Elsevier

Annals of Vascular Surgery

Volume 52, October 2018, Pages 72-78
Annals of Vascular Surgery

Clinical Research
National Trends of Thoracic Endovascular Aortic Repair Versus Open Repair in Blunt Thoracic Aortic Injury

https://doi.org/10.1016/j.avsg.2018.03.045Get rights and content

Background

Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Considering the advent of multiple thoracic endovascular aortic repair (TEVAR) devices over the past decade, improved outcomes of TEVAR supported in the literature, rapid diagnosis, and improved preoperative planning of BTAI using computed tomography imaging, we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. In addition, we hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair.

Methods

This was a retrospective analysis of the National Trauma Data Bank from 2007 to 2015. The primary end points of interest included the incidence of TEVAR and open repair, as well as mortality in BTAI patients undergoing intervention. Covariates were included in a multivariable analysis to determine risk for mortality in BTAI patients undergoing open repair versus TEVAR.

Results

We identified 3,628 BTAI patients undergoing intervention. Of these, 3,226 underwent TEVAR (87.9%), and 445 (12.1%) underwent open repair. Compared with open repair, TEVAR had a shorter mean length of stay (LOS) (19.8 vs. 21.3 days, P < 0.05) and lower rates of acute kidney injury (AKI) (5.6% vs. 9.0%, P < 0.05) and mortality (8.8% vs. 12.8%, P < 0.05). Open repair had greater risk for mortality than TEVAR (odds ratio = 1.63, confidence intervals = 1.19–2.23, P < 0.05).

Conclusions

The rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, whereas TEVAR increased from 12.1 to 25.7% during the same time period. We confirmed previous findings that endovascular repair is associated with decreased mortality, LOS, and major complications, including AKI. Future investigations should focus on identifying the ideal patient candidate for TEVAR and elucidate precise indications for TEVAR in BTAI.

Introduction

Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions, with a high prehospital mortality rate ranging between 25% and 85% based on autopsy results.1, 2, 3 The United States Food and Drug Administration (FDA) approved the first thoracic endovascular aortic repair (TEVAR) device in 2005, and since that time, 2 more devices have received FDA approval.4, 5 With the evolution of endovascular management of BTAI, there has been a transition from open repair to TEVAR. A large multicenter trial from the Western Trauma Association (WTA), including 8 verified trauma centers, found the mortality rate of TEVAR to be 5.7% compared with 10.7% in open repair (P = 0.54), with a lower rate of postoperative complications in the TEVAR group (5.7% vs. 22.7%, P < 0.05). Between 2000 and 2005, the rate of TEVAR in patients with BTAI undergoing repair was 13%, whereas the rate of open repair was 87%.1

Several BTAI classification or grading systems are available. The most widely accepted grading scale was proposed by the Society for Vascular Surgery.6 The American Association for the Surgery of Trauma classifies all thoracic aortic injuries, regardless of severity, as a grade 4 vascular injury.7 However, a frequent criticism of the various grading schemes is that none guides therapy. Recently, Heneghan et al.8 have proposed a simplified management guideline: minimal aortic injury can be successfully managed nonoperatively, moderate aortic injury can be managed with semi-elective TEVAR while severe aortic injury requires emergent TEVAR. Considering the advent of multiple FDA-approved TEVAR devices over the past decade, improved outcomes of TEVAR supported in the literature,9 rapid diagnosis, and improved preoperative planning of BTAI using computed tomography imaging,10, 11 we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. We additionally hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair.

Section snippets

Methods

The National Trauma Data Bank (NTDB) is a multicenter registry of trauma centers in North America, with new trauma activations added each year.12 We queried the NTDB from January 2007 through December 2015 to collect patients aged ≥18 years that presented with BTAI using the International Classification of Diseases (ICD version 9) diagnosis code 901.0 (injury of thoracic aortic) and with a concomitant blunt mechanism event code. The primary end points of interest included the incidence of TEVAR

Patient Demographics of BTAI and Primary Outcomes

Of the 5,494,609 patients, 14,422 were found to have a BTAI (0.3%). The mortality rate of BTAI patients in the emergency department was 19.8%. Of the patients who survived out of the emergency department, 3,628 underwent repair (25.4%). Of these, 3,226 underwent TEVAR (87.9%), and 445 (12.1%) underwent open repair. The rate of any repair for all BTAI increased steadily throughout the study period beginning with 19.1% in 2007 and increasing to 24.8% in 2015 (P < 0.05) (Table I). The rate of open

Discussion

Our study, analyzing 9 years of NTDB data, investigates the trends in repair in patients with BTAI. Over the study period, the rate of intervention has increased to almost 25% in 2015. The proportion of patients undergoing TEVAR has increased considerably, whereas those undergoing open repair has decreased. In confirmation of previous reports, we found that endovascular repair is associated with decreased mortality, LOS, and major complications, including AKI.

TEVAR has been established as a

Conclusion

The present report represents the largest contemporary national database study examining BTAI outcomes in the modern endovascular era. The rate of intervention in patients with BTAI has increased to almost 25% in 2015. However, the rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, whereas TEVAR increased from 12.1% to 25.7% during the same time period. We confirmed previous findings that endovascular repair is associated with decreased mortality, LOS, and major complications,

References (32)

  • F.H. Jonker et al.

    Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms

    J Vasc Surg

    (2011)
  • M.H. Murad et al.

    Comparative effectiveness of the treatments for thoracic aortic transaction

    J Vasc Surg

    (2011)
  • L.J. Leurs et al.

    Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries

    J Vasc Surg

    (2004)
  • S.S. Parmer et al.

    Endoleaks after endovascular repair of thoracic aortic aneurysms

    J Vasc Surg

    (2006)
  • A. Khoynezhad et al.

    One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial)

    J Thorac Cardiovasc Surg

    (2015)
  • T.C. Fabian et al.

    Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma

    J Trauma Acute Care Surg

    (1997)
  • Cited by (37)

    • Intraoperative TEE during TEVAR following blunt thoracic trauma: A case review

      2023, Annals of Vascular Surgery - Brief Reports and Innovations
    View all citing articles on Scopus

    Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    View full text