2007 Abstracts: Surgical and Endovascular Treatment Outcomes of Acute Traumatic Thoracic Aortic Injury

Background: Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented to the operating room for open surgical or endovascular repair.
Methods: Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n=48, 77%), or endovascular repair (n=14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open and endovascular groups. Differences are reported as significant if the P value was < 0.05, otherwise the P values are provided for interpretation of the results.
Results: Age, gender, presence of comorbidities, and mechanism of injury did not differ between open and endovascular groups. Additionally, RTS, ISS, and NISS scores were not significantly different. The proportion of patients with sternal fractures (14% vs. 0%), or unstable spinal fractures (36% vs. 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n=13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic stent-grafts (n=6; 43%) and abdominal aortic endograft components (n=8; 57%). Reported diameters of interposition grafts placed in open surgical patients (n=41) were >16 mm in 39 patients (95%). Renal complications (32% vs. 7%), and urinary tract infections (35% vs. 7%) approached significance between surgical and endovascular groups (P=0.082 and P=0.077 respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0% respectively (P=0.056). Significantly worse RTS, ISS, and NISS scores were associated with intraoperative death and death at 30 days in the surgical group. Endovascular repair was associated with significant reductions in operative time, estimated blood loss, and intraoperative blood transfusions. No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group.
Conclusion: Endovascular repair utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short-term for the treatment of blunt injuries of the descending thoracic aorta. Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions compared to conventional open repair. A higher ISS and NISS, as well as a lower RTS are associated with a poor outcome for patients undergoing open surgical repair. Assuming no contraindications to left subclavian artery coverage and appropriate device selection, >90% of patients with acute thoracic aortic transactions distal to the origin of the left subclavian artery may be candidates for currently available thoracic endografts or abdominal endograft components >18 mm based upon indirect measures of thoracic aortic luminal diameters.