Abstract
Purpose
To evaluate the relationship between the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) and prognosis.
Methods
This 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.
Results
In 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).
Conclusion
In 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.
Keywords: Blunt aortic injury, Thoracic endovascular aortic repair, Timing of treatment
1. Introduction
Blunt thoracic aortic injury (BTAI) has attracted increasing attention due to its extremely high mortality rate, with statistics showing that around 80% of individuals with this injury do not survive the journey to the hospital. The primary cause of BTAI is traffic accidents, with sudden deceleration and external crush injuries following closely behind. Azizzadeh et al.1 classified BTAI into 4 categories in 2009 according to the seriousness of aortic damage and advised surgical intervention for grades II−IV damage. Recently, due to advancements in endovascular devices, thoracic endovascular aortic repair (TEVAR) has been preferred for BTAI over traditional open surgery, with multiple studies validating the safety of this approach.2,3 However, there is still no high-quality evidence to support the timing of TEVAR in patients with BTAI. The recommendations from the Society for Vascular Surgery (SVS) advocated immediate TEVAR of BTAI to lower the risk of death.4 The guidelines from the Eastern Association for the Surgery of Trauma (EAST) in 2015 recommended elective TEVAR for stable patients,5 and recent studies have indicated that elective TEVAR can lower mortality rates and decrease long-term complications.6,7 Although the body of research on endovascular treatment of BTAI has increased in recent years, there are still relatively few studies comparing immediate and elective TEVAR. The purpose of this research was to assess the meaning of the timing of TEVAR for BTAI. This single-center retrospective study was performed to evaluate the safety, postoperative complications, and survival outcomes of immediate vs. elective TEVAR for BTAI.
2. Methods
2.1. Patients
A retrospective analysis was conducted on the information of patients diagnosed with BTAI and hospitalized at the First Affiliated Hospital of Zhengzhou University between October 2016 and September 2023. The Institutional Review Board approved this study. The analysis included all patients who received TEVAR treatment after being diagnosed with BTAI through whole-body CT angiography (CTA). After identifying 145 patients with BTAI who were admitted to our center, those treated with open repair (n = 7 (4.8%)) and non-operative management (n = 28 (19.3%)) were excluded. The patient screening flowchart is shown in Fig. 1. The clinical data of the patients, including demographics, comorbidities, operative details, and post-procedural outcomes, were analyzed. Immediate TEVAR was characterized as TEVAR conducted within 24 h of arrival at the emergency medical center (Fig. 2), while elective TEVAR was characterized as TEVAR conducted 24 h post arrival at the emergency medical center (Fig. 3). Perioperative bleeding was defined as perioperative anticoagulant treatment-related complicated bleeding.
Fig. 1.
BTAI patients screening flowchart.
BTAI: blunt thoracic aortic injury; CTA: CT angiography; TEVAR: thoracic endovascular aortic repair.
Fig. 2.
Images from a patient with blunt thoracic aortic injury who underwent immediate thoracic endovascular aortic repair. (A) CT angiography (CTA) volume reconstruction and (B) CTA multiplanar reconstruction showing pseudoaneurysm formation in the aortic isthmus. (C) Preoperative angiography. (D) Postoperative angiography showing that the pseudoaneurysm was completely covered and the left subclavian artery was partially occluded. (E) CTA volume reconstruction at the 1-year follow-up and (F) CTA multiplanar reconstruction showing that the stent was patent with no endoleak. The left subclavian artery was occluded, but the patient was asymptomatic and therefore untreated.
Fig. 3.
Images from a patient with blunt thoracic aortic injury who underwent elective thoracic endovascular aortic repair. (A) CT angiography (CTA) volume reconstruction and (B) CTA multiplanar reconstruction showing long-segment pseudoaneurysm formation in the descending aorta. (C) Preoperative angiography. (D) Postoperative angiography showing that the proximal tear of the aortic dissection was covered. (E) CTA volume reconstruction at the 1-year follow-up and (F) CTA multiplanar reconstruction showing that the stent was patent with no endoleak, and aortic remodeling was satisfying.
