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Intraoperative Therapeutic Heparin Is Safe During Thoracic Endovascular Aortic Repair (tevar) For Blunt Thoracic Aortic Injury With Concomitant Solid Organ Injury And/or Traumatic Brain Injury.
Maunil N. Bhatt, MD1, Christopher O. Audu, MD, PHD
2, Courtney R. Hanak, MD
3, Dina M. Filiberto, MD
1, Saskya Byerly, MD
1, Isaac W. Howley, MD
1, Erica L. Mitchell, MD EdM
1;
1University of Tennessee Health Sciences Center, Memphis, TN, USA,
2University of Michigan, Ann Arbor, MI, USA,
3Cleveland Clinic, Cleveland, OH, USA
OBJECTIVES: The safety of systemic heparinization during thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) with polytrauma is a controversial issue. 2011 Society for Vascular Surgery guidelines suggest using lower dose heparinization for TEVAR for BTAI than elective revascularization. Clear evidence is lacking on heparin use during TEVAR for BTAI with polytrauma. This study reviews outcomes of TEVAR with and without intraoperative therapeutic heparinization for patients with BTAI and traumatic brain injury (TBI) and/or solid organ injury (SOI).
METHODS: Over a period of 32 months (January 2021 - August 2023) at a high-volume urban trauma center, 78 cases of confirmed BTAI were identified and retrospectively analyzed. Patients were stratified to no heparin (NH) vs therapeutic heparin (TH). Collected data included demographics, injury grade, concomitant traumatic injuries, and treatment modality. Primary outcomes included complications related to use or lack of use of procedural heparin including periprocedural stroke, and progression of TBI or SOI after TEVAR.
RESULTS: Our cohort comprised 76 patients after excluding two who died pre-TEVAR. The median age was 42 +/- 37 years, 69.7% were men, and median injury severity score was 29 (interquartile range, 24-36.5). Grade of injury included grades I (n=34), II (n=7), III (n=30), and IV (n=5). Thirty-nine (51.3%) of patients received TEVARs including 4/6 grade II injuries. Sixteen (21.1%) patients had concomitant TBI, 6 (37.5%) underwent TEVAR, 4 with TH and two NH. One NH patient had peri-operative ipsilateral hemispheric stroke. No patients receiving TH had perioperative stroke. No TBI patient receiving TH for BTAI had TBI progression. Thirty (39.5%) patients presented with concomitant SOI, 14 (46.7%) underwent TEVAR with all but 2 (85.7%) receiving TH. Nine (64.3%) SOI patients required adjunctive measures to treat SOI pre-TEVAR, 4 splenectomies, 2 hepatectomies, and 3 organs embolized. Eight patients had both TBI and SOI on admission; 2 (25%) underwent TEVAR, one with TH and the other with NH. Neither had TBI progression. Of the 37 medically managed only patients, 3 (8.1%) had TBI progression.
CONCLUSIONS: We believe heparinization during TEVAR is safe for polytrauma patients including those with TBI and SOI. Failure to heparinize may increase risk of peri-operative stroke.
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