When and how should we manage thoracic aortic injuries in the modern era?

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was what are the optimum treatment modality and timing of intervention for blunt thoracic aortic injury (BTAI) in the modern era? Of the 697 papers found using the reported search, 14 (5 meta-analyses, 2 prospective and 7 retrospective studies) represented the best evidence to answer the clinical question. The author, journal, country, date of publication, patient group studied, study type, relevant outcomes, results and weakness of these papers are tabulated. All five meta-analyses reported a reduction in mortality with thoracic endovascular aortic repair (TEVAR) compared with open repair (OR), but only four found the same benefit on paraplegia rate. Similarly, the two prospective and four retrospective studies showed significantly lower mortality with TEVAR than with OR. Only one study (a meta-analysis) reported a significantly lower stroke rate with TEVAR than with OR, whereas the 13 others reported a similar or even higher stroke rate. Other complication rates were identical. Four studies demonstrated that non-operative management (NOM) as a treatment option for BTAI was associated with increased mortality, even if it has declined in recent years. One study emphasized that some cases with minimal aortic injuries (Grade I and II on CT scan) could benefit from NOM. Regarding the timing of repair, only three studies analysed outcomes of delayed repair and reported significantly lower mortality than for early repair. We conclude that with lower mortality and similar overall complications including paraplegia but higher stroke rate, TEVAR is the most suitable treatment for BTAI in the modern era, where expertise exists, especially for cases of multiple associated injuries and in the older age group. Delayed aortic repair can be proposed based on CT scan analysis, but emergent repair should still be advocated for imminent free aortic rupture. NOM remains a therapeutic option but only with selected patients.

Blunt thoracic aortic injury, Thoracic aorta, Endovascular procedure, Open repair

INTRODUCTION

A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION

In [patients with BTAI associated with multiple trauma], does [OR or TEVAR] achieve best [early survival with lower morbidity]?

CLINICAL SCENARIO

A 23-year old male was admitted to the Emergency Department following a high-impact road traffic collision. Whole body CT scan was performed revealing multiple injuries, including rupture of the aortic isthmus. There was no evidence of paraplegia or stroke. The patient was taken for immediate surgical repair, but we wondered whether endovascular repair would have been as effective, with reduced risk of complications, and even whether treatment could have been delayed. We resolve to check the published literature to inform our dilemma.

SEARCH STRATEGY

Medline from 1980 to August 2015 using PubMed interface (Aorta, Thoracic/injuries[MeSH Terms]) AND (Aorta, Thoracic/surgery [MeSH Terms]) was used.

SEARCH OUTCOME

Six hundred and ninety-seven papers were found using the reported search. Only studies comparing TEVAR and OR were selected. From this research, five meta-analyses and nine retrospective or prospective studies were identified.

These 14 studies provided the best evidence to answer the question and are presented in Table 1.

Table 1:

