arduous. Detecting small foreign bodies is crucial as they can serve as a focal point for subsequent infections. Initial assessments may mimic malignancy. Herein, we present a case of a retained foreign body masquerading as an endobronchial mass, accompanied by unilateral pleural effusion and persistent hypoxia. Subsequent bronchoscopy showed a pearly white endobronchial mass partially obstructing the segmental bronchus at the posterior basal segment of the right lower lobe of lung with accompanying right pleural effusion and atelectasis. Methods/Case Report This is a 58-year-old male with history of hypertension, deep vein thrombosis, transient ischemic attack, and a recent motor vehicle accident with blunt chest trauma. He had a thoracic spinal cord transection with grade III blunt thoracic aortic injury, developed anasarca, hypoxia, right pleural fluid requiring multiple thoracentesis, and right sided hemothorax requiring massive transfusion protocol. Subsequent evaluations, including bronchoscopic transbronchial forceps biopsies and bronchial wash and pleural fluid cytologic examinations showed no malignant cells. Repeat bronchoscopy was concerning for enlarging mass and obstruction. Bronchoscopy almost 2 months after MVA revealed an endobronchial foreign body (tooth) lodged in the left lower lobe of lung posterior segment. Results (if a Case Study enter NA) N/A Conclusion While aspiration of foreign bodies into the tracheobronchial tree is not uncommon especially in children, foreign bodies, particularly teeth, are rare in adults. Bronchial foreign body aspiration may occur in trauma, with diagnosis typically relying on history and physical examination. Detection remains challenging despite imaging advancements, with implications including infection nidus formation. In our case, delayed diagnosis highlights the importance of considering unusual etiologies in persistent pulmonary pathology. Retrospective imaging analysis and CT findings suggested a foreign body, emphasizing the utility of imaging in suspected cases. Prompt surgical intervention is crucial to prevent complications such as recurrent infections.

Effects of Timing of Repair on Mortality Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

Blunt thoracic aortic injuries (BTAI) are traditionally treated as emergencies with most fixed within 24 hours of arrival by thoracic endovascular aortic repair (TEVAR) regardless of grade of injury. However, the optimal timing of repair remains debated. All patients with grade 2 and 3 BTAI enrolled in the Aortic Trauma Foundation prospective multi-center registry from 2015 to 2022 were categorized dependent on timing of repair (ER=Early Repair<24 hours, LR=Late Repair>24 hours). Chi-square/Fisher's exact tests were used to compare patient/operative factors and logistic regression analysis was performed to identify factors related to 30-day mortality. 222 Grade 2 and 3 BTAI treated by TEVAR were analysed, with 179 in the ER group (81%). There was no difference between the groups regarding Injury Severity Score (ISS), Glasgow Coma Scale (GCS), age, or gender. Those in ER were more likely to have a widened mediastinum and a shorter distance from the left subclavian artery to the injury. 30-day in-hospital mortality occurred in 14 patients (6%); 2 of which were aortic-related. 30-day mortality was associated with a higher baseline incidence of CAD/PVD/previous cardiac revascularisation; lower systolic blood pressure, GCS, hemoglobin, platelet count and blood pH; and higher lactate and ISS on arrival. On multivariate regression analysis, lower haemoglobin, higher ISS, and Grade 3 BTAI were associated with 30-day mortality (p<0.05), although time to TEVAR was not. In selected patients, delay in performance of TEVAR for Grade 2 & 3 BTAI may be possible. Further research is necessary to identify other factors predictive of success.

TRIM25 activates Wnt/β-catenin signalling by destabilising MAT2A mRNA to drive thoracic aortic aneurysm development.

