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Improved mortality with endovascular repair of traumatic thoracic aortic injuries
Rodney P. Bensley, MD1, Ruby C. Lo, MD1, Margriet Fokkema, MD1, Mark C. Wyers, MD1, Allen D. Hamdan, MD1, Elliot L. Chaikof, MD1, Marc Schermerhorn, MD2.
1BIDMC, Boston, MA, USA, 2bidmc, boston, MA, USA.
OBJECTIVES:
Endovascular repair of traumatic thoracic aortic injuries (TAI) is being increasingly utilized as an alternative to conventional open surgical repair. Single institution reviews have shown a benefit with thoracic endovascular aortic repair (TEVAR) of TAI, but it is not clear if this is being realized nationally.
METHODS:
We studied all patients with a diagnosis of a traumatic thoracic aortic injury (ICD9 901.0) in the Nationwide Inpatient Sample, 2005-2009. Patients were grouped into nonoperative management, open repair, or TEVAR. Our primary outcome was in-hospital mortality. Secondary outcomes included length of stay and postoperative complications. Multivariable analysis was used to determine predictors of mortality.
RESULTS:
5390 patients were admitted with a TAI: 1308 TEVAR, 658 open repair, and 3424 nonoperative. Among treated patients, the proportion receiving TEVAR increased from 6.8% in 2005 to 81.8% in 2009 (p<.0001). The proportion of patients undergoing intervention increased from 20.6% in 2005 to 43.9% in 2009 (p<.0001). TEVAR patients were younger compared to open (43.6 vs. 40.0 years, p=.04). Overall in-hospital mortality was lower after TEVAR (13.7% vs. 7.2%, p<.0001) and improved yearly after TEVAR from 32.4% in 2005 to 2.9% in 2009 (p<.001). Mortality after open repair remained stable at 13% and untreated patients had a mortality of 23.5%. Length of stay was similar for TEVAR vs. open (18.6 vs. 20.8 days, p=.26). After open repair patients had higher rates of cardiac (8.8% vs. 4.5%,p<.001) and respiratory (52.3% vs. 40.5%,p80 (4.32[1.90-9.81]p<.001), male gender 2.17[1.38-3.44]p<.001), skull fracture (1.6,[1.00-2.67]p=.04), cerebral vascular disease (8.9[4.19-18.9]p<.0001), and open repair (2.05[1.48-2.84]p<.0001) were predictive of mortality in treated patients.
CONCLUSIONS:
TEVAR is now the dominant treatment method for traumatic TAI and has lower in-hospital mortality compared to open repair. However, most patients with TAI are young, and long term studies are needed to evaluate the long-term effects of TEVAR.
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