2.2. Treatment
Patients were closely monitored to maintain hemodynamic stability and received symptomatic treatment before TEVAR. CTA was performed weekly to closely monitor thoracic aortic injury progression. TEVAR was considered for grades Ⅲ − IV BTAI patients and grade Ⅱ BTAI patients with high-risk imaging factors or associated poor perfusion.8 For patients in stable condition, elective TEVAR for the treatment of BTAI was considered a priority, with weekly CTA to monitor the injury and manage any associated trauma. Immediate TEVAR was indicated for patients in whom CTA showed contrast extravasation or interruption of the aortic contour, clinical signs of hemodynamic instability or suspicion of severe intrathoracic hemorrhage, or a high probability of aortic rupture during the management of life-threatening concomitant injuries.
2.3. TEVAR
After the administration of anesthesia, the Seldinger technique was utilized to percutaneously puncture the femoral artery. For diagnostic digital subtraction angiography of the entire aorta, including the thoracic, abdominal, and ascending aorta, a pigtail catheter was inserted. Maximal tangential angiography was performed to identify aortic arch injury and the distance of the injury from the branch arteries. Thoracic stent grafts were delivered to the aortic arch with the assistance of fluoroscopy. The aortic stent grafts were introduced and deployed cautiously in the exact location as planned preoperatively. Digital subtraction angiography was conducted once more to verify the optimal positioning of the stent grafts and to detect any immediate leaks.
2.4. Follow-up
Patients were monitored through outpatient or inpatient medical record reviews and CTA imaging at intervals of 3-, 6-month, and 1-year post-intervention, followed by annual assessments to determine survival rates, symptoms, and complications related to TEVAR such as stent-graft placement and endoleaks.
2.5. Statistical analysis
Statistical analysis of the data was conducted using SPSS version 26.0 (SPSS Inc., Chicago, Illinois, US). Continuous variables were presented as either the mean ± standard deviation (SD) or median (Q1, Q3), and were compared using either the Student's 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. To adjust for baseline differences between patients undergoing immediate TEVAR or elective TEVAR, propensity scores were generated for each observation using log odds. A matched cohort was created using these propensity scores, which was realized using the propensity-score matching (PSM) extension program in SPSS 26.0. The baseline characteristics of the 2 groups were balanced according to 1:1 matching, and the match tolerance was set at 0.05. The selected covariates included age, sex, complications, severe comorbid injuries, cause and location of the aortic injury, prehospital time, injury severity score, Glasgow coma scale (GCS) score, SVS grading, hemoglobin concentration, creatinine concentration, shock, systolic blood pressure, and heart rate at admission.
3. Results
3.1. Patient characteristics
In total, the data of 110 patients who underwent TEVAR for BTAI were analyzed. The median age of the enrolled patients was 52 years (range: 13–76 years) and 92 (83.6%) patients were male. All the patients experienced traumatic incidents, 81 (73.6%) car crashes, 25 (22.7%) falls from heights, 2 (1.8%) crush injuries, and 2 (1.8%) bruises. Overall, 92 (83.6%) patients had aortic isthmus injuries and 18 (16.4%) had descending aorta injuries. Among the patients, 32 (29.1%) received immediate TEVAR, and 65 had ISS scores > 25. Baseline clinical characteristics and postoperative in-hospital outcomes of all included patients with ISS ≤ 25 vs. ISS > 25 are shown in Table 1. 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). The GCS score (median (Q1, Q3)) at admission was significantly higher in the elective group than in the immediate group (15 (12, 15) vs. 13.5 (9, 15), p = 0.039). Compared with the elective group, 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). After PSM, 32 patients who received immediate TEVAR matched with 30 patients who received elective TEVAR. The baseline clinical characteristics before and after PSM in the immediate and elective TEVAR groups are shown in Table 2.
Table 1.