Best evidence clinical papers

Author, date, journal and country Study type (level of evidence)	Patient group	Outcomes	Key results	Comments
Takagi et al. (2008), J Thorac Cardiovasc Surg, Japan [2] Meta-analysis	1966 to 2007 n = 565 17 studies	Mortality	Odds ratio: 0.43 (95% CI, 0.25–0.76; P < 0.01)	All retrospective non-randomized studies comparing TEVAR and OR Timing: not described
Tang et al. (2008), J Vasc Surg, USA [3] Meta-analysis	2001 to 2006 OR, n = 329 TEVAR, n = 370 33 studies	Mortality Paraplegia Stroke	OR (15%) versus TEVAR (8%) (P = 0.0076) OR (6%) versus TEVAR (0%) (P < 0.0001) OR (5%) versus TEVAR (1%) (P = 0.0028)	Fewer procedure-specific complications with TEVAR Timing: not described Weakness: Studies reported a small number of TEVAR series. Probability that only successful procedures were reported
Xenos et al. (2009), Eur J Cardiothorac Surg, USA [4] Meta-analysis	2003 to 2007 OR, n = 501 TEVAR, n = 358 23 studies	Mortality Paraplegia Stroke	Odds ratio: 0.34 (95% CI 0.18–0.66; P = 0.001) Odds ratio: 0.27 (95% CI, 0.11–0.63; P = 0.003) Odds ratio: 0.86 (95% CI, 0.26–2.8; P = 0.8)	All studies were retrospective and non-randomized Update of a first meta-analysis published in 2008 Timing: not described
Karmy-Jones et al. (2011), J Trauma, USA [5] Meta-analysis	2006 to 2010 62 studies and 6 meta-analysis	Mortality Paraplegia Stroke	OR (18%) versus TEVAR (8%) (P < 0.05) OR (4%) versus TEVAR 0.5%) (P < 0.05) OR (1%) versus TEVAR (2%) (P = NS)	TEVAR patients were significantly older than OR patients Timing: great variety in documentation concerning the timing of repair
Murad et al. (2011), J Vasc Surg, USA [6] Meta-analysis	1990 to 2009 n = 7768 139 studies	Mortality Any stroke Paraplegia Procedure failure Systemic infection Graft infection	OR (19%) and NOM (46%) versus TEVAR (9%) (P < 0.01) OR (3%) versus TEVAR (3%) (P = NS) OR (9%) versus TEVAR (3%) (P = 0.01) OR (6%) versus TEVAR (10%) (P = NS) OR (13%) versus TEVAR (5%) (P = 0.01) OR (11%) versus TEVAR (3%) (P = 0.01)	No significant difference in mortality between early and delayed repair Timing: not described
Azizzadeh et al. (2013), J Vasc Surg [7] Prospective	2002 to 2011 OR, n = 56 TEVAR, n = 50	Any complication including in-hospital mortality Mortality Cardiac Respiratory Stroke Paraplegia	Odds ratio: 0.33 (95% CI 0.11–0.97; P = 0.045) OR (9%) versus TEVAR (4%) OR (9%) versus TEVAR (6%) OR (57%) versus TEVAR (36%) OR (3.5%) versus TEVAR (2%) OR (0%) versus TEVAR (0%)	TEVAR patients were significantly older than OR patients Timing: not described
Estrera et al. (2013), J Thorac Cardiovasc Surg [8] Retrospective	1997 to 2012 OR, n = 106 TEVAR, n = 69 ER, n = 103 DR, n = 72	Mortality (30 days) Paraplegia Stroke Survival at 1 year Survival at 5 years	Aortic cross-clamping (31%) versus TEVAR (4%) (P = 0.002) Distal aortic perfusion (14%) versus TEVAR (4%) (P = NS) ER (22%) versus DR (5.5%) (P = 0.004) OR (10%) versus TEVAR (0% (P = NS) OR (3%) versus TEVAR (3%) (P = NS) OR (76%) vs TEVAR (92%) OR (75%) vs TEVAR (87%)	Based on the Houston Centre Trauma Registry Paraplegia occurred only in the aortic cross-clamping group Decrease in mortality of 3.6% per year (P < 0.002) Timing: The TEVAR population managed with delayed repair was significantly greater than the aortic cross-clamping group and the distal aortic perfusion group (P < 0.001)
Jonker et al. (2010), J Vasc Surg [9] Retrospective	2000 to 2007 OR, n = 261 TEVAR, n = 67	Mortality Stroke Paraplegia Cardiac Pulmonary Endoleak	OR (17%) versus TEVAR (6%) (P = 0.0024) OR (2%) versus TEVAR (3%) (P = NS) OR (2%) versus TEVAR (0%) (P = NS) OR (5%) versus TEVAR (3%) (P = NS) OR (38%) versus TEVAR (24%) (P = NS) TEVAR (9%)	Study based on database More associated injuries with TEVAR compared with OR (P < 0.05) Timing: not described Weakness: small TEVAR population
Arthurs et al. (2009), J Vasc Surg [10] Retrospective	2000 to 2005 NOM, n = 1642 OR, n = 665 TEVAR, n = 95	Mortality (30 days) Mortality in delayed group ARDS Pneumonia Myocardial infarction Stroke Paraplegia	OR (19%) and TEVAR (18%) versus NOM (65%) (P < 0.05) OR (12%) versus TEVAR (0%) (P < 0.05) OR (7%) vs TEVAR (2%) (P < 0.05) OR (18%) vs TEVAR (12%) (P < 0.05) OR (25%) vs TEVAR (4%) (P < 0.05) OR (1%) vs TEVAR (0%) (P = NS) OR (2%) vs TEVAR (1.5%) (P = NS)	Study based on National Trauma Data Bank Greater major abdominal injuries and combined head and abdominal injuries in TEVAR group Postoperative complications were not reliably coded in the database Timing: Only 5% of OR and 8% of TEVAR were delayed (>72 h) Weakness: Small TEVAR population
De Mestral et al. (2013), J Am Coll Surg [11] Retrospective	2002 to 2009 n = 487	In-hospital mortality	OR (13%) and NOM (23%) versus TEVAR (6%) (P = 0.005)	Based on Canadian Registry Mortality was stable during the study period for patients who underwent repair Mortality declined during study period for non-operative management (P = 0.011) Weakness: Some information was not registered in the database Timing for operative repair was not described
Patel et al. (2011), J Vasc Surg [12] Retrospective	1992 to 2010 OR, n = 90 TEVAR, n = 19	Mortality (30 days) Stroke Paraplegia Pneumonia	OR (6%) versus TEVAR (0%) (P = NS) OR (1%) versus TEVAR (11%) (P = NS) OR (2%) versus TEVAR (0%) (P = NS) OR (42%) versus TEVAR (68%) (P = 0.04)	Higher risk of reintervention with TEVAR compared with OR (P = 0.03) Low survival rate for patients over 60 years (P < 0.001) Timing: 72% of patients were managed with delayed repair 90% of TEVAR procedures were delayed Weakness: Small population
Demetriades et al. (2012), J Am Coll Surg [13] Prospective	2005 to 2007 ER, n = 109 DR, n = 69 OR, n = 68 TEVAR, n = 125	Mortality Mortality Endoleak	ER (17%) versus DR (6%) (P = 0.034) Odds ratio: 8.42 (95% CI, 2.76–25.69; P < 0.001) TEVAR (15%)	Timing: The two groups were similar with regard to injury severity, major associated injuries and type of aortic injury and aortic repair TEVAR patients were significantly older than OR (P = 0.044)
Di Eusanio et al. (2013), Ann Thorac Surg [14] Retrospective	1992 to 2010 OR, n = 31 TEVAR, n = 44	Mortality Paraplegia Stroke	OR (0%) versus TEVAR (1%) (P = NS) OR (0%) versus TEVAR (0%) (P = NS) OR (0%) versus TEVAR (1%) (P = NS)	Timing: 78% of patients underwent delayed aortic repair Only 2 patients died while waiting for surgery Weakness: Small population
DuBose et al. (2015), J Trauma Acute Care Surg [15] Retrospective	2008 to 2013 NOM, n = 123 OR, n = 61 TEVAR, n = 198	In-hospital mortality Paraplegia Stroke Endoleak	NOM (35%) versus operative management (11%) (P < 0.001) OR (20%) versus TEVAR (9%) (P = 0.02) OR (0%) versus TEVAR (0.5%) (P = NS) OR (0%) versus TEVAR (1%) (P = NS) TEVAR (3%)	In cases of minimal aortic injuries (Grade I and II), there was no difference in mortality and postoperative complications between TEVAR and NOM Postoperative complications were similar between TEVAR and OR Timing for operative repair was not described

