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Review of short-term outcomes for TEVAR after blunt traumatic aortic injury

B lunt thoracic aortic trauma (BTAT) is a life-threatening event, which is most commonly associated with deceleration injuries. Although the incidence of BTAT is low, it is considered the second most common trauma-related death, with the majority of injured patients dying at the scene of the accident. For thosewho survive and make it to the hospital, the estimated rate of mortality is 32%, with one third dying before operative intervention. In an autopsy study, BTAToccurred in one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. In addition, risk for multiple injuries including solid organ injury is not uncommon with BTAT; therefore, this clinical scenario can be of significant challenge for vascular specialists. One study has shown both hemodynamic instability and open surgical repair to be independent risk factors for higher hospital mortality after BTAT. The prognosis of BTAT is dismal not only because of aortic injury but also because of multiple associated solid organ injuries from the blunt trauma itself, which can be significant and distractive in the meantime. In the past, the gold standard therapy for patients with BTAT was open thoracic aortic repair with either primary anastomosis or an interposition graft. However, with the evolution in minimally invasive techniques for treating aortic aneurysms at different levels, indications have also extended to include traumatic aortic conditions, such as disruptions secondary to BTAT. The dismal outcome from open surgery is related not only to the impact of trauma but also to the stress of the surgical intervention itself, including thoracotomy, aortic clamping, one lung ventilation in most cases, concern of full heparinization in patients with other multiple trauma, and so on. Currently, thoracic endovascular aortic repair (TEVAR) has replaced open surgery as the initial and highly recommended therapy in a select group of patients. This relatively new therapy for patients with BTAT is still in its developing phase, and there is still no consensus knowledge regarding outcomes, especially in the younger patients. This review was designed to examine perioperative, short-term, and long-term outcomes of patients who underwent TEVAR for BTAT. Although open thoracic repair for degenerative thoracic aortic disease can be performed by experienced surgeons in select tertiary centers for a select group of patients with an acceptable relatively low (e15%) operative mortality rate, the operative mortality rate can be up to 50% in patients requiring emergency treatment for thoracic aortic trauma. The etiology is not entirely related to the aortic injury because these patients usually present with multiorgan trauma.6 There is no question that open thoracic aortic repair is still considered a valid option for patients with BTAT; however, after advances in stent-graft repair of abdominal and thoracic aneurysm disease, practitioners have expanded the indication to traumatic aortic injuries. In addition, retrospective experiences have shown successful use of TEVAR in emergency situations. Therefore, the paradigm of treating patients with BTAT is currently in favor of TEVAR if possible. This reviewwill summarize the most updated outcomes from current literature.