Baseline clinical characteristics and postoperative in-hospital outcomes of all included patients with ISS ≤ 25 vs. ISS > 25.
| Characteristics | ISS ≤ 25 (n = 45) | ISS > 25 (n = 65) | p value |
|---|---|---|---|
| Age (year), median (Q1, Q3) | 53 (35, 63) | 52 (40, 61) | 0.956 |
| Male, n (%) | 40 (88.9) | 52 (80.0) | 0.215 |
| Comorbidities, n (%) | |||
| Hypertension | 23 (51.1) | 17 (26.2) | 0.007 |
| CHD | 1 (2.2) | 3 (4.6) | 0.888 |
| Diabetes mellitus | 3 (6.7) | 6 (9.2) | 0.898 |
| Smoking | 27 (60.0) | 29 (44.6) | 0.113 |
| GCS, median (Q1, Q3) | 15 (15, 15) | 13 (9, 15) | < 0.001 |
| Prehospital time (h), median (Q1, Q3) | 5 (4, 6) | 4 (3, 5) | 0.030 |
| Shock, n (%) | 7 (15.6) | 4 (6.2) | 0.196 |
| SBP, mean ± SD | 135.3 ± 29.0 | 130.9 ± 25.8 | 0.400 |
| Heart rate, median (Q1, Q3) | 85 (75, 95) | 91 (80, 105) | 0.139 |
| Creatinine, median (Q1, Q3) | 71 (61, 89) | 73 (64, 105) | 0.539 |
| Hemoglobin (g/L), mean ± SD | 113.6 ± 21.8 | 105.5 ± 27.7 | 0.103 |
| Location of aortic injury, n (%) | 0.022 | ||
| Aortic isthmus | 42 (93.3) | 50 (76.9) | |
| Descending aorta | 3 (6.7) | 15 (23.1) | |
| SVS grading, n (%) | 0.613 | ||
| Grade II | 24 (53.3) | 38 (58.5) | |
| Grade III | 19 (42.2) | 26 (40.0) | |
| Grade IV | 2 (4.4) | 1 (1.5) | |
| Immediate TEVAR, n (%) | 13 (28.9) | 19 (29.2) | 0.969 |
| Complication in hospital | 6 (13.3) | 16 (24.6) | 0.146 |
| Stroke after TEVAR | 0 (0) | 4 (6.2) | 0.239 |
| Paraplegia after TEVAR | 0 (0) | 1 (1.5) | 1.000 |
| Acute renal injury | 1 (2.2) | 6 (9.2) | 0.279 |
| Pneumonia | 3 (6.7) | 4 (6.2) | 1.000 |
| Perioperative bleeding | 2 (4.4) | 1 (1.5) | 0.745 |
| ICU, median (Q1, Q3) | 4 (0, 10) | 9 (3, 19) | 0.003 |
| Length of hospital stay (days), median (Q1, Q3) | 16 (11, 25) | 21 (13, 31) | 0.119 |
| In-hospital aorta-related mortality, n (%) | 2 (4.4) | 3 (4.6) | 1.000 |
| In-hospital mortality, n (%) | 2 (4.4) | 11 (16.9) | 0.046 |
ISS: injury severity score; GCS: Glasgow coma scale; SBP: systolic blood pressure; SD: standard deviation; SVS: society for vascular surgery; TEVAR: thoracic endovascular aortic repair; ICU: intensive care unit.
Table 2.
Clinical baseline characteristics of the patients before and after.
