Non-operative management of blunt traumatic aortic injuries

Abstract

BACKGROUND

Blunt traumatic aortic injury (BTAI) is a life-threatening injury, commonly associated with high-speed motor vehicle collisions. Historically, open surgical repair was the standard treatment, however with the advancement of endovascular techniques such as thoracic endovascular aortic repair (TEVAR), management strategies shifted towards endovascular repairs. Non-operative management (NOM) strategies are also favored for patients with low-grade injuries and particularly high-grade injuries recently. The Society for Vascular Surgery (SVS) 2011 guidelines recommend that grade I injuries should be managed non-operatively; newer studies also support NOM for grade II injuries.

AIM

To review higher-grade injuries. NOM can be favored for selected patients with grade III injuries.

METHODS

A retrospective review of literature to assess NOM in BTAI, using the PubMed, CINHAL, EBSCO, and Google Scholar databases, included articles published in the last 20 years between January 2003 and December 2023. Studies included Cohort studies, case-control studies, and observational studies. Two authors independently screened the titles, abstracts, and performed data extraction. Outcomes were compared by the type of treatment: NOM vs endovascular repair (TEVAR) vs open repair.

RESULTS

We identified 27 studies in our review that met the selection criteria. Most of the studies were based on retrospective analysis of institutional data, and only 16 papers reported BTAI in accordance with SVS reporting standards. A trend of increasing mortality across the BTAI grade was observed. There were heterogeneous results regarding outcomes after non-operative compared with endovascular and surgical repair. For grade I and II BTAI, NOM was associated with lower mortality, reduced rates of unplanned intervention, and resolution of pathology on follow-up. There were reports of NOM of grade III BTAI with reasonable outcomes and a high rate of resolution on follow-up, but data were limited due to very few studies focusing on this subgroup.

CONCLUSION

This review article provides the most up-to-date literature. Currently literature supporting the NOM for low-grade BTAI (grades I and II) treatment. Current SVS guidelines recommend endovascular repair for grade III BTAI patients; however, a few studies showed that grade III BTAI can be managed non-operatively with active surveillance in a selected group of patients. Literature requires further studies to compare NOM vs TEVAR in higher-grade BTAI population.

Keywords: Blunt trauma; Aortic injury; Non-operative management; Outcomes; Thoracic endovascular aortic repair

Core Tip: The non-operative management of blunt traumatic grade I aortic injury is a relatively common practice. The management of grade II aortic injury varies; some providers prefer an endovascular approach, while others prefer non-operative management. Successful non-operative management is associated with lower mortality and resolution of the primary pathology. However, non-operative management if not routinely applied for higher grade aortic injuries and the majority prefer an endovascular approach for higher grade, III or more, injury.