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Acute Thoracic Aortic Pseudocoarctation after Blunt Thoracic Aortic Injury Mandates Emergent Thoracic Endovascular Aortic Repair to Reverse Hypoperfusion and Prevent Reperfusion Sequela
*Maunil Bhatt3, *Saskya Byerly1, *Dina M. Filiberto1, *Muhammad O. Afzal2, Timothy C. Fabian1, Martin A. Croce1, Erica L. Mitchell3
1Trauma/Critical Care Surgery, University of Tennessee Health Science Center, Memphis, TN; 2Radiology, University of Tennessee Health & Science Center, Memphis, TN; 3Vascular & Endovascular Surgery, University of Tennessee Health & Science University, Memphis, TN

Objective: Thoracic endovascular aortic repair (TEVAR) is now the standard operative treatment for blunt thoracic aortic injuries (BTAIs). While the optimal timing for TEVAR has not yet been established, registry studies suggest that mortality rates are higher, despite equivalent extrathoracic injuries and injury severity, for patients treated with TEVAR <24 hours of BTAI. Recent studies recommend delaying treatment >24 hours despite data lacking clinical details and imaging data. The purpose of this study is to elucidate clinical and imaging findings predictive for early morbidity and mortality (M&M) after BTAI and define criteria mandating emergent TEVAR.
Methods: We performed a retrospective analysis of a prospectively collected database for patients diagnosed with BTAI at our institution from January 2021 to October 2023. Clinical and thoracic aortic (TA) imaging data, including Society for Vascular Surgery (SVS) TA injury grade (G), were analyzed. Outcomes evaluated included in-hospital death, ischemic paraplegia (IP), visceral ischemia (VI), acute kidney injury requiring dialysis (AKID), and lower extremity ischemia (LEI). Correlations between presenting clinical and TA imaging findings, timing of TEVAR, and outcomes were evaluated.
Results: Over 33-months we saw 19,203 trauma patients, 13,717 (71%) the result of blunt trauma. Seventy-eight (0.57%) patients, 53 (67.9%) male, average age 43 (Range:16-79), presented with BTAI including 32 (41.0%) SVS GI, 10 GII (12.8%), 29 GIII (37.2%), and 7 GIV (8.9%) injuries. TEVAR was performed in 42 (53.8%) patients including 0% SVS GI, 14.3% (6) GII, 100% (29) GIII, and 100% (7) GIV injuries. Median time to TEVAR was 9 (IQR:5-32) hours. Hours to TEVAR by grade was 60 (IQR:48,72) for GII, 9 (IQR:5,23) for GIII, and 4 (IQR:3,7.5) for GIV injuries. Among high grade (III – IV) injuries, 7 (19.4%) presented with upper extremity hypertension (Systolic Blood Pressure > 160), weak/absent femoral pulses, and TA imaging of acute pseudocoarctation (PSC) defined by accordion-like TA contour abnormalities with 50-80% TA luminal narrowing. Overall, BTAI-related, and TA PSC-related in-hospital mortality was 6.4%, 5.1%, and 28.6% respectively. Amongst PSC patients, 1 presented with IP, 2 with VI, 2 with AKID, and 4 with LEI. Median hours to TEVAR for PSC patients was 4 (IQR:3.5, 6). Delayed TEVAR > 5 hours for PSC patients resulted in reperfusion syndrome (lower extremity and abdominal compartment), limb loss, and death for two TA PSC patients.
Conclusions: This is the largest single center series to study clinical details, imaging data, and outcomes after TEVAR for BTAIs. Contrary to recent literature supporting delayed TEVAR, our data support safe early TEVAR for high grade BTAIs. We have also identified a subset of BTAI injuries with TA PSC phenotype at risk for ischemic and reperfusion M&M if not addressed emergently. Emergent TEVAR in these patients may prevent ischemic and reperfusion sequela.
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