| Characteristics | Before matching |
After matching |
||||
|---|---|---|---|---|---|---|
| Immediate TEVAR (n = 32) | Elective TEVAR (n = 78) | p value | Immediate TEVAR (n = 32) | Elective TEVAR (n = 30) | p value | |
| Age (year), median (Q1, Q3) | 51 (44.0, 62.3) | 53 (35.3, 61.8) | 0.880 | 51 (44.0, 62.3) | 57 (36.0, 63.8) | 0.672 |
| Male, n (%) | 24 (75.0) | 68 (87.2) | 0.117 | 24 (75.0) | 25 (83.3) | 0.421 |
| Comorbidities, n (%) | ||||||
| Hypertension | 11 (34.4) | 29 (37.2) | 0.781 | 11 (34.4) | 10 (33.3) | 0.931 |
| CHD | 1 (3.0) | 3 (3.8) | 0.631 | 1 (3.1) | 3 (10.0) | 0.559 |
| Diabetes mellitus | 4 (12.5) | 5 (6.4) | 0.499 | 4 (12.5) | 3 (10.0) | 1.000 |
| Smoking | 14 (43.8) | 42 (53.8) | 0.336 | 14 (43.8) | 12 (40.0) | 0.765 |
| Cause of injury, n (%) | 0.511 | 0.508 | ||||
| Vehicle collision | 26 (81.3) | 55 (70.5) | 26 (81.3) | 25 (83.3) | ||
| Fall from heights | 6 (12.8) | 19 (24.4) | 6 (12.8) | 4 (13.3) | ||
| Crush injury | 0 (0) | 2 (2.6) | 0 (0) | 1 (3.3) | ||
| Injury caused by heavy objects | 0 (0) | 2 (2.6) | 0 (0) | 0 (0) | ||
| Severe concomitant Injuries, n (%) | ||||||
| Head injury | 12 (37.5) | 25 (32.1) | 0.583 | 12 (37.5) | 13 (43.3) | 0.640 |
| Chest injury | 23 (71.9) | 52 (66.7) | 0.594 | 23 (71.9) | 22 (73.3) | 0.898 |
| Abdominal injury | 10 (31.3) | 27 (34.6) | 1.000 | 10 (31.3) | 9 (30.0) | 0.915 |
| Pelvic injury | 8 (25.0) | 20 (25.6) | 0.677 | 8 (25.0) | 8 (26.7) | 0.881 |
| ISS, median (Q1, Q3) | 26 (23.3, 33.0) | 26 (21.0, 33.8) | 0.870 | 26 (23.3, 33.0) | 26 (21.0, 33.0) | 0.659 |
| GCS, median (Q1, Q3) | 13.5 (9.0, 15.0) | 15 (12.0, 15.0) | 0.039 | 13.5 (9.0, 15.0) | 15 (12.0, 15.0) | 0.346 |
| Shock, n (%) | 3 (9.4) | 8 (10.3) | 1.000 | 3 (9.4) | 4 (13.3) | 0.928 |
| SBP, mean ± SD | 130.2 ± 24.0 | 133.7 ± 28.4 | 0.534 | 130.2 ± 23.0 | 132.3 ± 31.3 | 0.759 |
| Heart rate, median (Q1, Q3)/mean ± SD | 91 (80.0, 100.5) | 86.5 (78.0, 100.8) | 0.437 | 92.7 ± 18.2 | 92.9 ± 21.1 | 0.966 |
| Creatinine, median (Q1, Q3) | 90.5 (63.8, 144.0) | 71.5 (58.3, 80.8) | 0.012 | 83.5 (61.0, 121.0) | 72.5 (62.8, 102.8) | 0.683 |
| Hemoglobin (g/L), mean ± SD/median (Q1, Q3) | 109.6 ± 27.1 | 108.5 ± 25.2 | 0.840 | 112 (95.8, 125.5) | 110 (94.3, 122.5) | 0.683 |
| Prehospital time (h), median (Q1, Q3) | 5 (3.0, 5.0) | 5 (3.3, 6.8) | 0.370 | 5 (4.0, 5.0) | 5 (4.0, 6.3) | 0.970 |
| Location of aortic injury, n (%) | 0.949 | 0.979 | ||||
| Aortic isthmus | 27 (84.4) | 65 (83.3) | 27 (84.4) | 25 (83.3) | ||
| Descending aorta | 5 (3.1) | 13 (16.7) | 5 (3.1) | 5 (16.7) | ||
| SVS grading, n (%) | 0.436 | 1.000 | ||||
| Grade II | 15 (46.9) | 47 (60.3) | 14 (43.8) | 14 (46.6) | ||
| Grade III | 16 (50.0) | 29 (37.2) | 17 (48.6) | 16 (53.3) | ||
| Grade IV | 1 (3.1) | 2 (2.6) | 1 (3.1) | 0 (0) | ||
TEVAR: thoracic endovascular aortic repair; CHD: coronary heart disease; ISS: injury severity score; GCS: Glasgow coma scale; SD: standard deviation SBP: systolic blood pressure; SVS: Society for Vascular Surgery.
