Non-operative management of blunt traumatic aortic injuries

Table 1 Details of studies included in our review

Ref.	Design	Demographics	Details of BTAI	Management strategies	Primary and secondary outcomes
Kepros et al[29], 2002	Retrospective, institutional	N = 5, mean age 365 years; 40% male	Aortic intimal tear (no further detail or grading)	Non-operatively	No mortality observed; 0%
Ott et al[6], 2004	Retrospective; institutional	N = 18; n = 12 open vs n = 6 endo; median 43.5 endo vs 31.5 open, P = 0.18; 58.3% male open vs 66.7% male endo	Not mentioned	Endovascular vs open	In-hospital mortality: 0% endo vs 16.7% open, P = 0.53; paraplegia: 0% endo vs 16.7% open, P = 0.53; RLN injury: 0% endo vs 8.3% open, P = 1.00; ARDS: 0.0% vs 8.3%, P = 1.00; sepsis: 0.0% vs 41.67%, P = 0.11; MI: 0.0% vs 16.67%, P = 0.53; tracheostomy: 16.67% vs 33.33%, P = 1.00; arrhythmia: 33.33% vs 16.67%, P = 0.57; PE: 16.67% vs 8.33%, P = 1.00
Hirose et al[1], 2005	Retrospective, institutional data	N = 7; age 48.7 ± 22.7 years; 42.9% male	3/7 intimal flap; 4/7 pseudoaneurysm	Non-operative	In-hospital mortality 14.2%; five-year survival 71.4%; of those that survive, 50% had stable disease, 50% had resolution
Stampfl et al[15], 2006	Retrospective, institutional	n = 12; conservative (ages 41 and 76); surgery [age 30 (20-58)]; stent [age 47 (20-74)]	Local dissection, n = 8; contained rupture, n = 4	Conservative (n = 2); surgery n = 5 (4 for rupture, 1 for dissection; stent n = 5	No mortality in any group; surgery group: One return to OR; EVAR: One endoleak at 2 days, stented; no aortic reintervention in other patients or groups; no endoleaks in follow-up, mean follow-up 63 months (5-108)
Arthurs et al[3], 2009	Retrospective, NTDB	N = 2402; age 41 ± 20 years; 42% male; NOM: n = 1642; age 42 ± 21 years; OAR: n = 665; age 39 ± 18 years; TEVAR: n = 95; age 41 ± 21 years	Data not available	68% non-operative; 28% open; 4% endovascular	30-day Mortality: 6.5% non-op vs 19% open vs 18% endovascular, P < 0.05; paraplegia: 0.3% vs 2% vs 1.6%; ARDS: 4% vs 7% vs 2%, P < 0.05; PNA 9% vs 18% vs 12%, P < 0.05; myocardial infarction: 22% vs 25% vs 4%, P < 0.05; acute renal failure: 3% vs 6% vs 10%, P < 0.05; stroke 02% vs 0.6% vs 1.6%, P = NS; ICU LOS: 11.5 ± 13 days vs 12 ± 12 days vs 13 ± 11 days, P = NS; hospital LOS: 12 ± 19 days vs 19 ± 20 days vs 23 ± 23 days, P < 0.05
Caffarelli et al[30], 2010	Retrospective; institutional	N = 53; Non-operative: n = 29; age 45 ± 15 years; 69.0% male; operative: n = 24; age 46 ± 20 years; 75% male	Non-op: 6 intimal injury; 2 IMH; 19 PSA	All non-op	93% survival; no aortic deaths; 1 failed non-op; 2 had delayed repair at OSH after discharge; follow-up mean 107 days; median 31 days; 21 (78%) stable injuries; 5 (18%) complete resolution; 1 (4%) PSA progression
Mosquera et al[13], 2011	Retrospective; institutional	N = 37 (conservative; age 44.2 ± 19.3) vs 22 surgical (age 30.8 ± 9.8) vs 7 endo (age 44.9 ± 13.8)	Transection: 24.3% conservative vs 86.4% surgical vs 85.8% endovascular; conservative: 40.5% IMH; 27.1% partial intimal tear; 8.1% PSA		In-hospital mortality: 21.6% conservative vs 22.7% surgical vs 14.3% endovascular (P = 0.57); aortic-related complications: 100% vs 0% vs 0%, P < 0.001; 1-year survival: 75.6% vs 77.2% vs 85.7%; 5-year survival: 72.3% vs 77.2% vs 85.7%, P = 0.59; no 10-year survival in endo group (suggests that long-term durability not known)