This study explored the roles of methionine adenosyltransferase 2A (MAT2A) and tripartite motif containing 25 (TRIM25) in the progression of thoracic aortic aneurysm (TAA). The TAA model was established based on the β-aminopropionitrile method. The effects of MAT2A on thoracic aortic lesions and molecular levels were analyzed by several pathological staining assays (hematoxylin-eosin, Verhoeff-Van Gieson, TUNEL) and molecular biology experiments (qRT-PCR, Western blot). Angiotensin II (Ang-II) was used to induce injury in vascular smooth muscle cells (VSMCs) in vitro. The effects of MAT2A, shMAT2A, shTRIM25 and/or Wnt inhibitor (IWR-1) on the viability, apoptosis and protein expressions of VSMCs were examined by CCK-8, Annexin V-FITC/PI and Western blot assays. In TAA mice, overexpression of MAT2A alleviated thoracic aortic injury, inhibited the aberrant expressions of aortic contractile proteins and dedifferentiation markers, and blocked the activation of Wnt/β-catenin pathway. In Ang-II-induced VSMCs, up-regulation of MAT2A increased cellular activity and repressed the expression of β-catenin protein. TRIM25 knockdown promoted activity of VSMCs, inhibited apoptosis, and blocked the Wnt/β-catenin pathway activation by binding to MAT2A. IWR-1 partially counteracted the regulatory effects of shMAT2A. Collectively, TRIM25 destabilises the mRNA of MAT2A to activate Wnt/β-catenin signaling and ultimately exacerbate TAA injury.

Risk Factors for Adverse In-Hospital Outcomes in Patients With Traumatic Blunt Thoracic Aortic Injuries Undergoing Thoracic Endovascular Aortic Repair (TEVAR): An Analysis of the US Nationwide Inpatient Sample.

Thoracic endovascular aortic repair (TEVAR) is a treatment for traumatic blunt thoracic aortic injury (BTAI) with good survival rates and safety. However, there is limited study on the risk factors for in-hospital mortality and complications. This study aimed to identify risk factors associated with poor in-hospital outcomes after TEVAR. This is a population-based, retrospective observational study. Data of adults ≥20 years admitted for BTAI who received TEVAR were extracted from the Nationwide Inpatient Sample (NIS) database 2005 to 2018. The primary outcome was in-hospital mortality, and the secondary outcomes were length of stay (LOS) and unfavorable discharge (ie, non-routine discharge, including nursing homes or long-term care facilities). Associations between study variables and in-hospital outcomes were determined using univariate and multivariable logistic and linear regression analyses. Data of 1095 participants (representing 5360 hospitalized patients in the United States) were analyzed. Multivariable analysis revealed that older age (adjusted odds ratio [aOR]=1.02) and having at least 1 perioperative complication (aOR=4.01) were significantly associated with increased risk for in-hospital mortality. Patients with at least 1 perioperative complication (aOR=11.19) had significantly increased odds for prolonged LOS. Risk for unfavorable discharge was significantly increased by older age (aOR=1.02), household income at quartile 2 (aOR=1.58), Charlson Comorbidity Index (CCI) 2 to 3 (aOR=1.66), and having at least 1 complication (aOR=3.94). Complications including perioperative cerebrovascular accident (CVA) (aOR=2.75), venous thromboembolism (VTE) (aOR=2.87), pneumonia (aOR=3.93), sepsis (aOR=4.69), infection (aOR=4.49), respiratory failure (aOR=4.55), mechanical ventilation (aOR=3.27), and acute kidney injury (AKI) (aOR=3.09) significantly predicted prolonged LOS. In adults with traumatic BTAI undergoing TEVAR, advanced age and perioperative complications are risk factors for poor in-hospital outcomes. Acute kidney injury, CVA, respiratory failure, and sepsis are strong predictors of prolonged LOS, unfavorable discharge, and in-hospital mortality. The study identifies advanced age and perioperative complications as key risk factors for poor in-hospital outcomes in patients undergoing TEVAR for BTAI. Clinicians should be vigilant in managing these patients, particularly those with comorbidities, to mitigate risks. The findings suggest a need for tailored perioperative care strategies to improve survival rates and reduce complications. This research highlights the critical importance of early identification and intervention in high-risk patients, offering an innovative approach to refining TEVAR protocols and enhancing patient outcomes in trauma care.

Evaluating the effectiveness of immediate vs. elective thoracic endovascular aortic repair for blunt thoracic aortic injury

