title: Review of the management of blunt thoracic aortic injuries according to current treatment recommendations.
abstract: BACKGROUND
  Blunt thoracic aortic injury (BTAI) is associated with high mortality. Recent Society for Vascular Surgery (SVS) guidelines recommend repair of all but SVS grade I injuries. This study's objective was to retrospectively determine guideline adherence at the authors' trauma center, and its impact on mortality.
  
  
  METHODS
  A retrospective review of the trauma database at the authors' university-affiliated trauma center identified and graded all BTAIs between 1999 and 2011. Patient demographics, treatment, and outcomes were recorded.
  
  
  RESULTS
  Imaging was available for 52 of 59 (85.2%) patients with BTAI. For these 52 patients, injury distribution was: 14 (27.0%) grade 1; 1 (1.9%) grade 2; 35 (67.3%) grade 3; and 2 (3.8%) grade 4. Nonoperative management was used for 92.8% (13), 100% (1), 34.3% (12), and 0% of grade 1, 2, 3, and 4 injuries, respectively. The operatively managed grade I injury was initially misclassified as grade 3. He was lost to follow-up after discharge. Of the 12 patients with nonoperatively managed grade 3 injuries, 7 (58.3%) died before consideration of endovascular repair and another died early secondary to brain injury. The remaining 4 (11.4%) with nonoperatively managed grade 3 injuries survived to discharge but were lost to follow-up. For grade 3 injuries, endovascular repair was significantly associated with decreased mortality (odds ratio [OR], 0.10; 0.02-0.53; P=0.007). Exclusion of those with presentation-day mortality negated this significant association (OR, 0.84; 0.07-9.68; P=1.00).
  
  
  CONCLUSIONS
  Minor deviation (9.6%) from guidelines did not result in additional morbidity/mortality. However, a high rate of loss to follow-up limits conclusions. The mortality reduction seen with endovascular repair for grade 3 injury is inflated by patients who die before repair is considered in the nonoperative group. Larger prospective studies with appropriate inclusion and exclusion criteria and improved follow-up are needed to determine the consequences of selective nonoperative management of these injuries.
authors.affiliation: Division of General Surgery, London Health Sciences Centre & University of Western Ontario, London, Ontario, Canada.
authors.forename: Biniam
authors.initials: B
authors.lastname: Kidane
authors.forename: Neil G
authors.initials: NG
authors.lastname: Parry
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Forbes
mesh_terms: D000328:Adult; D001013:Aorta, Thoracic / Q000293:injuries / Q000601:surgery*; D005260:Female; D019983:Guideline Adherence / Q000592:standards; D006801:Humans; D015601:Injury Severity Score; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009864:Ontario; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014193:Trauma Centers; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D057772:Vascular System Injuries / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*