Paul et al[28], 2011	Retrospective; institutional	N = 47; (n = 15; 41.5 ± 13.9; 66.6% male non-op) vs operative (n = 19, open, 44.5 ± 23.7, 62% male; n = 13, endo, 45.2 ± 20; 79% male)	Operative repair; non-op; 2 false on angion; 2 PSA and 11 intimal tear	Non-op; 2 false; 5 resolved; 8 stable	Mortality: 10.6%; 5/32 in operative vs 0% in non-operative; follow-up imaging: Non-operative; 2 aortogram (-); 5 resolved; 8 stable
Mosquera et al[14], 2012	Retrospective; institutional	N = 52; 9 patients MAI; 43 SAI	No formal grading; intimal tear < 10 mm MAI; rest SAI; PSA in SAI	9 MAI; 100% conservative; 43 SAI (26 conservative; 9 open; 8 TEVAR)	In-hospital mortality: 22.2% MAI vs 30.2% SAI, P = 0.94; ICU LOS: 17.2 ± 16 days MAI vs 18.5 ± 14.2 days SAI, P = 0.81; one-year mortality 77.8% vs 69.6%, P = 0.46; five-year mortality: 77.8% vs 63.6%, P = 0.46; MAI: 6/7 resolution; 1 developed PSA
Kidane et al[5], 2013	Retrospective, institutional	N = 59; non-op 43.4 (14.5) vs TEVAR 43.2 (21.8); non-op 53.6% male vs TEVAR 80.0%	Grades 1: 14 (27.0%); grade 2: 1 (1.9%); grade 3: 35 (67.3%); grade 4: 2 (3.8%)	Non-operative vs TEVAR; grade I: 13 NOM, I TEVAR; grade II: 1 NOM; grade III: 12 NOM, 23 TEVAR; grade IV: 2 TEVAR	Mortality: Non-operative 428% vs TEVAR 20.7% (not stratified by treatment type in each grade); grade I: 21.4% mortality; grade II: 0% mortality; grade III: 37.1% mortality; grade IV: 50% mortality
Rabin et al[27], 2014	Retrospective; institutional	N = 97; 31 grade I; 35 grade II; 24 grade III; 7 grade IV		Grade I: 28/31 MM; 3 TEVAR; grade II: 13 MM; 11 TEVAR; grade III: 4 MM; 18 TEVAR; 2 open; grade IV: 5 open; 2 TEVAR	Grade I mortality: 10%; grade II: 20%; grade III: 21%; grade IV 29%; grade I: MM: 14.2% mortality vs 0% TEVAR; grade II: MM 46.2% mortality vs TEVAR 4.5% mortality; grade III: 5.6% TEVAR vs 0% OAR; grade IV: 50% TEVAR vs 80% OAR; follow-up: Grade I: 11 resolved; 5 unchanged; 2 small increases in injuries but no intervention (no aortic-related deaths, ruptures, complications); Grade II: 5 unchanged; 1 subsequent elective repair
DuBose et al[20], 2015	Retrospective; multi-institutional	N = 382; NOM, n = 123; age 447 ± 18.0 years; 32.5% male; operative, n = 259; age 404 ± 17.6 years; 24.7% male	Grade 1, 94; grade 2, 68; grade 3, 192; grade 4, 28	Grade I: 76.6% NOM vs 5.3% OAR vs 18.1% TEVAR; grade II: 27.9% NOM vs 7.4% OAR vs 64.7% TEVAR; grade III: 12.5% NOM vs 21.9% OAR vs 65.1% TEVAR; grade IV: 25.0% NOM vs 32.1% OAR vs 42.9% TEVAR	NOM: 32%, 2 failures(1 grade I, 1 grade III); open repair in 61 patients (16%); TEVAR was done in 198 patients (52%). 6 patients of TEVAR failed, required 2 rpt TEVAR and 4 open repairs; overall in-hospital mortality 18.8% (NOM: 9.8%, OR: 13.1%, TEVAR: 2.5%); TEVAR was protective (P = 0.03); Aortic-related mortality 6.5%; 9.8% in NOM vs 5.0% P = 0.12; managed NOM grade I: 76.6%, grade II: 27.9%, grade III: 12.5%, grade IV: 25%. Failure rates: Grade I: 1.4%, grade II: 0%, grade III: 4.2%, grade IV: 0%; Managed w/TEVAR: Grade I: 18.1%, grade II: 64.7%, grade III: 65.1%, grade IV: 42.9%; failure rates: Grade I: 0%, grade II: 2.3%, grade III: 2.4%, grade IV: 16.7%
