Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study.
BACKGROUND
The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes.


METHODS
This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair (< or = 24 hours) and delayed repair groups (> 24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries.


RESULTS
There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2%) of which underwent early repair and 69 (38.8%) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95% CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239).


CONCLUSIONS
Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.
Demetriades
Demetrios
D
Multicenter Clinical Trials Committee, American Association for the Surgery of Trauma, USA. demetria@usc.edu
Velmahos
George C
GC
Scalea
Thomas M
TM
Jurkovich
Gregory J
GJ
Karmy-Jones
Riyad
R
Teixeira
Pedro G
PG
Hemmila
Mark R
MR
O'Connor
James V
JV
McKenney
Mark O
MO
Moore
Forrest O
FO
London
Jason
J
Singh
Michael J
MJ
Spaniolas
Konstantinos
K
Keel
Marius
M
Sugrue
Michael
M
Wahl
Wendy L
WL
Hill
Jonathan
J
Wall
Mathew J
MJ
Moore
Ernest E
EE
Lineen
Edward
E
Margulies
Daniel
D
Malka
Valerie
V
Chan
Linda S
LS
D000328:Adult; D001013:Aorta, Thoracic / Q000293:injuries*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D022125:Lacerations / Q000401:mortality / Q000601:surgery; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000401:mortality / Q000601:surgery; D015999:Multivariate Analysis; D016017:Odds Ratio; D011446:Prospective Studies; D012121:Respiration, Artificial; D013997:Time Factors; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000401:mortality* / Q000601:surgery*; D055815:Young Adult