Management of moderate blunt thoracic aortic injuries in patients with solid organ injury

Abstract

Objective: Blunt thoracic aortic injuries (BTAIs) are the second leading cause of trauma-related deaths in the United States. Using the Harborview grading system, BTAIs can be classified as minimal, moderate or severe. Patients with BTAIs often present with multiple concomitant injuries, including solid organ injuries (SOIs), which can influence treatment decisions. Although moderate BTAIs can undergo semi-elective repair, the optimal management of moderate BTAIs with associated SOIs is unknown. The aim of this study was to analyze our experience with patients presenting with concomitant moderate BTAIs and SOIs.

Methods: We conducted a single-center retrospective study of patients who underwent thoracic endovascular aortic repair (TEVAR) for treatment of moderate BTAIs between March 2015 and December 2023. SOIs and their grades were identified, and our institutional SOI protocol was followed for each patient. Our endpoints included surgical timing, outcomes, and the need for reintervention.

Results: A total of 214 patients presented with BTAIs during the study period. Eighty-eight patients underwent TEVAR for moderate BTAIs, and 46 of those (52%) presented with concomitant SOI. SOIs included liver (63%), spleen (59%), and kidney (37%) injuries. Patients with SOIa did trend towards longer time from presentation to repair; however, no difference was noted intraoperatively in the dosing of heparin used or activated clotting time between the two groups. Only one patient experienced a bleeding complication associated with their SOI after receiving systemic heparinization during TEVAR and required a return to the operating room for a splenectomy on postoperative day 1. Patients with SOIs did have a longer length of stay; no aortic-related mortalities were noted in either group. Thirty-day all-cause mortality was 4% for patients with SOIs and 5% for patients without SOIs (P = .92).

Conclusions: Patients with moderate BTAI and SOI can safely undergo TEVAR with systemic heparinization without an increased risk of complications. Their prolonged hospital length of stay underscores the severity of their injuries and the multifaceted challenges involved in managing this critically ill patient population.

Keywords: Blunt aortic injury; Solid organ injury; TEVAR; Vascular trauma.