Gandhi et al[7], 2016	Retrospective, institutional	N = 35 (17 TEVAR vs 18 NOM); 44 (23) TEVAR vs 47 (20) NOM; 64.7% male TEVAR vs 55.6% male non-op	Grade 3	TEVAR vs non-operative	In-hospital mortality: 11.8% TEVAR vs 27.8% non-op, P = 0.402; aortic-related death 0% vs 6%, P = 1.00; any complications: 64.7% vs 50.0%, P = 0.728; AKI: 23.5% vs 22.2%, P = 1.00; PNA: 29.4% vs 22.2%, P = 0.711; respiratory failure: 17.6% vs 5.6%, P = 0.338; UTI: 17.6% vs 5.6%, P = 0.338; aortic injury; resolved/improved: 92.9% vs 87.5%, P = 0.674; worsened: 7.1% vs 12.5%
Tanizaki et al[17], 2016	Retrospective; institutional	N = 18; age 58.2 years (24-88); 66.7% male	Grade III: 18 (100%)	Initial NOM for all	22% mortality; 0% ARM; 14 patients followed non-operatively up for an average of 40.9 months; six grade III injuries were resolved; six grade III injuries were unchanged but did not require intervention; two patients in grade III had progression of pseudoaneurysm; 2/18 NOM required repair
Shackford et al[21], 2017	Retrospective; multi-institutional	255 patients total, TEVAR n = 176 (68%), age 46 years (28-60), 71% male; open n = 28 (10.8%), age 29 years (19-51); 71.4% male; NOM n = 51 (19.7%); age 42 (28-54); 64.7% male	No grading described		The overall In-hospital mortality was 5.9% (TEVAR 5.7%, Open 10.7%, NOM 3.9%. P = 0.535); 1 ARM in the TEVAR group; regarding the primary outcome of mortality, including In-hospital and post-discharge deaths, there was no significant difference between the three groups (TEVAR n = 12, 6.8%, Open n = 3, 10.7%, NOM n = 2, 3.9%, P = 0.485)
Spencer et al[26], 2017	Retrospective; institutional	N = 30; TEVAR 14; age 52 years (32-65); 79% male; NOM 16; 43 (37-66); 50% male	Grade I: 16; grade II: 14	Grade I: 50%TEVAR; 50% NOM; grade II: 8 NOM; 6 TEVAR	TEVAR 14% mortality vs NOM 6%, P = NS; failure rate for grade 1-2 patients were 0%; all patients in the TEVAR group showed stable stents with no leak; 2 patients in the NOM group had progression(One from grade 1 to grade 2, one from grade 2 to grade 3), resolution in 3 grade 1 patients, and the remainder of 11 patients were stable
Sandhu et al[31], 2018	Retrospective; institutional	N = 48; NOM; age 37.5 ± 15.1 years; 70.8% male; TEVAR grade II: 23; age 40.2 ± 14.3; 82.6% male	Grade I: 26; grade II:45	Grade 1 26 NOM; grade II: 48.9% NOM vs 51.1% TEVAR	NOM: Overall 42% mortality (3.9% grade I; 4.6% grade II; 0% ARM); 71% had follow-up data; 84% resolved; 16% persistent injury; median injury resolution time was 39 days for grade 1 and 62 days for grade 2; TEVAR: 0% 30-day mortality
Gaffey et al[4], 2019	Retrospective, institutional	N = 15; age 45 ± 20.6 years; 60% male	Grade II	Non-operative	30-day mortality: 1/15; Five-year mortality: 2/15; follow-up CT 69 months (7-138); no repair performed; resolution: 73.3%; no change 26.7%
