Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results

Abstract

Objective

This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up.

Methods

During the study interval (November 2000–October 2020), a total of 38 patients (63% male; average age 37.5 years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter.

Results

Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft’s diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up.

Conclusions

Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.

Keywords

thoracic endovascular repair blunt traumatic thoracic aortic injury (TAI)long-term follow-up procedure-related complications MRI endoprosthesis complications

Background

Thoracic aortic injuries (TAIs) have been described mostly since 1900 as a consequence of road trauma.¹ Thoracic aortic injuries are defined as blunt when not caused by penetrative chest injury. To date, of all cases of blunt trauma resulting in substantial injury to the thorax, motor vehicle collisions account for a majority, followed by falls from height, pedestrian-automobile collisions, and crush injuries. Blunt TAIs occur in approximately 0.5%–2% of all nonlethal motor vehicle collisions and 10%–20% of all high-speed deceleration fatalities. About 80–90% of TAIs immediately result in the patient’s death from a grade 4 injury (rupture of aortic wall). In survivors, the lethality rate increases by 1–2% every hour afterwards and only 2% of the untreated patients survive beyond four months.^1–3 Thoracic aortic injury is a “critical” injury with high mortality and an uncertain prognosis. The prognosis of the polytraumatized patients with TAI becomes worse if multiple injuries (abdominal, neurosurgical, bone, or thoracic) are associated. If possible, the patient should be referred to a trauma center. Patients need stabilization of vital functions and fast identification and treatment of the most serious and potentially fatal injuries. Computed tomography is the gold standard in the management of polytraumatized patients, if hemodynamically stable. Until a few years ago, only open surgery with extracorporeal circulation was used. This treatment is characterized by high morbidity, especially for subsequent anticoagulation therapies and coagulopathies in the polytraumatized hemorrhagic patients (pulmonary contusions, multiple fractures, limb injuries, cranial lesions, internal organs fractures such as liver, kidney, bladder etc.). In the last decade, open surgery has been replaced by endovascular treatment (TEVAR) with excellent immediate results (mortality reduction and few cases of major complications such as paraplegia, stroke or renal failure).^4–6 This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic TAI, through long-term clinical and diagnostic follow-up. Computed tomography, magnetic resonance imaging, and chest radiographs have been used in the diagnostic follow-up.

Methods

Study design

This study is a multi-center (Circolo Hospital and Macchi Foundation of Varese, Italy–Mater-Domini University Hospital of Catanzaro, Italy), retrospective analysis of prospectively collected data of consecutive patients with TAI, who had undergone, from November 2000 to October 2020, thoracic endovascular aortic repair. Inclusion criteria, met by all patients, are I) blunt traumatic thoracic aortic injury (TAI); II) treatment with thoracic endovascular aortic repair (TEVAR); III) evaluation by a multidisciplinary team of vascular surgeons, interventional radiologists, and anesthetists; IV) age ≥18 years. Exclusion criteria are (I) missed clinical and radiological follow-up at 6 months after the endovascular treatment; (II) death after TEVAR of associated traumatic injuries (intracerebral hemorrhage, abdominal hemorrhage, etc.). In all cases, a computed tomography (CT) angiography and a total body CT scan (multislice CT Lightspeed Plus, GE, Milwaukee, USA; Aquilion 64, Toshiba, Tokyo, Japan) were performed after trauma. Classifications by Ishimaru and Criado^7,8 were used to describe aortic anatomy, defining the five possible landing zones of the thoracic aorta during the endovascular repair. The study was approved by the Institutional Review Board and an informed consent was obtained by each patient to allow a retrospective data analysis for research purposes.