DR: delayed repair; ER: early repair; NOM: non-operative management; TEVAR: thoracic endovascular aortic repair; OR: open repair; NS: non-significant.

RESULTS

Takagi et al. [2] in their meta-analysis of 17 retrospective comparative studies showed significantly lower mortality with TEVAR than with OR [odds ratio: 0.43 (95% CI, 0.25–0.76; P < 0.01)]. They found the same results in 11 studies with similar preoperative data in both groups [odds ratio: 0.38 (95% CI, 0.20–0.73; P < 0.01)].

Tang et al. [3] analysed 33 studies on BTAI treatment by either TEVAR or OR and they reported a significantly lower mortality, paraplegia and stroke rate with TEVAR than with OR (8 vs 15%; P = 0.0076, 0 vs 6%; P < 0.0001, 1 vs 5%; P = 0.0028, respectively). Nevertheless, TEVAR was associated with a high rate (13%) of endovascular-related complications such as endoleak and stent collapse.

Xenos et al. [4] in a meta-analysis of 23 retrospective studies described a significantly lower mortality and paraplegia rate with TEVAR than with OR [odds ratio: 0.34 (95% CI, 0.18–0.66; P = 0.001) and odds ratio: 0.27 (95% CI, 0.11–0.63; P = 0.003) respectively]. However, the analysis of only seven studies on stroke rate did not reveal any difference.

Similarly, Karmy-Jones et al. [5] in a meta-analysis of 62 reviews and 6 meta-analyses found improved mortality and paraplegia rates in patients treated with TEVAR than with OR (8 vs 18%; P < 0.05 and 0.5 vs 4%; P < 0.05, respectively), although the TEVAR population was older. Stroke rate was similar between the two groups.

Murad et al. [6] performed the largest meta-analysis involving 139 studies with 7768 patients. Postoperative mortality was significantly lower with TEVAR than with OR or with NOM (9 vs 19% or 46%; P < 0.01, respectively). Paraplegia rate and systemic infection were higher with OR than with TEVAR (P < 0.01). Stroke rate was equal in the three groups.

