Evolution of treatment for traumatic thoracic aortic injuries

Objective To review the evolution of traumatic thoracic aortic injury (TTAI) treatment at a single institution. Methods Retrospective analysis of all patients included in an institutional trauma registry and vascular surgery database who underwent treatment of TTAI between January 1999 and January 2011. Results Ninety-one patients (69 males) were treated for TTAI. The mean age was 38.5 years (range, 16-79 years). Forty-one patients underwent open repair (OR) and 50 thoracic endovascular repair (TEVAR), 37 with thoracic stent grafts (TSG) alone, 11 with infrarenal aortic extender cuffs (AEC), and two with a combination of TSG and AEC. OR was performed exclusively until 2004; the last one was performed in January 2007. All TTAIs have since been treated with TEVAR. The left subclavian artery (LSA) was fully covered in 10 patients (20%) and partially covered in eight patients, with revascularization in only two cases. The use of AEC and avoidance of LSA coverage increased after 2007. Baseline characteristics and injury severity scores were similar between groups. The mortality rate was higher in the OR group (19.5% vs 6.0%; P = .06), although it did not reach statistical significance. The overall incidence of morbidities was similar between the two groups (42% OR vs 50% TEVAR). Two patients developed paraplegia (4.4%) after OR compared with none after TEVAR. In the TEVAR group, a pseudoaneurysm, an iliac artery thrombosis, and a retroperitoneal hematoma developed in one patient each. Overall, eight patients (16%) developed stent graft-related complications (SRC), with two developing early (within 30 days) complications. All complications were related to poor apposition, requiring 10 reinterventions. Four patients underwent open conversions with no mortality. Nine out of 10 SRCs were associated with the use of thoracic stent graft malapposition. No patient treated with AEC had endoleaks or SRC. Conclusions TEVAR for TTAI has superior survival outcomes and has replaced OR. SRC requiring reintervention is associated with malapposition and the use of TSG. Until TTAI-specific endografts become available, use of AEC may minimize malapposition and reduce reinterventions. Routine overstenting of the LSA is not necessary and may increase SRC.