Treatment

The endovascular procedure was performed in dedicated angiographic suites. A retrograde approach with surgical exposure of the common femoral artery has been preferred. In the cases of iliac arteries obstruction or small vessel diameter, a vascular access by common iliac artery or abdominal aorta was used. In all cases, general anesthesia was performed with cardio-respiratory monitoring and short-term antibiotic prophylaxis (cefazoline 2g or vancomycin 1g). Fluoroscopic monitoring in anterior left-angled projection was performed during the release of the prostheses. Various models of endografts were used (Medtronic Talent, Medtronic Valiant, Medtronic Valiant Captivia, Gore Tag, Gore Excluder, Gore C-Tag, and Cook Zenith TX2). We have overestimated the diameter of the prosthesis by 20% compared to CT-angiography measurements. A controlled hypotension (90 mm/hg) was maintained during procedures. After endoprosthesis’ positioning, we assessed the subclavian artery’s revascularization by Doppler-US examination to exclude any sign of ischemia. Post-procedural complications (incomplete endoprosthesis’ sealing or endoleaks) were immediately treated and, if necessary, left subclavian artery (LSA) embolization were performed. Associated vascular lesions, like traumatic splenic injury, were treated simultaneously to ensure the best treatment and prognosis. A dual anti-platelet therapy (in most cases, acetylsalicylic acid 100 mg/day plus clopidogrel 75 mg/day) has been administered at least for 1 year after endovascular treatment.

Follow-up

Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter, according to recommendations of Society for Vascular Surgery.⁹ A different schedule was used according to previous recommendations by other international societies.¹⁰ In all cases, a clinical and radiological follow-up was performed every year after endovascular treatment.

Statistical analysis

Data were maintained in an Excel spreadsheet (Microsoft Inc, Redmond, Wash) and the statistical analyses were performed on a per-protocol basis, using SPSS software (SPSS, version 22 for Windows; SPSS Inc, Chicago IL, USA). Kolmogorov–Smirnov test and Shapiro–Wilk test were used to verify the normality assumption of data. Categorical data are presented as frequency (percentage value). Continuous normally distributed data are presented as mean ± standard deviation. Continuous not normally distributed data are presented as median (interquartile range: 25th and 75th percentiles—IQR). A p-value of <0.05 was considered statistically significant for the aforementioned tests.

Results

During the study interval (November 2000–October 2020), a total of 38 patients (63% male; average age 37.5 years) with TAI underwent thoracic endovascular aortic repair. One patient was excluded from the study because he had a <6 months follow-up and two patients were excluded from the study because they died after treatment of associated traumatic injuries.

Thirty-two of the 38 patients underwent diagnostic CT immediately after the trauma, while 6 underwent CT during the weeks/months after. The other 6 patients had unrecognized post-traumatic aortic lesions: one of them underwent a CT scan for the onset of recent chest pain, while in the other five cases patients were asymptomatic (Figures 1 and 2). The clinical presentation was chest pain in 14 patients (36.8%), dyspnea in four patients (10.5%) and hemorrhagic shock in 15 patients (39.5%). 10.5% of the patients had associated vascular lesions, while 84.2% of the patients had associated non-vascular lesions. The median value of hemoglobin count at clinical onset was 9.1 g/dl. Population data are reported in Table 1.

Figure 1.

First case-polytrauma patient (2011) with an incidental finding in 2012 of a chronic PSA. CT angiography with axial images (a, b) showing voluminous chronic PSA at the isthmus level, in the presence of parietal lamellar calcifications. Sagittal MIP, (c) and 3D (d) reconstructions, plus angiography (e), confirm voluminous chronic isthmic PSA. Advancement of the endoprosthesis (f). Angiography demonstrates the exclusion of the PSA and the correct positioning with the regular expansion of the endoprosthesis in the descending aorta (g).

Figure 2.

First case-polytrauma patient. Follow-up with CT angiography at 6 months (asymptomatic patient). Axial images (a) and 3D (b), paracoronal MIP (c) and sagittal MIP (d) reconstructions highlight a partial collapse of the endograft in its most distal portion.

Table 1.

Population data.