PurposeTo evaluate the relationship between the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) and prognosis. MethodsThis is a single-center retrospective cohort study. Patients who received TEVAR for BTAI at our institution from October 2016 to September 2023 were divided into 2 categories depending on the injury severity score (ISS) (≤ 25 vs. > 25) and when the TEVAR was performed for BTAI (within 24 h vs. after 24 h), respectively. The analysis included all patients who received TEVAR treatment after being diagnosed with BTAI through whole-body CT angiography. Patients treated with open repair and non-operative management were excluded. After propensity-score matching for various factors, outcomes during hospitalization and follow-up were compared. These factors included demographics, comorbidities, concomitant injuries, cause and location of aortic injury, Glasgow coma scale score, society for vascular surgery grading, hemoglobin concentration, creatinine concentration, shock, systolic blood pressure, and heart rate at admission. The comparison was conducted using SPSS 26 software. Continuous variables were presented as either the mean ± standard deviation or median (Q1, Q3), and were compared using either the t-test or the Mann-Whitney U test. Categorical variables were expressed as n (%), and comparisons were made between the 2 groups using the χ2 test or Fisher’s exact test. Statistical significance was defined as a 2-sided p < 0.05. ResultsIn total, 110 patients were involved in the study, with 65 (59.1%) patients having ISS scores > 25 and 32 (29.1%) receiving immediate TEVAR. The perioperative overall mortality rate in the group with ISS > 25 was significantly higher than that in the group with ISS ≤ 25 (11 (16.9%) vs. 2 (4.4%), p < 0.001). Upon admission, the elective group exhibited a notably higher Glasgow coma scale score (median (Q1, Q3)) compared to the immediate group (15 (12, 15) vs. 13.5 (9, 15), p = 0.039), while the creatinine concentration (median (Q1, Q3)) at admission was significantly higher in the immediate group (90.5 (63.8, 144.0) vs. 71.5 (58.3, 80.8), p = 0.012). The final sample included 52 matched patients. Complications occurred significantly less frequently in the elective group compared to the immediate group (16 (50.0%) vs. 3 (10.0%), p < 0.001). Single-factor analysis of variance showed that complications in hospitalized patients were significantly associated with immediate TEVAR as the sole independent risk factor (odds ratio: 9.000, 95% confidence interval: 2.266 – 35.752, p = 0.002). ConclusionIn this propensity-score matched analysis of patients undergoing TEVAR for BTAI, elective TEVAR was significantly associated with a lower risk of complication rates. In this study using propensity-score matching, patients who underwent elective TEVAR for BTAI had lower complication rates than immediate TEVAR.

968 Optimal Timing for Endovascular Aortic Repair in Patients with Blunt Thoracic Aortic Injury: A Systematic Review and Meta-Analysis

Abstract Aim The optimal timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI) remains a topic of debate. We performed a systematic review and meta-analysis to compare early versus delayed TEVAR in BTAI. Method We systematically searched PubMed, Embase, Cochrane Central and Clinicaltrials.gov in up to October 2023 to include studies comparing TEVAR performed &amp;lt;24 hours versus &amp;gt;24 hours in BTAI. Safety outcomes were pooled as odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). Subgroup analysis was performed with propensity-score matching or multivariate-analysis studies. Statistical analysis was performed with RevMan 5.4.1 and R software. The protocol was registered in PROSPERO (ID:CRD42023427392). Results Nine studies with 4163 patients were included, of whom 30.2%(n=1257) underwent delayed TEVAR. Mortality was significantly lower in the delayed TEVAR group (OR 0.44; 95% CI 0.32–0.59; p&amp;lt;0.001; I²=0%), with consistent results when restricted to multivariate studies (p&amp;lt;0.001). Although delayed TEVAR resulted in significantly lower rates of sepsis (OR 0.37; 95% CI 0.18–0.78; p=0.009; I²=67%), it was also associated with increased durations of hospital stay (MD 3.28; 95% CI 1.58–4.98; p&amp;lt;0.001), ICU stay (MD 2.53; 95% CI 0.92–4.14; p=0.002), AKI (OR 1.71; 95% CI 1.04–2.83; p=0.04), and ventilator use (MD 1.20; 95% CI 0.51-1.89; p&amp;lt;0.001). Conclusions Our findings show that delayed TEVAR is associated with lower mortality and sepsis, but also an increased risk of in-hospital complications. This may guide future prospective studies to investigate optimal timings according to grades of injury and associated complications.

Intravascular Ultrasound May Not Impact Graft Sizing in Endovascular Repair of Blunt Thoracic Aortic Injury.

Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for severe blunt thoracic aortic injuries (BTAI). Successful outcomes rely on accurate endograft sizing, but initial imaging may underestimate aortic diameters. This study examines the impact of intravascular ultrasound (IVUS) on endograft sizing and clinical outcomes in BTAI patients. A prospectively collected multi-institutional dataset from the Aortic Trauma Foundation was analyzed. Patients with BTAI undergoing TEVAR with IVUS were compared to patients who underwent TEVAR alone. Demographics and operative variables were compared, focusing on IVUS effects on endograft sizing by examining maximal proximal and distal aortic diameter on initial CT imaging compared to the graft diameters used during TEVAR. 293 patients underwent TEVAR for BTAI with IVUS utilized in 124 cases (42.3%). The average graft size in the IVUS and non-IVUS groups were similar proximally (26.91 ± 4.3mm IVUS vs 27.77 ± 4.7mm non-IVUS, P = 0.116) and distally (25.96 ± 4.7mm IVUS vs 26.51 ± 4.7mm non-IVUS). IVUS did not impact the difference between graft size and initial CT measurements proximally (4.32 ± 4.8mm IVUS vs 4.23 ± 3.9mm non-IVUS, P = 0.859) or distally (4.17 ± 5.9mm IVUS vs 4.50 ± 4.3mm non-IVUS, P = 0.606). Although delayed hemorrhagic and ischemic stroke occurred less frequently in IVUS patients (0.8% IVUS vs 7.1% non- IVUS, P = 0.024), in-hospital mortality was similar between groups (5.6% IVUS vs 7.7% non-IVUS, P = 0.581). IVUS is not associated with significant changes in endograft sizing compared to sizing based on CT scan alone in BTAI patients. IVUS was not associated with differences in mortality but was associated with a decrease in delayed hemorrhagic and ischemic stroke. Routine IVUS in BTAI patients may not be necessary for accurate sizing, but there may be a relationship between IVUS and stroke.

Traumatic Thoracic Aortic Coarctation after Blunt Thoracic Aortic Injury Mandates Emergent Thoracic Endovascular Aortic Repair.

This study sought to elucidate clinical and imaging findings predictive for malperfusion syndrome after blunt thoracic aortic injury (BTAI). There is limited literature on malperfusion syndrome after BTAI, and the timing of thoracic endovascular aortic repair (TEVAR) in patients with this condition has not been defined. A retrospective analysis of prospectively collected data of patients with BTAI treated between January 2021 and October 2023. Clinical and thoracic aortic (TA) imaging data, time to TEVAR, in-hospital death, and malperfusion/reperfusion sequelae (paraplegia, renal/visceral/limb ischemia, and compartment syndromes) were assessed. Correlations between clinical and imaging findings, time to TEVAR, and outcomes were evaluated. Of the 19,203 trauma patients evaluated, 13,717 (71%) had blunt injuries and 77 (0.6%) had BTAI. The majority (67.5%) were male, with a median age of 40 years (IQR: 33-55). TEVAR was performed in 42 (54.5%) patients. Seven (9.1%) patients presented with clinical and TA imaging criteria for traumatic thoracic aortic coarctation (TTAC), including diminished/absent femoral pulses and TA luminal narrowing of 50% to 99%. The median time to TEVAR was 9 (IQR: 5-32), 11, and 4 hours for all non-TTAC and TTAC BTAI patients, respectively ( P =0.037). Only TTAC patients presented/developed malperfusion/reperfusion sequelae. In-hospital mortality rates were 7.8%, 5.8%, and 29% for all non-TTAC and TTAC BTAI patients, respectively ( P =0.09). Aortic-related mortality occurred in only 2 (2.6%) TTAC patients. Patients with clinical and TA imaging manifestations of TTAC are predisposed to malperfusion/reperfusion sequelae if TEVAR is delayed. We recommend the emergent repair of all BTAIs with TTAC.

16-year outcomes of blunt thoracic aortic injury treated with thoracic endovascular aortic repair: A single-institution experience.