3.2. Perioperative results
The total rate of aortic injury-related mortality in the perioperative period was 4.5% (5/110). The perioperative results (within 3 postoperative days) after PSM of the immediate and elective groups are shown in Table 3. In the immediate group, a total of 16 perioperative complications occurred, including 2 cases of ischemic stroke, 1 of cerebral hemorrhage, 1 of paraplegia, 4 of acute renal injury, 5 of pneumonia, and 3 of perioperative bleeding. In the elective group, there was 1 case of ischemic stroke, 2 of pneumonia, and 3 of acute renal injury. The overall incidence of complications in the elective group was significantly lower than in the immediate group (16 (50.0%) vs. 3 (10.0%), p < 0.001). Regarding aortic injury-related mortality during hospitalization, the elective group had a lower mortality rate compared to the immediate group, although the difference was not deemed statistically significant (3 (9.4%) vs. 0 (0), p = 0.260). Univariate analysis of variance revealed that immediate TEVAR was the unique significant risk factor for complications in hospitalized patients (odds ratio (OR): 9.000, 95% confidence interval (CI): 2.266–35.752, p = 0.002).
Table 3.
Postoperative in-hospital outcomes of all included patients who underwent immediate vs. elective TEVAR in the propensity-score-matched cohort.
| Variables | Early TEVAR (n = 32) | Delayed TEVAR (n = 30) | p value |
|---|---|---|---|
| Complication in hospital, n (%) | 16 (50.0) | 3 (10.0) | < 0.001 |
| Stroke after TEVAR | 3 (9.4) | 0 (0) | 1.000 |
| Paraplegia after TEVAR | 1 (3.1) | 0 (0) | 1.000 |
| Acute renal injury | 4 (12.5) | 2 (6.7) | 0.954 |
| Pneumonia | 5 (15.6) | 1 (3.3) | 0.228 |
| Perioperative bleeding | 3 (9.4) | 0 (0) | 0.260 |
| ICU, median (Q1, Q3) | 9 (1.5, 16.5) | 4 (0, 17.8) | 0.738 |
| Length of hospital stay (days), median (Q1, Q3) | 19 (10.0, 26.8) | 20 (14.0, 30.0) | 0.195 |
| In-hospital aorta-related mortality, n (%) | 3 (9.4) | 0 (0) | 0.260 |
| In-hospital mortality, n (%) | 6 (18.8) | 3 (10.0) | 0.537 |
TEVAR: thoracic endovascular aortic repair; ICU: intensive care unit.
3.3. Follow-up
Out of the 110 patients with BTAI, 97 were followed up over 47 months on average (range: 3–83 months). During the follow-up period, 5 patients died, including 2 from pulmonary infection, 1 from sudden cardiac arrest, 1 from renal failure, and 1 from lung cancer. None of the patients who underwent follow-up experienced paraplegia or chest pain symptoms. Among the 97 patients, there were 2 cases of stroke, 1 of subclavian steal syndrome, 2 of left upper limb weakness, and 2 of renal failure. At radiological follow-up, there were 2 cases of stent thrombosis, 1 of endoleak, and 3 of secondary intervention (2 cases of laser fenestration and 1 of embolization of the left subclavian artery). The follow-up results after PSM are shown in Table 4. No significant difference was observed between the 2 groups in terms of neurological complications, stent thrombosis or endoleak, incidence of renal failure, and mortality (p = 0.947, p = 1.000, p = 0.481, and p = 0.947, respectively).
Table 4.
Follow-up outcomes of patients who underwent immediate vs. elective TEVAR in the propensity-score-matched cohort, n (%).
| Outcomes | Immediate TEVAR (n = 26) | Elective TEVAR (n = 27) | p value |
|---|---|---|---|
| Neurological complications | 2 (3.8) | 1 (3.7) | 0.947 |
| Stent thrombosis or endoleak | 1 (3.8) | 2 (7.4) | 1.000 |
| Renal failure | 1 (3.8) | 0 (0) | 0.481 |
| Death | 2 (7.7) | 1 (3.7) | 0.947 |
TEVAR: thoracic endovascular aortic repair.