Variables		All patients (n = 38)
Age (years) – mean		37.5 (±16.2)
Sex (M/F)		24 (63%)/14 (37%)
Symptoms (Yes/No)		33 (86.8%)/5 (13.2%)
Clinical presentation
	Asymptomatic	5 (13.2%)
	Chest pain	14 (36.8%)
	Dyspnea	4 (10.5%)
	Hemorrhagic shock	15 (39.5%)
Associated vascular lesions (Yes/No)		4 (10.5%)/34 (89.5%)
Associated non-vascular lesions (Yes/No)		32 (84.2%)/6 (15.8%)
Hemoglobin (g/dl) – median		9.1 (7.1–12.6)

At CT-angiography, 65.8% of the lesions were pseudoaneurysm, 15.8% of the lesions were dissection, and 18.4% of the lesions were rupture of the thoracic aorta. According to Criado/Ishimaru classifications,^7,8 the 38 thoracic aortic lesions were localized in 7 cases (18.4%) at the distal arch (zone 2) and in 31 cases (81.6%) at the descending aorta (zone 3 and 4). Computed tomography–angiography enabled the accurate measurement of the morphological characteristics of the aortic lesions (average length 40.1 mm; average maximum diameter 35 mm; average distance from brachiocephalic trunk 164.5 mm), fundamental for the choice of the endoprosthesis and for planning the endovascular procedure. Lesion data are detailed in Table 2.

Table 2.

Lesion data.

Variables		All patients (n = 38)
Type of thoracic aortic injury (TAI)
	Pseudoaneurysm	25 (65.8%)
	Dissection	6 (15.8%)
	Rupture	7 (18.4%)
Site, according to Criado/Ishimaru classification
	Distal arch – 2	7 (18.4%)
	Descending aorta – 3/4	31 (81.6%)
Lesion length (mm) – mean		40.1 (±11.9)
Lesion maximum diameter (mm) – mean		35 (±8.1)
Distance from brachiocephalic trunk (mm) – mean		164.5 (±21.5)

The endovascular procedures were performed in urgency regime in 12 cases (31.6%) and emergency regime in 20 cases (52.6%). The other 6 patients (15.8%) had unrecognized post-traumatic aortic lesions, treated in elective regime. In 34 patients (89.5%), vascular access by the common femoral artery was used; in two cases (5.3%) the common iliac artery was used and in the other two cases (5.3%) a direct abdominal trans-aortic access. Thirty-seven patients have been treated with a single endoprosthesis, while in one case two endoprostheses have been used due to a distal type I endoleak. A total of 39 endografts have been used. Preoperative CT-angiography measurements have been used to choose the correct size of the endoprosthesis (average diameter 28.1 mm; average length 115.2 mm) to cover the aortic lesions in all their extension and to have adequate proximal and distal landing zones. In 9 patients (23.7%) the origin of the left subclavian artery was intentionally covered. In one case, the embolization of the left subclavian artery was performed with a “vascular-plug” by brachial access, for a type II endoleak at the post-procedural angiography. In 9 patients, some adjunctive procedures were carried out: 2 splenectomies performed before TEVAR, while four bone stabilizations and three thoracic drainages were performed after the endograft deployment. The median duration of the endovascular procedure was 72.5 min, with a median fluoroscopy time of 42 min. Endovascular procedure data are detailed in Table 3.

Table 3.

Endovascular procedure data.

Variables		All patients (n = 38)
Intervention regime
	Elective	6 (15.8%)
	Urgency	12 (31.6%)
	Emergency	20 (52.6%)
Vascular access site
	Common femoral artery	34 (89.5%)
	Common iliac artery	2 (5.3%)
	Abdominal aorta	2 (5.3%)
Number of endograft used (1/2)		37 (97.4%)/1 (2.6%)
Endograft length (mm) – mean		115.2 (±21.6)
Endograft diameter (mm) – mean		28.1 (±3.9)
Left subclavian artery coverage (yes/No)		9 (23.7%)/29 (76.3%)
Procedure duration (min) – median		72.5 (30)
Fluoroscopy time (min) – median		42 (19)

Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure (such as malposition, dislocation, aortic, or iliac–femoral axis laceration) were observed. The median duration of diagnostic follow-up was 80 months (IQR, 68.2 months). In all cases, the aortic hematoma and hemothorax were completely solved. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses (Figures 3 and 4) of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. One of the collapses occurred 1 month after the procedure, while the second and the third were identified at the 6-months and at the 1-year follow-up. Type Ia endoleak was identified at the 6-months follow-up (Figures 5 and 6). No further complications related to endograft (endoleaks, infections, rupture, partial, or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft’s diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up (Figures 7 and 8). In all cases, CT-angiography examinations were performed at the follow-up. All patients discharged from the hospital were still alive at the time of their last follow-up. Outcomes and follow-up data are detailed in Table 4.