Blunt thoracic aortic injury (BTAI) is associated with considerable mortality and morbidity. Thoracic endovascular aortic repair (TEVAR) has essentially replaced open aortic repair (OAR) with superior outcome. The objective of this study was to evaluate the early and intermediate-term outcomes in patients sustaining BTAI treated with TEVAR, and to evaluate the prevalence and impact of left subclavian artery (LSA) coverage. This retrospective analysis includes patients undergoing TEVAR for BTAI between February 2006 and December 2022 at the Helsinki University Hospital, Finland. The primary endpoints were 30-day and 2-year mortality, technical success of stent-graft system deployment, and procedural and device-related complications. The secondary endpoints pertained to reintervention events: conversion to OAR, re-TEVAR, any endovascular/surgical reinterventions for optimal stent-graft function, or any reinterventions during follow-up. A total of 38 consecutive BTAI patients treated with TEVAR were included in the analyses. Median patient age was 45.5 years (range, 15-79) and 66% were male. The median follow-up period was 39 months. Technical success was 100%, 30-day mortality was 0%, and 2-year mortality was 11% in the study cohort. Coverage of LSA without revascularization (13/18) resulted in one postoperative nondisabling stroke (1/13), no paraplegia, and one had ischemic left arm findings (1/13). Only one patient required reintervention (LSA embolization; 1/38). In this institutional series, we provide further evidence in favor of TEVAR for BTAI treatment. We demonstrated that TEVAR is linked to highly favorable outcomes in the short and intermediate term, and coverage of LSA without revascularization was quite well tolerated.

Sex-specific Outcomes and Predictors of Mortality in Blunt Thoracic Aortic Injury

Sex-specific Outcomes and Predictors of Mortality in Blunt Thoracic Aortic Injury

Long-Term Outcomes of Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Is Not Related to the Severity of Aortic Injury

Long-Term Outcomes of Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Is Not Related to the Severity of Aortic Injury

Single Retrograde Thoracic Branch Endoprosthesis vs Traditional Endovascular Repair With Subclavian Coverage for Treatment of Blunt Thoracic Aortic Injuries

Single Retrograde Thoracic Branch Endoprosthesis vs Traditional Endovascular Repair With Subclavian Coverage for Treatment of Blunt Thoracic Aortic Injuries

Safe and Effective Change in Blunt Thoracic Aortic Injury Treatment With Application of the Harborview Classification

Safe and Effective Change in Blunt Thoracic Aortic Injury Treatment With Application of the Harborview Classification

TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm: Case report and systematic review.

Blunt thoracic aortic injuries (BTAIs) involving the aortic arch are a challenging condition. Thoracic endovascular aortic repair (TEVAR) with fenestration, which expands the proximal landing zone, is able to exclude the injury while preserving blood flow in supra-aortic branches. Here we report a case of TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm and perform a systematic review. A 24-year-old man suffering a blunt thoracic injury and a left femoral fracture was sent to our hospital. A pseudoaneurysm was found in the aortic arch between the brachiocephalic artery and the left common carotid artery. The patient underwent emergent TEVAR with fenestrations of all supra-aortic branches, which excluded the pseudoaneurysm and preserved the patency of all branches. The orthopedic team then treated the femoral fracture. The patient's recovery was unremarkable. We performed a systematic review on TEVAR with fenestrations for BTAI. Six patients (75%) received TEVAR with single fenestration, 1 patient (12.5%) received TEVAR with two fenestrations, and 1 patient (12.5%) had fenestrations of all supra-aortic branches. Except one patient died in the perioperative, other patients survived without stent-related complications in the short-term follow-up. TEVAR with fenestration is feasible for treating BTAI involving the aortic arch in selected patients.

Endovascular repair for acute aortic syndrome involving the descending aorta

This review paper delves into the acute aortic syndromes, with a particular focus on those affecting the descending thoracic aorta, including acute type B aortic dissection (aTBAD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), blunt traumatic thoracic aortic injury (bTAI), and ruptured aneurysm of the descending thoracic aorta (rDTA). These conditions present with sudden-onset symptoms such as severe chest or back pain, necessitating immediate medical attention. While traditional open surgical repair was historically the mainstay of treatment, advancements in endovascular techniques have revolutionized management approaches. Endovascular treatment offers advantages such as reduced operative time, blood loss, and hospital stay, making it a safer option for high-risk patients. However, it is crucial to carefully evaluate patients for endovascular suitability, considering the potential complications and risks associated with these techniques. This paper aims to provide an updated overview of acute aortic syndromes involving the descending thoracic aorta, analyze available therapeutic options, and review contemporary treatment modalities, shedding light on the technical aspects and considerations guiding clinical decision-making in this complex and life-threatening scenario.

Current expert-based opinions on endovascular treatment of blunt thoracic aortic injury: A state-of-the-art narrative review on indications, techniques, results, and challenges.

Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma which warrants prompt recognition with expedited management. Clinical manifestations of BTAI may not be straightforward to detect and may be misdiagnosed. Therefore, diagnosis of BTAI requires a high index of suspicion based on the mechanism of injury along with urgent transfer to centers with appropriate expertise and facilities. We provide an expert-based narrative review on endovascular treatment of BTAI highlighting indications, techniques, results, and challenges. Multiple imaging modalities can be used including computed tomography angiography, transesophageal echocardiography, magnetic resonance imaging, and intravascular ultrasound. Whilst conservative pharmacological management can be a safe option in low-grade BTAI, thoracic endovascular aortic repair has become the gold-standard strategy in most cases, replacing open surgical repair. Nevertheless, it is important to account for patient demographics particularly age, severity of injury, choice of endograft including its type and size, and endovascular technique including landing zone and left subclavian artery revascularization. Overall, TEVAR in BTAI has been shown to be an efficacious strategy with favorable early outcomes. In contrast, less is known on the long-term clinical outcomes of TEVAR in BTAI. Hence, despite the optimal early technical and clinical success rates, concerns remain about the need for long-term surveillance. The exact timing of follow-up and the integration of different modalities that can also investigate potential downstream cardiovascular effects remain hot topics for future research. Finally, industry should focus on developing more compliant endografts to improve the stiffness mismatch between the endograft and the aorta to optimize results.

Long-term Outcomes of Endovascular Repair for Blunt Thoracic Aortic Injury: A 10 Year Multi-center Experience.

This study aimed to assess the long-term outcomes in patients treated by thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI). From January 2010 to December 2019, this retrospective observational study was conducted at 3 centers, involving 62 consecutive BTAI patients who underwent TEVAR. Computed tomography angiography scans were planned to be conducted at 6 months post-procedure, and annually thereafter. Technical success was achieved in all 62 procedures (100%), which included cases of dissection (n=35, 56.45%), pseudoaneurysm (n=20, 32.26%), and rupture (n=7, 11.29%). Mean injury severity score was 31.66±8.30. A total of 21 supra-arch branches were revascularized by chimney technique, with 12 cases involving the left subclavian artery (LSA) and 9 cases involving the left common carotid artery. In addition, 11 LSAs were covered during the procedure. The in-hospital mortality rate was 1.61% (n=1). The mean follow-up time was 86.82±30.58 months. The all-cause follow-up mortality rate was 3.28% (n=2). Stenosis or occlusion of 3 supra-arch branches (4.92%) was identified at follow-up, with 2 cases (3.28%) requiring re-intervention. No spinal cord ischemia, endoleak, or migration was observed. Despite only including patients with long-term follow-up, this study confirms the long-term safety and effectiveness of TEVAR for BTAI. For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. This study confirms the long-term safety and effectiveness of endovascular treatment for blunt thoracic aortic injury (BTAI). For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. Through a remarkably extended follow-up period (86.82±30.58 months) conducted at multiple centers in China, this study confirms the long-term safety and effectiveness of endovascular treatment for BTAI.

Endovascular Repair Blunt Thoracic Aortic Injury in Adolescent: A Case Series.

Blunt traumatic aortic injury (BTAI) is a rare occurrence in adolescents, yet it is associated with a high mortality rate necessitating immediate treatment. Although endovascular repair has become the preferred treatment for such injuries in adults, its effectiveness in adolescents remains uncertain. Blunt traumatic aortic injury typically presents with concomitant injuries to other organs and carries a high perioperative mortality rate with operative repair (OR). In this report, we describe the treatment of 3 clinical cases of BTAI in adolescents using thoracic endovascular aortic repair (TEVAR). These cases contribute pertinent evidence supporting the efficacy of intravascular repair for BTAI. Operative repair (OR) remains the gold standard for treating BTAI in adolescents. Nevertheless, TEVAR therapy presents a viable alternative for patients with multiple injuries in whom anticoagulation is contraindicated. Further long-term observation is necessary to assess the lasting effects of TEVAR therapy. This study has provided insights into endovascular repair for adolescent BTAT, offering clinicians significant reference material for choosing treatment strategies for adolescent BTAT. The study aims to demonstrate the safety and effectiveness of endovascular repair treatments in a series of clinical cases involving adolescent BTAI.