title: Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study.
abstract: BACKGROUND
  Blunt thoracic aortic injuries (BTAIs) are composed of a spectrum of lesions ranging from intimal tear to rupture, yet optimal management and ultimate outcome have not been clearly established.
  
  
  METHODS
  This is a retrospective multicenter study of BTAIs from January 2008 to December 2013. Demographics, diagnosis, treatment, and in-hospital outcomes were analyzed.
  
  
  RESULTS
  Nine American College of Surgeons-verified Level I trauma centers contributed data from 453 patients with BTAIs. After exclusion of patients expiring before imaging (58) and transfers (13), 382 patients with imaging diagnosis were available for analysis (Grade 1, 94; Grade 2, 68; Grade 3, 192; Grade 4, 28). Hypotension was present on admission in 56 (14.7%). Computed tomographic angiography was used for diagnosis in 94.5%. Nonoperative management (NOM) was selected in 32%, with two in-hospital failures (Grade 1, Grade 4) requiring endovascular salvage (thoracic endovascular aortic repair [TEVAR]). Open repair (OR) was completed in 61 (16%). TEVAR was conducted in 198 (52%), with 41% of these requiring left subclavian artery coverage. Complications of TEVAR included endograft malposition (6, 3.0%), endoleak (5, 2.5%), paralysis (1, 0.5%), and stroke (2, 1.0%). Six TEVAR failures were treated by repeat TEVAR (2) or OR (4). Overall in-hospital mortality was 18.8%, and aortic-related mortality was 6.5% (NOM, 9.8%; OR, 13.1%; TEVAR, 2.5%) (Grade 1, 0%; Grade 2, 2.9%; Grade 3, 5.2%; Grade 4, 46.4%). The majority of aortic-related deaths (18 of 25) occurred before the opportunity for repair. Independent predictors of aortic-related mortality among BTAI patients were higher chest Abbreviated Injury Scale (AIS) score, grade, and Injury Severity Score (ISS); TEVAR was protective (p = 0.03; odds ratio, 0.21; confidence interval, 0.05-0.88).
  
  
  CONCLUSIONS
  Failures and aortic-related mortality of NOM following BTAI Society of Vascular Surgery Grade 1 to 3 injuries are rare. TEVAR seems independently protective against aortic-related mortality. Early complications of TEVAR have decreased relative to previous reports. Prospective long-term follow-up data are required to better refine indications for intervention.
  
  
  METHODS
  Level IV.
authors.affiliation: From the University of Texas-Houston (J.J.D., S.S.L., C.M., A.A.), Houston; University of Texas Southwestern-Austin (M.D.T., C.V.R.B.), Austin; and University of Texas Southwestern-Dallas, Dallas, Texas; R Adams Cowley Shock Trauma Center (M.B., J.P., T.S.), University of Maryland, Baltimore, Maryland; Loma Linda University Medical Center (T.A.O., X.L.-O., C.D.), Loma Linda; and Los Angeles County + University of Southern California Hospital (O.R., K.I., D.D.), Los Angeles, California; Louisiana State University Health Sciences Center (J.M., W.M.), New Orleans, Louisiana; Mayo Clinic-Rochester (M.Z., M.Al., M.Am., D.J.), Rochester, New York; and University of Arizona School of Medicine (G.V., A.E.), Tucson, Arizona.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: DuBose
authors.forename: Samuel S
authors.initials: SS
authors.lastname: Leake
authors.forename: Megan
authors.initials: M
authors.lastname: Brenner
authors.forename: Jason
authors.initials: J
authors.lastname: Pasley
authors.forename: Thomas
authors.initials: T
authors.lastname: O'Callaghan
authors.forename: Xian
authors.initials: X
authors.lastname: Luo-Owen
authors.forename: Marc D
authors.initials: MD
authors.lastname: Trust
authors.forename: Jennifer
authors.initials: J
authors.lastname: Mooney
authors.forename: Frank Z
authors.initials: FZ
authors.lastname: Zhao
authors.forename: Ali
authors.initials: A
authors.lastname: Azizzadeh
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D000792:Angiography; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D012042:Registries; D012189:Retrospective Studies; D013898:Thoracic Injuries / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*