Outcomes Following Thoracic Endovascular Aortic Repair For Blunt Thoracic Aortic Injury Stratified By Society For Vascular Surgery Aortic Injury Grade
Sai Divya Yadavalli, MD1, Anne-Sophie Romijn, MD2, Vinamr Rastogi, MD1, Steven Summers, BA1, Christina L. Marcaccio, MD1, Sara L. Zetterval, MD MPH3, Benjamin W. Starnes, MD3, Hence JM Verhagen, MD PhD4, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Massachusetts General Hospital, Boston, MA, USA, 3University of Washington, Seattle, WA, USA, 4Erasmus University Medical Center, Rotterdam, Netherlands.
OBJECTIVE: Although the SVS aortic injury grading (AIG) system has been established for severity of injury in blunt thoracic aortic injury (BTAI) patients, prior literature on its association with outcomes following TEVAR is limited.
METHODS: We identified patients with BTAI undergoing TEVAR in zones 2 to 5 within the VQI between 2013-2022. We stratified patients based on their SVS (AIG) (Grade 1 [G1], intimal tear; Grade 2 [G2], intramural hematoma; Grade 3 [G3], pseudoaneurysm; and Grade 4 [G4], transection/extravasation). We assessed perioperative outcomes and 5-year mortality utilizing multivariable logistic and Cox regression analyses. Secondarily, we assessed trends in SVS AIG over time.
RESULTS: Overall, 1,311 patients were included (G1, 8%; G2, 19%; G3, 57%; G4,17%). Baseline characteristics were similar except for higher prevalence of renal dysfunction, severe chest injury (AIS>3), and lower GCS with increasing AIG (p-trend<.05). Rates of perioperative mortality by AIG were: G1 6.6%, G2 4.9%, G3 7.2%, and G4 14% (P-trend=.003) and rates of aortic related mortality were G1 0, G2 2.9%, G3 3.9%, and G4 11% (P-trend<.001). Rates of 5-year mortality were: G1 11%, G2 10%, G3 11%, and G4 19% (P=.004). G1 patients had the highest rates of perioperative bowel ischemia (3.8% vs G2, 0.80% vs G3, 0.70% vs G4, 2.7%; P=.013) and spinal cord ischemia (2.8% vs G2, 0.40% vs G3, 0.40% vs G4, 2.7%; P=.008). Following risk-adjusment, there was no association between AIG and perioperative mortality (G4 vs. G1; OR:1.4 [95%CI: 0.53-4.2]), or 5-year mortality (HR:1.3 [95%CI: 0.57-2.8]). The proportion of TEVAR patients with a G2 injury decreased over time (18% to 6.7%; P-trend=.021). However, the proportion of G1 injury remained consistent (3.9% to 6.7%; P-trend=.88)
CONCLUSIONS: Following TEVAR for BTAI, there was higher peri-operative and 5-year mortality in G4 patients. However, after risk-adjustment, there was no association between SVS AIG and perioperative and 5-year mortality. Furthermore, we found that over 5% of BTAI patients who underwent TEVAR had a G1 injury, and this proportion remained consistent over time. Given the higher rates of bowel and spinal cord ischemia in G1 patients, these results emphasize the importance of medical management in these patients.
| Grade 1 | Grade 2 | Grade 3 | Grade 4 | ||||||
| (N=106) | (N=244) | (N=741) | (N=220) | ||||||
| Event rate (%) | Event rate (%) | Event rate (%) | Event rate (%) | ||||||
| Ref | OR* [95% CI] | OR* [95% CI] | OR* [95% CI] | ||||||
| Perioperative Mortality | 6.6 | 4.9 | 7.2 | 14 | |||||
| Ref | 0.68 [0.23-2.1] | 0.96 [0.40, 2.7] | 1.41 [0.53, 4.2] | ||||||
| Any Complication | 16 | 20 | 21 | 27 | |||||
| Ref | 1.1 [0.56, 2.3] | 1.4 [0.76, 2.7] | 1.6 [0.82, 3.2] | ||||||
| Acute Kidney Injury | 15 | 12 | 10 | 15 | |||||
| Ref | 0.89 [0.42, 2.0] | 0.75 [0.39, 1.6] | 0.89 [0.42, 2.0] | ||||||
| Spinal Cord Ischemia | 2.8 | 0.4 | 0.4 | 2.7 | |||||
| Ref | 0.12 [0.01-1.0] | 0.13 [0.02-0.72] | 0.78 [0.18-4.1] | ||||||
| Stroke | 1.9 | 5.7 | 2.3 | 4.1 | |||||
| Ref | 3.2 [0.76, 22] | 0.90 [0.22, 6.2] | 2.0 [0.43, 14] | ||||||
| Bowel Ischemia | 3.8 | 0.8 | 0.7 | 2.7 | |||||
| Ref | 0.29 [0.03-2.1] | 0.25 [0.05-1.4] | 0.49 [0.08-3.1] | ||||||
| Leg Ischemia | 1.9 | 0.8 | 1.5 | 1.8 | |||||
| Ref | 0.34 [0.04, 2.9] | 0.61 [0.15, 4.1] | 0.69 [0.12, 5.2] | ||||||
| Pulmonary Complications | 11 | 15 | 17 | 23 | |||||
| Ref | 1.4 [0.66, 3.2] | 1.7 [0.90, 3.7] | 2.2 [1.1, 4.9] | ||||||
| Cardiac Complication | 0.9 | 1.6 | 1.9 | 2.3 | |||||
| Ref | 1.9 [0.27, 38] | 2.3 [0.42, 41] | 2.3 [0.34, 46] | ||||||
| Reintervention/Reoperation | 2.8 | 1.2 | 2.0 | 5.5 | |||||
| Ref | 0.48 [0.09, 2.7] | 0.69 [0.18, 2.7] | 1.4 [0.40, 6.7] | ||||||
| Event rate (%) | Event rate (%) | Event rate (%) | Event rate (%) | ||||||
| Ref | HR* [95% CI] | HR* [95% CI] | HR* [95% CI] | ||||||
| 5-year Mortality | 11 | 10 | 11 | 19 | |||||
| Ref | 0.81 [0.34-1.9] | 0.99 [0.47-2.1] | 1.3 [0.57-2.8] | ||||||
| *Odds Ratios and Hazard Ratios obtained from models adjusted for Age, Gender, Glasgow Coma Score, Severe Head/Neck Trauma, Severe Face Trauma, Severe Chest Trauma, Severe Abdominal Trauma, Chronic Kidney Disease (GFR <60), Obesity, Anemia, and Left Subclavian Occlusion/revascularization (binary-yes/no) | |||||||||
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