TEVAR Broadens Treatment Eligibility and Decreases Overall Mortality in Traumatic Thoracic Aortic Injury

BACKGROUND:Aortic injury is the second leading cause of death in trauma. Thoracic endovascular aortic repair (TEVAR) has recently been applied to traumatic aortic injuries as a minimally invasive alternative to open surgery, and is gaining favor as the preferred treatment option. We sought to determine the impact of TEVAR on national trends in the management of aortic trauma.
METHODS:The Nationwide Inpatient Sample (NIS) was queried from the years 2001-2007, and patients diagnosed with injury to the thoracic aorta were selected (ICD-9 code 901.0). Patients were evaluated based on open surgical repair, TEVAR, or non-operative management, before and after widespread adoption of TEVAR for aortic trauma (2001-2005 and 2006-2007). Chi-square and Student’s t-test analyses were performed to determine trends in the use of open surgery, use of TEVAR, inpatient mortality, major complications, and length of stay.
RESULTS:There was an average of 241 inpatient admissions with a diagnosis of thoracic aortic trauma per year in the NIS, corresponding to an estimated 1180 admissions per year in the United States. Comparing the two time periods (2001-2005 and 2006-2007), there was a significant increase in TEVAR (p<0.001) with a concomitant decrease in open repair (p<0.001) in 2006-2007. The overall number of interventions significantly increased (p<0.001). Overall mortality significantly decreased (24.8% vs. 18.7%, p=0.006), corresponding to a trend towards improved survival in the non-operative group (27.8% vs. 25.0%, p=0.053). There was no improvement in open repair mortality rates between the two time periods. Comparing intervention types, the TEVAR group had a significantly higher percentage of patients with intra-abdominal injuries (85% vs. 70%, p=0.002), and hemothorax (48% vs. 36%, p=0.038) than the open surgery group, however there were no differences in the number of closed head injuries or major orthopedic fractures. The open surgery group had higher rates of post-operative respiratory failure (61% vs. 50%, p=0.047), but no differences were seen in paraplegia or renal failure. Overall in-hospital mortality was 22.9%; 26.3% among the non-operative group, 12.2% with open repair, and 10.4% with TEVAR. There was no significant difference in mortality between open repair and TEVAR. Length of stay was shorter among the TEVAR group compared to open (15 vs. 22 days, p=0.001).
CONCLUSIONS:Among patients with aortic trauma, the use of TEVAR has decreased the rate of open aortic repair, and also increased the overall number of patients receiving intervention. Since the wider adoption of TEVAR in 2006, fewer patients are managed non-operatively, and overall survival has improved. There is no difference in mortality between TEVAR and open repair in our study, which may reflect more aggressive treatment in the TEVAR group of those who previously would not have been offered intervention due to injury severity. Evidence suggests that TEVAR has made a significant impact in the management of this trauma population nationally, although more studies are indicated to further clarify its role in traumatic aortic disruption.