Figure 3.

Second case-polytrauma patient. CT angiography (a, b) demonstrates Psa at the isthmic level, with associated hemomediastinum. Angiography (c) demonstrates the correct positioning of the endoprosthesis which appears regularly expanded. CT angiography at 1 month after TEVAR (D, E) shows correct expansion and patency of the prosthesis, which in the most cranial images presents a partial collapse despite being open.

Figure 4.

Second case-polytrauma patient. Follow-up with CT angiography at 12 months (asymptomatic patient). Axial images (a, b) confirm the correct expansion and patency of the prosthesis except for a partial collapse of the prosthesis in its most caudal portion. Paracoronal (c) and sagittal (d) MIP reconstruction, plus 3D reconstruction (E), demonstrate the collapse of the prosthesis in the descending aorta.

Figure 5.

Third case-polytrauma patient. CT angiography with axial images (a) and paracoronal MIP reconstruction (b), plus angiography (c), showing an acute PSA (arrow) at the concavity of a right-sided aortic arch. Advancement of the endoprosthesis (d). Angiography demonstrates the exclusion of the PSA and the correct positioning with the regular expansion of the endoprosthesis in the descending aorta; the left subclavian artery was intentionally covered (e).

Figure 6.

Third case-polytrauma patient. Follow-up with CT angiography at 6 months (asymptomatic patient). Axial images (a) and MIP paracoronal reconstruction (b) showing a millimeter type IA Endoleak (arrow). Parasagittal MIP (c) and 3D (d) reconstructions confirm the correct positioning with the regular expansion of the endoprosthesis.

Figure 7.

Fourth case-polytrauma patient. CT angiography with axial images (a) and parasagittal MIP (b) and 3D (c) reconstructions highlighting an acute PSA (arrow) at the aortic isthmus. Follow-up with CT angiography at 60 months demonstrates the exclusion of the PSA and the correct positioning with the regular expansion of the endoprosthesis in the descending aorta (d).

Figure 8.

Fourth case-polytrauma patient. Follow-up with MR angiography plus chest radiograph at 72 months. TRUFI sagittal localization sequence (a). 3D Flash MR angiography sequence (b) and MR angiography reconstruction (c) showing the correct positioning and the regular patency of the endoprosthesis (arrows) in the descending aorta. T1 axial post-contrast sequence (d) demonstrates the regular expansion of the endograft in the absence of endoleaks (arrows). Chest radiograph with PA (e) and lateral (f) projections highlight the complete expansion of the endoprosthesis and the regular morphology of the endoprosthetic meshes (arrows).

Table 4.

Outcomes and follow-up data.

Variables		All patients (n = 38)
Procedure-related complications (yes/No)		4 (10.5%)/34 (89.5%)
Type of procedure-related complications
	Endoleak	1 (2.6%)
	Infolding	3 (7.9%)
Follow-up duration (months) – median		80 (68.2)
TAI-related death at follow-up (yes/No)		0 (0%)/38 (100%)
Use of MRI at follow-up (yes/No)		20 (52.6%)/18 (47.4%)
Use of chest radiograph at follow-up (yes/No)		34 (89.5%)/4 (10.5%)
Use of CT at follow-up (yes/No)		38 (100%)/0 (0%)

