title: Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study.
abstract: BACKGROUND
  The purpose of this American Association for the Surgery of Trauma multicenter study is to assess the early efficacy and safety of endovascular stent grafts (SGs) in traumatic thoracic aortic injuries and compare outcomes with the standard operative repair (OR).
  
  
  METHODS
  Prospective, multicenter study. Data for the following were collected: age, blood pressure, and Glasgow Coma Scale (GCS) at admission, type of aortic injury, injury severity score, abbreviate injury scale (AIS), transfusions, survival, ventilator days, complications, and intensive care unit and hospital days. The outcomes between the two groups (open repair or SG) were compared, adjusting for presence of critical extrathoracic trauma (head, abdomen, or extremity AIS >3), GCS score </=8, systolic blood pressure <90 mm Hg, and age >55 years. Separate multivariable analysis was performed, one for patients without and one for patients with associated critical extrathoracic injuries (head, abdomen, or extremity AIS >3), to compare the outcomes of the two therapeutic modalities adjusting for hypotension, GCS score </=8, and age >55 years.
  
  
  RESULTS
  One hundred ninety-three patients met the criteria for inclusion. Overall, 125 patients (64.9%) were selected for SG and 68 (35.2%) for OR. SG was selected in 71.6% of the 74 patients with major extrathoracic injuries and in 60.0% of the 115 patients with no major extrathoracic injuries. SG patients were significantly older than OR patients. Overall, 25 patients in the SG group (20.0%) developed 32 device-related complications. There were 18 endoleaks (14.4%), 6 of which needed open repair. Procedure-related paraplegia developed in 2.9% in the OR and 0.8% in the SG groups (p = 0.28). Multivariable analysis adjusting for severe extrathoracic injuries, hypotension, GCS, and age, showed that the SG group had a significantly lower mortality (adjusted odds ratio: 8.42; 95% CI: [2.76-25.69]; adjusted p value <0.001), and fewer blood transfusions (adjusted mean difference: 4.98; 95% CI: [0.14-9.82]; adjusted p value = 0.046) than the OR group. Among the 115 patients without major extrathoracic injuries, higher mortality and higher transfusion requirements were also found in the OR group (adjusted odds ratio for mortality: 13.08; 95% CI [2.53-67.53], adjusted p value = 0.002 and adjusted mean difference in transfusion units: 4.45; 95% CI [1.39-7.51]; adjusted p value = 0.004). Among the 74 patients with major extrathoracic injuries, significantly higher mortality and pneumonia rate were found in the OR group (adjusted p values 0.04 and 0.03, respectively). Multivariate analysis showed that centers with high volume of endovascular procedures had significantly fewer systemic complications (adjusted p value 0.001), fewer local complications (adjusted p value p = 0.033), and shorter hospital lengths of stay (adjusted p value 0.005) than low-volume centers.
  
  
  CONCLUSIONS
  Most surgeons select SG for traumatic thoracic aortic ruptures, irrespective of associated injuries, injury severity, and age. SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications. There is a major and urgent need for improvement of the available endovascular devices.
authors.affiliation: demetria@usc.edu
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
authors.forename: George C
authors.initials: GC
authors.lastname: Velmahos
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
authors.forename: Riyad
authors.initials: R
authors.lastname: Karmy-Jones
authors.forename: Pedro G
authors.initials: PG
authors.lastname: Teixeira
authors.forename: Mark R
authors.initials: MR
authors.lastname: Hemmila
authors.forename: James V
authors.initials: JV
authors.lastname: O'Connor
authors.forename: Mark O
authors.initials: MO
authors.lastname: McKenney
authors.forename: Forrest O
authors.initials: FO
authors.lastname: Moore
authors.forename: Jason
authors.initials: J
authors.lastname: London
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Singh
authors.forename: Edward
authors.initials: E
authors.lastname: Lineen
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Spaniolas
authors.forename: Marius
authors.initials: M
authors.lastname: Keel
authors.forename: Michael
authors.initials: M
authors.lastname: Sugrue
authors.forename: Wendy L
authors.initials: WL
authors.lastname: Wahl
authors.forename: Jonathan
authors.initials: J
authors.lastname: Hill
authors.forename: Mathew J
authors.initials: MJ
authors.lastname: Wall
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: Daniel
authors.initials: D
authors.lastname: Margulies
authors.forename: Valerie
authors.initials: V
authors.lastname: Malka
authors.forename: Linda S
authors.initials: LS
authors.lastname: Chan
mesh_terms: D000328:Adult; D001013:Aorta, Thoracic / Q000293:injuries* / Q000601:surgery*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D019917:Blood Vessel Prosthesis Implantation; D016009:Chi-Square Distribution; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011446:Prospective Studies; D012307:Risk Factors; D012955:Societies, Medical; D018709:Statistics, Nonparametric; D015607:Stents; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000401:mortality / Q000601:surgery*