When and how should we manage thoracic aortic injuries in the modern era?: Table 1:

Abstract

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.

Endovascular Repair of Traumatic Isthmic Ruptures: Special Concerns

“…Up-to-date guidelines published by the European Society of Cardiology (ESC) and the European Society for Vascular Surgery (ESVS) support TEVAR as the primary method for TAIR repair, now based on stronger evidence (Class I, Level B) (28, 29). A recent review of 5 meta-analyses, 2 prospective, and 7 retrospective studies also supported the abovementioned guidelines concluding that TEVAR is the most suitable treatment for TAIR where expertise exists (30). …”

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“…Is an excellent method Open Access Journal of Surgery for diagnosis to triage patients with suspected aortic injury, showing a sensitivity ranging from 93% to 100% and specificity of 87% to 100% [3,15,16] (Figure 2). With this test, you can distinguish the mediastinal blood from other causes dilation of the mediastinum, in addition to show if there is intimate or laceration, hematoma, aortic pseudoaneurysm, periaortic rupture contained or active extravasation of IV contrast [11]. It's worth pointing out that the primary diagnostic criterion is the demonstration of two lumens full of contrast separated by an intimate tab [15].…”

Endovascular management of penetrating and non-penetrating aortic injury

“…There have been decreases in hospital mortality due to delayed repair. This trend, however, may be confounded by the reduced trauma burden among those patients stable enough to undergo delayed intervention [44,45]. Im- in endograft collapse, while undersizing can result in attachment zone endoleak [34,51].…”