Discussion

In the last twenty years, the endovascular treatment of TAI became the treatment of choice compared to “open” surgery, as it reduces mortality and morbidity.^10-13 Currently, there are studies with a small number of cases because the incidence of TAI is low, except for a few multicenter studies or work performed by trauma centers, which describe acute complications with medium-term follow-up after TEVAR. TEVAR for TAI treatment is feasible and safe also in patients with associated lesions and in young patients. Long-term results are scarce in the literature, but it is equally true that the late complications’ rate is relatively low.^12,14–18 Therefore, the most important findings of our study are the length of long-term follow-up and the absence of significant morphological changes of the native aorta determined by mechanical forces exerted by the endograft. The most recent guidelines^5,9,10 recognize that TEVAR for TAI is associated with better immediate technical results than traditional surgery, especially immediately after the procedure, where survival is the main purpose of the intervention. However, the long-term durability and efficiency of this less invasive treatment over open surgical repair remain uncertain. Besides, a recent systematic review found no RCTs conducted to determine whether the use of TEVAR for the treatment of blunt TAI is associated with reduced mortality and morbidity when compared to conventional open repair.¹⁹ Another comprehensive evidence is from a systemic review by Murad et al.,²⁰ which was based on 27 comparative observational nonrandomized studies with very low-quality evidence suggesting that, compared with the open repair or nonoperative management, endovascular repair of thoracic aortic transection is associated with better survival. There are two negative aspects related to the long-term follow-up of TEVAR for TAI. The first concern is the limited number of reported cases with long-term follow-up and the second is the low participation of patients in the follow-up.^{11,15,21–28} Furthermore, only a few of these studies specify the participation of patients in follow-ups with clinical evaluation and CT angiography. Instead, our study presents a collection of consecutive cases with long-term follow-up and with a low rate of withdrawal thanks to the strong adherence to scheduled checkups. These are two key points because literature data enlightens that it’s difficult for authors to continue obtaining data from patients (only 30–65% of patients continue follow-up).^{25, 26} In our study, none of the patients came from a catchment area far from our centers. This logistical aspect and the patient recruitment capacity may have been the two decisive factors in achieving this result.

A long-term comparison, in terms of clinical outcome, between TEVAR and surgery is still absent. Patel et al.²⁵ reported that the risk of treatment failure was higher in the TEVAR group, but this had been determined only by re-treatment that occurred in the first year; after that, no long-term complications were observed. A retreatment rate of 5.8% was estimated in patients with a follow-up lasting longer than 3 years after treatment with TEVAR. This rate is higher than that of surgical treatments but is lower than that of TEVARs for non-traumatic diseases.^{11,15,16,25–28} Endovascular treatment in these patients had excellent results and low mortality.²⁵ In our series, we have recorded a low rate of late complications. Because we had a wide range of endografts, we were able to treat virtually all diameters of the native aorta. Furthermore, hypovolemic shock affects the diameter of the descending aorta in trauma victims; therefore, the choice of the endograft was made taking this aspect into account. Prosthetic collapses were not treated because patients were clinically asymptomatic; at CT examination the prostheses presented a slight collapse in the most distal part, while they were open and well expanded in the proximal tract. The aortic tracts distal to prostheses were regularly opened without signs of ischemia of the splanchnic circle and lower limbs. The type I-A endoleak was not treated for the small size and the unfavorable anatomy of the aortic arch; monitoring over time with close follow-up was performed without evidence of progression.

Given that TEVAR is no longer restricted to a cohort of older patients, the consequences of lifelong surveillance deserve special consideration, especially in younger patients treated for TAI.^9,29,30 As stated in the recommendations of the Society for Vascular Surgery,⁹ it will be necessary to show that the benefits of surveillance after TEVAR are justified by the risks and costs over time. Complications prevail in the short term and include unsuccessful exclusion and endograft infolding. However, long-term device behavior is still uncertain so that surveillance regimens in those patients may be relaxed yet not completely stopped.³¹ According to recommendations of the Society for Vascular Surgery⁹ and previous recommendations by other international societies,¹⁰ radiological follow-up was performed with yearly lifelong CT-angiography. In young patients, follow-up made by CT is worrying about the annual cumulative exposure of ionizing radiation. A single CT scan of the chest exposes the patient to approximately 7 mSv of ionizing radiation.³² A single exposure to 10 mSv of ionizing radiation causes cancer in one patient every thousand. In a 40-year-old patient (life expectancy of at least 30 years) who underwent annual chest CT follow-up, the cumulative dose will be approximately 210 mSv; this would significantly increase the risk of developing malignant conditions such as cancer and leukaemia.³³ Hence, MRI has been proposed as a valid alternative in patients with endografts compatible with the magnetic field, associated with a chest X-ray. Rasche et al.³⁴ evaluated 20 patients who underwent an endovascular procedure for TAI with CT and MRI. In this study, MRI performed for the evaluation of endoprostheses (MR-compatible) showed the presence of signal artefacts, up to complete signal voids, as the main limitation. Another limitation is the lack of long-term follow-up and complications. The authors concluded that MRI can give a global assessment of the complications of the thoracic endoprosthesis and proposed MRI as an “imaging” examination to identify complications related to TEVAR. However, given the limitations of a poor long-term follow-up period in the study, MRI was not proposed as a standard, but as a valid alternative. MRI plus chest radiograph can highlight endoleaks, alterations in the structure of the endoprosthesis and its dislocation over time.^5,10,11