Dubose et al[19], 2021	Prospectively collected; multi-institutional; registry	N = 296; age 44.5 ± 18 years; 76% male; NOM: n = 83 (28.0%); OAR n = 6 (2.0%); TEVAR n = 173 (58.4%)	Grade I n = 67 (22.6%), grade II n = 52 (17.6%), grade III n = 140 (47.3), grade IV n = 37 (12.5%)	Most of the patients underwent TEVAR (58.4%), Medical Management (28.0%), and open repair only 2%; I: 91% MM; 9% TEVAR; II: 61.5% MM; 38.5% TEVAR; III: 11.4% MM; 1.4% open; 86.4% TEVAR; IV: 2.7% MM; 10.8% open; 70.3% TEVAR	Overall mortality was 14.2% (42/296) (Table 1), with ARM at 4.7% (14/296)
					For grade 1 and 2 patients, 59.7% managed medically, and 40.3% underwent TEVAR. No significant difference in aortic-related mortality for grade 1 and 2 injuries; I: 7.5% overall mortality; 1.5% ARM; II: 17.3% mortality; 1.9% ARM; III: 10% mortality; 1.4% ARM; IV: 37.8% mortality; 27.0% ARM
McCurdy et al[24], 2020	Single center; retrospective	N = 229; age 45.8 ± 19.7 years; 70.3% male; TEVAR: n = 61; 45.4 ± 15.7; 68.9% male; OAR: n = 66; 40.6 ± 20.0; 75.8% male; NOM: n = 102; 49.5 ± 19.7; 67.7% male	I: 69 (30.1%); II: 19 (8.3%); III: 69 (30.1%); IV: 72 (31.4%)	TEVAR vs OAR vs NOM; I: 5 vs 12 vs 52; II: 5 vs 1 vs 13; III: 29 vs 19 vs 21; IV: 22 vs 34 vs 16; overall: 44% NOM, 27%; TEVAR, and 29% OAR	Overall, 30-day mortality was 22%; NOM 30-day mortality: 8% for grade 1, 15% for grade 2, 48% for grade 3, and 94% for grade 4; TEVAR: 16% for grade I/II and 0% for grade III/IV; NOM 30%, 8.2% for the TEVAR group, and 21% for open surgery group
Madigan et al[25], 2022	Retrospective; institutional	N = 176; NOM: n = 64; age 39 years (26-58); 28.1% female; TEVAR; n = 112; age 39 (26-58) years; 24.1% female	Grade I n = 36; grade II n = 24; grade III n = 115; grade IV n = 1	63.6% selected for TEVAR; grade I: 1/36; grade II 9/24; grade III 101/115; grade IV 1/1	30-day morbidity: 44.6% NOM vs 48.7% TEVAR, P = 0.64; 1-year mortality: 1.8% NOM vs 3.1% TEVAR, none of the NOM patients had progression; 44% resolution at follow-up; complete resolution of the aortic injury was seen in 28.6% of the grade 1 injuries and 20% of the grade 2 injuries at 30 days; remainder were stable; no progression 14 of grade 3 patients were treated NOM, most common reason to manage NOM was smaller size of PSA < 8 m without presence of peri-aortic hematoma, without proximal zone (Zone 0-1) lesion, and injuries in patients at extremes of age (< 18 or > 80). None of these lesions had progressed during follow-up, and one of the lesions resolved at 2-year follow-up
Sun et al[16], 2022	Single-center 10-year retrospective study between 2013 and 2022	N = 72	Grade 1 = 1 (1.4%); grade 2 = 17 (23.6%); grade 3 = 52 (72.2%); grade 4 = 2 (2.8%)		Total 72 patients, 60 patients with/ TEVAR, 8 NOM, 4 open surgery; total all-cause mortality was 12.5%, aortic-related mortality was 4.2%; TEVAR patients were grade 2 ( n = 15) and 3 (n = 45), grade 3 patients had a higher rate of ICU admission (0% vs 13.3%) and similar in-hospital mortality (1.7% vs 5%)