In their prospective study, Azizzadeh et al. [7] showed that the OR group had a three-time higher complication risk including in-hospital mortality than TEVAR [odds ratio: 0.33 (95% CI, 0.11–0.97; P = 0.045)]. Mortality, cardiac and respiratory complications were higher for the OR group than for the TEVAR (9, 9, 57% vs 4, 6, 36%, respectively). No paraplegia occurred and stroke rate was similar in both groups (3.5 vs 2%, respectively).

Estrera et al. [8] reported significantly higher mortality in the OR group with aortic cross-clamping than in the TEVAR (31 vs 4%; P = 0.002, respectively) but not with the group using distal aortic perfusion. Moreover, with this procedure paraplegia occurred more frequently than with the use of distal aortic perfusion or TEVAR (10 vs 0% and 0%, P = NS, respectively). Mortality was lower with delayed repair than with immediate repair (5.5 vs 22%; P = 0.004). At 1- and 5-year follow-up, survival rates were 76 and 75%, respectively, for OR and 92 and 87%, respectively, for TEVAR. The authors showed a reduction of overall mortality by 3.6% per year (P < 0.002).

Jonker et al. [9] reported lower mortality with TEVAR than with OR (P < 0.05), although the TEVAR population had greater major associated injuries (P < 0.05). However, they showed no difference in paraplegia rates between TEVAR and OR (P = NS).

In their retrospective study based on the National Trauma Data Bank, Arthurs et al. [10] observed equal mortality between TEVAR and OR, probably due to a smaller TEVAR population with greater major associated injuries than the OR group (P < 0.05). Paraplegia and stroke rates were equal, but contributing centres did not always record data. Cardiopulmonary complications were higher with OR (P < 0.05). Only a few operative repairs were delayed; OR (5%) and TEVAR (8%). No operative deaths occurred with TEVAR in the delayed group.

de Mestral et al. [11] performed a retrospective study based on the Canadian National Trauma Registry. They observed lower mortality with TEVAR as first-line treatment, than with OR or with NOM (6 vs 13% or 23%; P = 0.005, respectively).

Patel et al. [12] reported the results of a centre with a strategy for selective delayed repair in patients with associated injury. The majority of patients (72%) benefited from delayed repair and no deaths occurred in the TEVAR group. Moreover, they found that age over 60 years was an independent risk factor for morbidity and mortality.

Demetriades [13], in their first prospective study including 193 patients, demonstrated improved mortality with TEVAR compared with OR [odds ratio: 8.42 (95% CI, 2.76–25.69; P < 0.001)], in patients with or without major associated injuries. However, TEVAR was associated with a high device-related complication rate (20%); endoleak was the most common. Multivariate analysis showed a correlation between complication rate and experience of a medical centre.

Demetriades [13] conducted a second prospective study on timing of aortic repair of 178 patients. They showed a better survival rate with delayed (>24 h) than early repair (P < 0.05). According to the European Society of Cardiology guidelines [16], delayed repair could not be proposed in cases of imminent free aortic rupture.

Di Eusanio et al. [14], in their single-centre experience of delayed aortic repair (TEVAR and OR), reported a very low overall mortality rate (3.9%). Delayed repair may allow regression of intramural haematoma ensuring better stability.

DuBose et al. [15] performed a multicentre retrospective study. They showed lower mortality for operative management (TEVAR and OR) compared with that of NOM (11 vs 35%, P < 0.001, respectively). However, for minimal BTAI (Grade I and II on CT scan), mortality was not significantly different between TEVAR and NOM. The ESC [16] emphasizes that some cases with minimal aortic injuries could benefit from NOM. For operative management, postoperative complications were equal except for mortality, which was significantly lower with TEVAR than with OR. The authors reported a low rate of endovascular-specific complications (endoleak 3%).

CLINICAL BOTTOM LINE

We conclude that with lower mortality and similar overall complications including paraplegia but higher stroke rate, TEVAR is the most suitable treatment for BTAI in the modern era, where expertise exists, especially in cases of multiple associated injuries and in the older age group.

Delayed aortic repair can be proposed based on CT scan analysis, but emergent repair should still be advocated for imminent free aortic rupture. NOM remains a therapeutic option but only with selected patients.

Conflict of interest: none declared.

ACKNOWLEDGEMENTS

The authors are grateful to Nikki Sabourin-Gibbs, Rouen University Hospital, for her help in editing the manuscript.