4. Discussion
BTAI is a clinically rare critical condition that ranks as the second leading cause of death from blunt trauma, surpassed only by intracranial hemorrhage.9 BTAI incidents are primarily caused by automobile crashes. Other causes include motorcycle accidents, falls from height, injuries from chest compression, and other forms of crush injury.10 The precise pathogenic mechanisms of BTAI remain unclear. Aortic injury to the aorta may result from the simultaneous sudden application of multiple forces acting on the aorta. Currently, the proposed pathogenesis mechanisms include torsional shear forces, sudden deceleration injury, and the formation of a “bone clamp” effect between the vertebrae and the sternum.11 The majority of injuries occur at the aortic isthmus. In the present research, 92 (83.6%) of the aortic injuries involved the aortic isthmus, while 18 (16.4%) cases involved the descending aorta. Patients with BTAI often present with concomitant injuries to other systems, commonly including cranial trauma and fractures. Some severe associated injuries may involve intracranial hemorrhage, severe pulmonary and bronchial injuries, and intra-abdominal solid organ rupture with active hemorrhage, amongst others. In clinical practice, these additional injuries can mask the signs of BTAI and hinder the definite diagnosis and timely treatment of it. In this study, there were 37 concomitant cranial injuries, 75 thoracic injuries, 37 intra-abdominal organ injuries, and 37 pelvic injuries. During hospitalization, 13 deaths occurred, resulting in an overall mortality rate of 11.8%.
Rapid progress in imaging techniques has laid a strong groundwork for the diagnosis of BTAI, particularly the widespread adoption of CTA technology. This allows for a timely and clear determination of the existence or nonexistence of BTAI among individuals who have experienced trauma while allowing for the observation of other concurrent injuries. The use of CTA avoids the damage caused by vascular angiography. Moreover, CTA provides important clinical data such as the location, extent, and severity of BTAI. CTA is effective for observing minor internal and external injuries to the aorta and it has become the primary diagnostic choice for BTAI. Based on the radiologic features of BTAI on CTA, Azizzadeh et al.1 proposed classifications for BTAI, with Azizzadeh's classification being adopted by the SVS, named the SVS grading system. Although new grading systems continue to emerge, the SVS grading system holds the highest level of utilization in grading BTAI.12, 13 It categorizes aortic injuries into 4 levels: grade I (intimal tear), grade II (intramural hematoma), grade III (pseudoaneurysm), and grade IV (complete rupture). In this study, all patients underwent CTA to confirm the diagnosis of BTAI. Based on the analysis of the results obtained by CTA, BTAI was found in the ascending aorta in 8 cases, the aortic isthmus in 72, and the descending aorta in 18. According to the 2011 guidelines promulgated by SVS,4 injuries designated as grade I may be managed nonoperatively, whereas those classified as grade II, III, and IV mandate reparative interventions. Despite these recommendations, a persistent discourse persists regarding the most effective strategy for treating intramural hematoma, particularly in the context of grade II injuries. In trauma patients diagnosed with BTAI, strict blood pressure control should be implemented promptly to mitigate further expansion of the dissection, thereby preventing rupture or damage to vital organs. Lately, several retrospective studies have indicated that medication therapy could be considered a safe option for specific instances of grade II injuries.14,15 Osgood et al.16 reported on 49 cases of grade I and II patients, indicating that under medical management, complete resolution or no change in aortic injury was reported in 95% of cases, with only 5% showing injury progression. Sandhu et al.17 analyzed 338 patients classified as SVS grade I and II BTAI, evaluating both operative and nonoperative management outcomes. The results indicated that, in patients classified as grade I and II BTAI, age > 35 years and a high ISS score were associated with a poorer prognosis in patients. In this study, 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). However, there was no significant difference in aortic-related mortality between the 2 groups. Additionally, among grade II patients, those undergoing medical management did not exhibit a higher mortality rate in contrast to patients receiving TEVAR. Therefore, strict medical management and intensive monitoring in SVS grade I and II BTAI patients also contribute to the clinical outcomes. Early prioritized intervention for other severe concomitant injuries in grade I and II patients with high ISS may potentially enhance overall survival rates.