Al-Thani et al[18], 2022	Retrospective observational study between 2000-2020; single center	N = 87; NOM: Age 40.6 ± 16.4 years; 97.1% male; OAR: Age 37.1 ± 10.9 years; 47.4% male; TEVAR: 34.1 ± 13.8; 84.8% male	Grade 1 10 (11.5%); grade 2 12 (13.8%); grade 3 36 (41.4%); Grade 4 29 (33.3%)	40% NOM n = 35; 60% treated operatively n = 52; TEVAR 33 patients (63.5%); open surgery 19 patients (36.5%); grade I: 10 NOM; grade II: 12 NOM; grade III: 4 NOM vs 10 OAR vs 22 stent; grade IV: 9 NOM vs 9 OAR vs 11 stent	Overall, in-hospital mortality was 25.3%; significantly higher in-hospital mortality in the conservative group (40%), compared to open surgery (31.6%) and TEVAR (6.1%); TEVAR patients n = 33; grade I: 0% mortality; grade II: NOM 25% mortality; grade III: 50% NOM vs 20% OA vs 45% stent; grade IV: 100% NOM vs 44.4% OAR vs 9.1% stent
Arbabi et al[12], 2022	Prospective, multi-institutional; aortic trauma foundation	N = 432; NOM: n = 114; 38.5 (29); 69.3% male; intervention; n = 318, age 45 years (IQR 29); 78.3% male	Grade I 102; grade II 62; grade III 221; grade IV 47	114 patients underwent MM; 68 (59.6%) grade 1, 27 (23.7%) grade II, 18 (15.8%) grade III and 1(0.9%) grade IV; intervention: Grade I 34 (10.7%), grade II 35 (11.0%), grade III 203 (60.8%), grade IV 46 (14.5%)	12/114 required intervention; with 11 undergoing TEVAR and 1 open; grade I 1.5% failure rate; grade II 0% failure rate; grade III 55.5% failure rate; grade IV 100% failure rate; 30-day mortality rate of 1.7%; in-hospital mortality rate of 7.9%; no aortic-related mortality
Ye et al[11], 2022	Retrospective, institutional	N = 12, age 60 (16.1) years, 50% male	Grade 2 n = 2; grade 3 n = 10	NOM: n = 7; TEVAR n = 5; median 2 days	Mortality: 0% vs 40%, P = 0.182; LOS: 41.5 (17.5-69.0) vs 3.0 (1.5-38.5), P = 0.177
Yadavalli et al[22], 2023	Retrospective cohort, collected data from VQI, between 2013 to 2022	N = 1311	Grade 1 = 106 (8%); grade 2 = 244 (19%); grade 3 = 741 (57%); grade 4 = 220 (17 %)	All patients underwent TEVAR	Primary outcomes were peri-op (within 30 days) and 5-year mortality; higher grades with higher mortality overall (grade 1: 6.6%, grade 2: 4.9 %, grade 3: 7.2%, grade 4 14%); 5-year mortality rates were higher with grade 4 as well. (grade 1 11%, grade 2: 10%, grade 3 11%, and grade 4: 19%)
Golestani et al[23], 2024	Retrospective analysis of Aortic Trauma Foundation (Multicenter Registry)	N = 269	Grade 1 186; grade 2 83	218 patients Non-operative; 51 TEVAR	There was a significant difference in mortality between NOM alone and TEVAR (8% vs 18% P = 0.009); patients with/TEVAR increased incidence of DVT( 12% vs 1%, P = 0.002); hospital and ICU length of stay were not different

RLN: Recurrent laryngeal nerve; ARDS: Acute respiratory distress syndrome; MI: Myocardial infarction; PE: Pulmonary embolism; NOM: Non-operative management; OAR: Open aortic repair; TEVAR: Thoracic endovascular aortic repair; PNA: Pneumonia; NS: Not significant; ICU: Intensive care unity; LOSLength of stay:; IMH: Intramural hematoma; PSA: Pseudoaneurysm; OSH: Outside hospital; MAI: Minimal aortic injury; SAI: Significant aortic injury; AKI: Acute kidney injury; UTI: Urinary tract infection; CT: Computed tomography.