Implementation and results of a practical grading system for blunt thoracic aortic injury

Objective: We previously proposed a grading system for blunt thoracic aortic injury (BTAI) designed to guide therapy. This study analyzed our outcomes since implementing this system. Methods: A single-center, retrospective study was conducted of consecutive patients presenting with BTAI between January 2014 and December 2017. This grading system classified injuries into minimal, moderate, or severe on the basis of computed tomography imaging. Primary end points included timing of operation and mortality. Secondary end points included associated injuries, aortic anatomy, and operative details as well as 30-day follow-up. Results: During the study period, 87 patients with BTAI were identified. The majority of patients had a moderate injury occurring just distal to the left subclavian artery (LSA); 59 patients underwent thoracic endovascular aortic repair (TEVAR), whereas none of the patients with minimal injury (n = 24) required surgical treatment. The mean time to repair was 53 hours (1-191 hours) for moderate injury and 3.6 hours (0-7 hours) for severe injury. The average diameter and length of the endograft was 26 mm and 112 cm, respectively, and the LSA was covered in 42% of patients. Intravascular ultrasound to confirm sizing was used in 83% of cases. Most patients (92%) received intravenous heparin during TEVAR; the remainder received only heparin sheath flush because of concern for intracranial hemorrhage. None of the patients underwent LSA revascularization or developed stroke or spinal cord ischemia as a result of the procedure. Operative complications were seen in 6% of patients and included 1 femoral pseudoaneurysm, 1 lower extremity compartment syndrome, 1 type II endoleak requiring LSA embolization, and 1 intracranial bleed. The 30-day mortality was 7% (one aorta-related death). On 30-day postoperative follow-up, computed tomography imaging uniformly revealed positive aortic remodeling, and no secondary aortic intervention was required. Conclusions: Institutional implementation of our grading system has streamlined treatment of BTAI, and our results confirm the following: patients with minimal injury do not require surgical treatment; patients with moderate injury can safely undergo TEVAR in a semielective manner once they are stable from other injuries; and patients with severe injury require emergent repair. These procedures are expeditious and can be successfully performed percutaneously with a single endograft. Complications are rare, and follow-up reveals excellent remodeling of the aorta, likely resulting in lengthened interval surveillance requirements for these patients.