Clinical ResearchNational Trends of Thoracic Endovascular Aortic Repair Versus Open Repair in Blunt Thoracic Aortic Injury
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.
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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,
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2023, Annals of Vascular SurgeryIntraoperative TEE during TEVAR following blunt thoracic trauma: A case review
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Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.