Knowledge of the long-term behavior of devices is the main cause for concern, preventing the interruption of surveillance regimes. Morphological changes of the aorta due to age can still occur over the years, resulting in endograft-related complications.^35,36 In our experience, we have not observed aortic morphological changes with a median follow-up duration of 80 months. In light of these late results, TEVAR may be considered effective and long-lasting.

Among TEVAR complications, the main ones described are the collapse and the poor positioning of the endograft resulting in endoleak. Our experience is in agreement with literature data, as we have found three endograft collapses and one endoleak during follow-up, resulting in 10.5% of procedure-related complications. The two main factors associated with an increased risk of long-term procedure-related complications are the mismatch between the endograft and aortic diameters and the bird-beak configuration, defined as a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch.^35,37 Furthermore, in our case series patients with the aforementioned procedure-related complications were clinically asymptomatic, like that of Jonker’s series.³⁶

A classification scheme for grading the severity of the aortic injury has been proposed by Azizzadeh.³⁸ Clinical practice guidelines of the Society for Vascular Surgery for the endovascular repair of traumatic thoracic aortic injury⁵ suggest expectant management with serial imaging for type I injuries. Riesenman et al.²⁶ opted for medical non-operative management in three cases with first degree lesions, but a pseudoaneurysm developed six months after the follow-up (one-third of cases). Marone et al.¹⁶ delayed four stable injury treatments, but then all TAIs were treated when patients showed signs of instability. More recent data show that TEVAR remains equivalent in outcomes to medical management for minimal injuries.³⁹ The optimal management for minimal blunt traumatic TAI remains controversial. In our case history, we have immediately treated four cases of type I TAI in patients with severe chest pain. This approach can be criticized because it exposes the patient to the risks related to the endograft; however, complications related to the endograft are low and the purpose of treatment is survival, despite recent literature data would have modified our strategy. Further evidence is needed to establish the best treatment for type I TAI.

Limitations of the study are the lack of a control group to compare long-term outcomes of the open surgical repair, the retrospectivity of the analysis and the scarcity of data in the literature, necessary to evaluate the congruence and the consistency of the data presented.

Conclusions

Thoracic endovascular repair (TEVAR) is a safe and effective treatment for blunt traumatic thoracic aortic injury (TAI). Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI, making MR-angiography plus chest radiograph a possible alternative to CT-angiography that needs to be tested in further comparative studies.

Footnotes

Author contributions

RM and DL conceived the study concepts and design. RM, DL, RS, MUB, MP, and GC performed literature research and assisted in data collection. RM, DL, and AMI were in charge of manuscript editing. MP performed the statistical analysis using the provided database. All authors read and approved the final manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Consent to participate

Written informed consent for patient information and images to be published was provided by the patients or a legally authorized representative.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

ORCID iDs

Roberto Minici

Raffaele Serra

Appendix

References

Steenburg

Ravenel

Ikonomidis

, et al. Acute traumatic aortic injury: imaging evaluation and Management. Radiol 2008; 248(3): 748–762.

Wee

Syn

, et al. The endovascular repair of blunt traumatic thoracic aortic injury in Asia: A systematic review and meta-analysis. Vascular 2019; 27: 213–223.

