Blunt Traumatic Aortic Injury: Revisting the Role of Medical Management in the Endovascular Era

BACKGROUND: Traumatic aortic injury (TAI) is a rare yet highly lethal injury associated with blunt force deceleration injury. The adoption of thoracic endovascular aortic repair (TEVAR) has become a safer option than traditional open repair, however the timing of such repair is still debatable. The purpose of this study is to review a rural trauma center experience with TAI, in which prolonged time to definitive care is a major factor.
METHODS: A retrospective analysis was performed, reviewing all patients who presented with TAI between 2000 and 2009. Electronic records, including clinical, demographic, operative, and anatomical variables, of all cases were systematically reviewed. Clinical endpoints included injury grade as previously described, follow-up time, mortality, and aortic-related mortality. The study population was divided into two groups; individuals that underwent open or endovascular surgical repair (SR) and those managed medically (MM).
RESULTS: Fifty-six patients presented with blunt TAI, and had complete data for analysis. Thirty-five patients (62.5%) were surgically repaired (22 open, 13 TEVAR) while 21 (37.5%) were managed medically. With the exception of CAD, the patient co-morbidity profiles were not statistically different. Mean hospital arrival time to the trauma center between the SR and MM groups was not significantly different (188.6 ± 30.3 versus 253 ± 65.3 minutes respectively). Aortic injury grade between the two groups was not significant (2.7 ± 0.1 and 2.3 ± 0.2, respectively). Injury severity score (ISS) and abdominal abbreviated injury score (AIS) were not significant between the groups. Head injury score was worse in the MM group, while chest injury score was worse in SR group (P < 0.05). There were nine (42.9%) deaths in the MM group while there were only two (5.7%) in the SR group (P < 0.001). One MM (9%) death was attributed to aortic injury while the remaining ten (91%) were due to multi-system trauma. Mean follow-up time in the SR and MM groups was 453.3 ± 109.2 and 299.9 ± 91.4 days, respectively. Long-term survival was 57% in the MM and 94% in the SR groups.
CONCLUSION: These data provide an aortic injury grade-matched group of patients to examine the acute natural history of TAI in the endovascular era. The low aortic-related mortality in the medically managed group demonstrates that it is not necessary to perform immediate operative intervention in patients sustaining TAI. Further investigation should evaluate whether patients with delayed presentation of blunt TAI should initially be considered for medical management with subsequent staged and well-planned endovascular treatment, rather than immediate surgical repair.