Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard

BACKGROUND: Incidence and treatment of blunt thoracic aortic injury (BTAI) has evolved, likely from improved imaging and emergence of endovascular techniques; however, multicenter data demonstrating this are lacking. We examined trends in incidence, management, and outcomes in BTAI. STUDY DESIGN: The American College of Surgeons National Trauma Databank (2003 to 2013) was used to identify adults with BTAI. Management was categorized as nonoperative repair, open aortic repair (OAR), or thoracic endovascular repair (TEVAR). Outcomes included demographics, management, and outcomes. RESULTS: There were 3,774 patients. Median age was 46.0 years (interquartile range [IQR] 29.3, 62.0 years), with 70.8% males, and median Injury Severity Score (ISS) of 34.0 (IQR 26.0, 45.0). The number of BTAIs diagnosed over the decade increased 196.8% (p < 0.001), median ISS decreased from 38 to 33 (p < 0.001), and significantly more patients were treated at a level I trauma center (p < 0.001). After FDA approval of TEVAR devices, there was a significant increase in endovascular repair overall (1.0% to 30.6%, p < 0.001) and in those treated operatively (0.0% to 94.9%, p < 0.001), with a marked decrease in OAR. Use of TEVAR was associated with significantly reduced median ICU LOS (9.0 vs 12.0 days, p = 0.048) and mortality (9.3% vs 16.6%; p = 0.015) compared with OAR. In modern BTAI care, TEVAR has nearly completely replaced OAR. CONCLUSIONS: The diagnosis of BTAI has increased, likely due to more sensitive imaging. Nearly 70% of patients get nonoperative care. Treatment with TEVAR improves outcomes relative to OAR. Part of the proportional increase in TEVAR use may represent overtreatment of lower grade BTAI amenable to medical management, and warrants further investigation. (C) 2019 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.