Irace

Laurito

Venosi

, et al. Mid- and long-term results of endovascular treatment in thoracic aorta blunt trauma. Scientific World J 2012; 2012: 396873. doi: 10.1100/2012/396873

Ait Ali Yahia

Bouvier

Nedelcu

, et al. Imaging of thoracic aortic injury. Diagn Interv Imaging 2015; 96(1): 79–88.

Lee

Matsumura

Mitchell

, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011; 53(1): 187–192.

Carmona

Redondo

Pareja

, et al. Endovascular treatment of descending thoracic aortic rupture: mid- to long-term results in a single-centre registry. J Cardiovasc Med (Hagerstown) 2012; 13(4): 266–268.

Criado

Barnatan

Rizk

, et al. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta. J Endovasc Ther 2002; 9(2): 1132–1138.

Ishimaru

Endografting of the aortic arch. J Endovasc Ther 2004; 11(2): 1162–1171. doi: 10.1583/04-1407.1

Zierler

Jordan

Lal

, et al. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg 2018; 68(1): 256–284.

10.

Erbel

Aboyans

Boileau

ESC Committee for Practice Guidelines . 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35(41): 2873–2926. doi: 10.1093/eurheartj/ehu281. Erratum in: Eur Heart J. 2015 Nov 1;36(41):2779. PMID: 25173340.

11.

Urgnani

Lerut

Da Rocha

, et al. Endovascular treatment of acute traumatic thoracic aortic injuries: a retrospective analysis of 20 cases. J Thorac Cardiovasc Surg 2009; 138(5): 1129–1138. doi: 10.1016/j.jtcvs.2008.10.057

12.

Azizzadeh

Kristofer

Charlton

, et al. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. J Vasc Surg 2013; 57: 108–115.

13.

Mouawad

Paulisin

Hofmeister

, et al. Blunt thoracic aortic injury - concepts and management. J Cardiothorac Surg 2020; 15(1): 62. doi:10.1186/s13019-020-01101-6

14.

Marcheix

Dambrin

Bolduc

, et al. Endovascular repair of traumatic rupture of the aortic isthmus: midterm results. J Thorac Cardiovasc Surg 2006; 132: 1037–1041.

15.

Orend

Zarbis

Schelzig

, et al. Endovascular treatment (EVT) of acute traumatic lesions of the descending thoracic aorta-7 years’ experience. Eur J Vasc Endovasc Surg 2007; 34: 666–672.

16.

Marone

Kahlberg

Tshomba

et al. Single-center experience with endovascular treatment of acute blunt thoracic aortic injuries. J Cardiovasc Surg 2013; 54: 123–131.

17.

Choi

Kim

Lee

, et al. Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease. Korean J Intern Med 2021; 36(1): S72–S79. doi:10.3904/kjim.2019.080

18.

Lioupis

MacKenzie

Corriveau

, et al. Midterm results following endovascular repair of blunt thoracic aortic injuries. Vasc Endovascular Surg 2012; 46(2): 109–116. doi: 10.1177/1538574411431648

19.

Pang

Hildebrand

Bachoo

. Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. Cochrane Database Syst Rev 2019; 2(2): CD006642. doi: 10.1002/14651858.CD006642.pub3

20.

Murad

Rizvi

Malgor

, et al. Comparative effectiveness of the treatments for thoracic aortic transection [corrected]. J Vasc Surg 2011; 53(1): 193–199.e1-21. doi: 10.1016/j.jvs.2010.08.028. Erratum in: J Vasc Surg. 2011 Aug;54(2):600. PMID: 21035988.

21.

Cheng

Wang

, et al. Long-term Outcomes of Endovascular and Open Repair for Traumatic Thoracic Aortic Injury. JAMA Network Open 2019; 2(2): e187861. doi: 10.1001/jamanetworkopen.2018.7861

22.

Hundersmarck

van der Vliet

QMJ

Winterink

, et al. Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. Eur J Trauma Emerg Surg 2020. doi: 10.1007/s00068-020-01432-y. Epub ahead of print. PMID: 32632630.

23.

