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Early Versus Delayed Thoracic Endovascular Aortic Repair For Blunt Thoracic Aortic Injury: A Propensity Score-matched Analysis
Anne-Sophie C. Romijn, MD1, Vinamr Rastogi, MD2, Jefferson A. Proaņo-Zamudio, MD1, Sai Divya Yadavalli, MD2, Christina L. Marcaccio, MD2, Georgios Giannakopoulos, MD3, Haytham MA Kaafarani, MD MPH1, Frank W. Bloemers, MD PhD3, Hence JM Verhagen, MD PhD4, Marc L. Schermerhorn, MD2, Noelle Saillant, MD1.
1Massachusetts General Hospital, Boston, MA, USA, 2Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Amsterdam University Medical Center, Amsterdam, Netherlands, 4Erasmus University Medical Center, Rotterdam, Netherlands.

OBJECTIVES: Current guidelines recommend delayed Thoracic Endovascular Aortic Repair (TEVAR) following Blunt Thoracic Aortic Injury (BTAI). However, this recommendation was based on small, retrospective studies that were not designed to address the endovascular management of traumatic aortic injuries specifically. In this study, we aim to examine the impact of timing on outcomes following TEVAR for BTAI using a nationwide database, taking the aortic injury grade into consideration.METHODS: Patients undergoing TEVAR for BTAI in the Trauma Quality Improvement Program (TQIP) between 2016-2019 were included. Transfer patients and patients with grade 4 aortic injury were excluded. Outcomes included in-hospital mortality and complications, and we assessed the proportion of delayed TEVAR use over time. A 1:1-propensity score-matched cohort was created based on time to repair (early: ≤24hrs vs. delayed: >24hrs). Matching was based on demographics, comorbidities, injury severity score (ISS), vital signs, and aortic injury grade.RESULTS: Overall, 1,339 patients were included, of whom 1,054 (79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs. delayed; 25% vs. 32%; p=0.014 | Table), fewer early interventions for grade-1 occurred, and grade-3 aortic injuries often were intervened upon within 24 hours (grade-1: 28% vs. 47%; grade-3: 49% vs. 23%; p<0.001). After matching, the final sample included 542 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (12% vs. 4.1% / RR 3.0 [95%CI 1.5-5.8]; p=<0.001) and a longer intensive care unit (ICU) length of stay (7.0days; [4.0-15] vs. 10days; [7.0-19]; p<0.001). Furthermore, no differences in in-hospital complications were observed between the early and delayed group. CONCLUSIONS: In this propensity-score matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.

Table. Outcomes following early vs delayed TEVAR for BTAI
Early TEVAR (N=271)Delayed TEVAR (N=271)Relative risk (95%CI)P-value
In-hospital mortality33 (12%)11 (4.1%)3 (1.5-5.8)<0.001
24 hour in-hospital mortality6 (2.2%)0 (0.0%)NA0.014
Length of hospital stay (days)7.0 (1.0-17)11 (1.0-23)NA0.082
ICU length of stay (days)8.0 (4.0-15)11 (7.0-19)NA<0.001
Days on the vent 4.5 (1.0-12)7.0 (1.0-13)NA0.270
In-hospital complications
Cardiac arrest requiring CPR17 (6.3%)14 (5.2%)1.2 (0.6-2.4)0.580
Central line-associated bloodstream infection1 (0.4%)3 (1.1%)0.33 (0.03-3.2)0.340
Deep SSI3 (1.1%)4 (1.5%)0.75 (0.17-3.3)0.705
Deep vein thrombosis3 (1.1%)4 (1.5%)1.0 (0.40-2.5)1.000
Pulmonary embolism9 (3.3%)14 (5.2%)0.64 (0.28-1.5)0.291
Acute kidney injury15 (5.5%)21 (7.7%)0.71 (0.38-1.4)0.303
Myocardial infarction1 (0.4%)5 (1.8%)0.2 (0.02-1.7)0.141
Organ space SSI2 (0.7%)1 (0.4%)2.0 (0.18-22)0.570
Acute respiratory distress syndrome14 (5.2%)6 (2.2%)2.3 (0.91-60)0.078
Severe sepsis11 (4.1%)6 (2.2%)1.8 (0.69-4.9)0.226
Stroke/cerebrovascular accident9 (3.3%)11 (4.1%)0.82 (0.34-1.9)0.649
Superficial incisional SSI2 (0.7%)1 (0.4%)2.0 (0.18-22)0.570
Ventilator associated pneumonia10 (3.7%)17 (6.3%)0.59 (0.27-1.3)0.173
Alcohol withdrawal syndrome1 (0.5%)3 (1.4%)0.32 (0.03-2.1)0.324
Catheter associated UTI8 (3.7%)6 (2.8%)1.3 (0.45-3.6)0.637

Data are presented as median (IQR) for continuous measures, and n (%) for categorical measures.CPR: cardiopulmonary resuscitation; SSI: surgical site infection; UTI: urinary tract infection.

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