One of the primary treatment options for patients with early BTAI is open-chest artificial vessel replacement surgery under extracorporeal circulation. However, the open surgery of BTAI usually requires thoracotomy and complex cardiopulmonary bypass, resulting in greater trauma, long operation time, and high incidence of complications. The substantial intraoperative bleeding increases the incidence of neurological complications. Additionally, thoracotomy can exacerbate respiratory issues caused by chest and lung injuries. Since the initial successful application of TEVAR by Semba et al.,18 for the treatment of BTAI, it has progressively emerged as the preferred choice for managing BTAI.19, 20, 21 TEVAR offers the following advantages: avoidance of complications associated with extracorporeal circulation, less surgical trauma, a higher success rate, reduced anesthesia risks, and faster postoperative recovery with a shorter hospital stay. Additionally, the rate of perioperative mortality and the incidence of complications are significantly lower in TEVAR compared to open surgery.22,23
Timing considerations for TEVAR implementation in BTAI patients are not unified. Many researches indicated that the risk of aortic rupture in patients was highest within the first 24 h after BTAI. According to reports, 57% of deaths occurred due to BTAI either at the site of the incident or before arrival to the hospital, and 37% of patients die within 4 h of hospital admission.24 The SVS guidelines recommend urgent repair (within 24 h) in patients with BTAI for grade II−IV injury, who do not have severe associated injuries, or urgent repair after treatment of severe associated injuries.4 However, elective repair has garnered substantial attention in recent years. Recent studies have suggested elective TEVAR for hemodynamically stable patients with BTAI. Research conducted by Demetriades et al.25,26 found that the mortality rate of BTAI patients decreased by 9% during the period from 1997 to 2008. Moreover, a meta-analysis of 7 researches conducted by the EAST showed that overall mortality (9% vs. 21%) and the rate of paraplegia (0.6% vs. 5.5%) were lower with elective TEVAR than with immediate TEVAR. The EAST guidelines recommend elective TEVAR for BTAI in hemodynamically stable patients until other critical and potentially fatal injuries are effectively managed and after sufficient fluid resuscitation.5
In this study, to eliminate selection bias introduced by clinicians, PSM was used to match patients with similar clinical data. According to the principles of PSM, among the matched patients (30 patients with elective TEVAR and 32 patients with immediate TEVAR), the overall complication rate in the elective group was significantly lower than that in the immediate group (OR: 12.000, 95% CI: 3.819–35.140, p < 0.001). The matched patients underwent postoperative follow-up, and the 1-year follow-up results showed no significant difference between the 2 groups in systemic complications, stent-related complications, and mortality rates. However, the long-term outcomes of the aortic stents require further follow-up.
This study has some limitations that should be considered, including its single-center retrospective design, small sample size, and short follow-up period. In addition, despite our efforts to minimize the impact of confounding factors, the variability in the severity of patients’ concomitant injuries and the extent of aortic damage may have led to unavoidable selection bias.
In conclusion, TEVAR is safe and effective for BTAI repair, but the timing of TEVAR must be carefully determined. In this PSM analysis of patients who underwent TEVAR for BTAI, elective TEVAR was significantly associated with a reduced risk of complications. However, owing to the often-severe concomitant injuries of patients with BTAI, future research should focus on optimizing the timing of intervention based on the characteristics of each patient's injuries and anatomic factors.
CRediT authorship contribution statement
Zhaohui Hua: Conceptualization, Methodology, Writing - original draft, Funding acquisition. Baoning Zhou: Formal analysis, Investigation, Writing - original draft. Wenhao Xue: Formal analysis, Investigation, Writing - original draft. Zhibin Zhou: Formal analysis, Investigation. Jintao Shan: Formal analysis, Investigation. Lei Xia: Formal analysis, Investigation. Yunpeng Luo: Formal analysis, Investigation. Yiming Chai: Formal analysis, Investigation. Zhen Li: Conceptualization, Methodology, Writing - review & editing, Project administration, Funding acquisition.
Ethical statement
This study was performed by the Declaration of Helsinki and was approved by the institutional committee on research ethics.
Funding
This work was supported by the National Natural Science Foundation of China (82370503).
Declaration of competing interest
The authors have no competing interests to declare.
Footnotes
Peer review under responsibility of Chinese Medical Association.
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