Gennai

Leone

Andreoli

, et al. Influence of thoracic endovascular repair on aortic morphology in patients treated for blunt traumatic aortic injuries: long term outcomes in a multicentre study. Eur J Vasc Endovasc Surg 2020; 59(3): 428–436. doi: 10.1016/j.ejvs.2019.05.008

24.

Brenner

Teeter

Hadud

, et al. Long-term outcomes of thoracic endovascular aortic repair: a single institution's 11-year experience. J Trauma Acute Care Surg 2017; 82(4): 687–693. doi: 10.1097/TA.0000000000001365

25.

Patel

Hemmila

Williams

, et al. Late outcomes following open and endovascular repair of blunt thoracic aortic injury. J Vasc Surg 2011; 53(3): 615–620; discussion 621. doi: 10.1016/j.jvs.2010.09.058

26.

Riesenman

Brooks

Farber

. Acute blunt traumatic injury to the descending thoracic aorta. J Vasc Surg 2012; 56(5): 1274–1280. doi: 10.1016/j.jvs.2012.04.035

27.

Canaud

Alric

Branchereau

, et al. Lessons learned from midterm follow-up of endovascular repair for traumatic rupture of the aortic isthmus. J Vasc Surg 2008; 47(4): 733–738.

28.

Fernandez

Mestres

Maeso

, et al. Endovascular treatment of traumatic thoracic aortic injuries: short- and medium-term Follow-up. Ann Vasc Surg 2010; 24(2): 160–166. doi: 10.1016/j.avsg.2009.05.013

29.

Grabenwöger

Alfonso

Bachet

, et al. European Association for Cardio-Thoracic Surgery (EACTS); European Society of Cardiology (ESC); European Association of Percutaneous Cardiovascular Interventions (EAPCI). Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2012; 42(1): 17–24. doi: 10.1093/ejcts/ezs107

30.

Hiratzka

Bakris

Beckman

, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Catheter Cardiovasc Interv 2010; 76(2): E43–E86. doi: 10.1002/ccd.22537

31.

Khoynezhad

Donayre

Azizzadeh

, et al. RESCUE investigators. One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Thorac Cardiovasc Surg 2015; 149(1): 155–161.e4. doi: 10.1016/j.jtcvs.2014.09.026

32.

Larke

Kruger

Cagnon

, et al. Estimated radiation dose associated with low-dose chest CT of average-size participants in the National Lung Screening Trial. AJR Am J Roentgenol 2011; 197(5): 1165–1169. doi: 10.2214/AJR.11.6533

33.

Miller

. Potential long-term complications of endovascular stent grafting for blunt thoracic aortic injury. Scientific World J 2012; 2012: 897489. doi: 10.1100/2012/897489

34.

Rasche

Oberhuber

Trumpp

, et al. MRI assessment of thoracic stent grafts after emergency implantation in multi trauma patients: a feasibility study. Eur Radiol 2011; 21(7): 1397–1405. doi: 10.1007/s00330-011-2074-x

35.

Forbes

Harris

Lawlor

, et al. Aortic dilatation after endovascular repair of blunt traumatic thoracic aortic injuries. J Vasc Surg 2010; 52(1): 45–48. doi: 10.1016/j.jvs.2010.01.094

36.

Jonker

Giacovelli

Muhs

, et al. Trends and outcomes of endovascular and open treatment for traumatic thoracic aortic injury. J Vasc Surg 2010; 51(3): 565–571. doi: 10.1016/j.jvs.2009.10.046

37.

Marrocco-Trischitta

Spampinato

Mazzeo

, et al. Impact of the bird-beak configuration on postoperative outcome after thoracic endovascular aortic repair: a meta-analysis. J Endovasc Ther 2019; 26(6): 771–778. doi: 10.1177/1526602819865906

38.

Azizzadeh

Keyhani

Miller

3rd , et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009; 49(6): 1403–1408. doi: 10.1016/j.jvs.2009.02.234

39.

DuBose

Charlton-Ouw

Starnes

, et al.

AAST/Aortic Trauma Foundation Study Group. Do patients with minimal blunt thoracic aortic injury require thoracic endovascular repair?

J Trauma Acute Care Surg 2021; 90(2): 384–387. doi: 10.1097/TA.0000000000002995