Page 68 - Read Online

Page 12 of 19 Rinaldi et al. Vessel Plus 2024;8:21 https://dx.doi.org/10.20517/2574-1209.2023.65

These grades represent a spectrum of severity, with Grade I being the least severe and Grade IV being the
[56]
most severe and life-threatening . Early recognition and appropriate management are crucial in bTAI
cases due to the high mortality rates associated with these injuries. Prompt diagnosis is necessary to improve
the patient's chances of survival.

Management
Endovascular repair with TEVAR has become the preferred treatment approach for patients with acute
bTAI. TEVAR has shown lower early and late morbidity and mortality rates compared to open surgical
repair [57,58] . However, there are certain considerations to keep in mind during the endovascular management
of bTAI. One critical aspect is the selection of the appropriate stent-graft. In patients with severe
hypotension, standard 10%-20% stent-graft oversizing based on preoperative CT imaging may not be
sufficient, increasing the risk of type I endoleak. Additionally, patients with bTAI are often at a young age,
and have aortic diameter variations during the cardiac cycle, and angled aortic arches, which can result in
proximal inadequate apposition of the stent-graft (bird’s beak effect) and subsequent potential
complications, such as graft collapse [59-61] . Careful procedure planning is necessary to address these
challenges and avoid complications. In this scenario, intra-vascular ultrasound (IVUS) can be a valuable
adjunctive tool during the procedure, providing real-time measurements of the aorta before and after stent-
[62]
graft deployment .
To achieve an adequate proximal sealing zone, intentional coverage of the left subclavian artery (LSA) may
be necessary, especially in patients with isthmic aortic lesions. The RESCUE trial, which evaluated TEVAR
in patients with bTAI, reported that among the treated patients, some required complete LSA coverage,
while others required partial LSA coverage. The trial demonstrated that these patients did not experience
[63]
strokes or spinal cord injuries, and only a small number required LSA revascularization .

It is important for the treatment team to carefully assess the individual patient's anatomy, hemodynamic
status, and potential risks in order to plan the most appropriate and effective endovascular repair strategy
for bTAI [Figure 8].

The indications for treatment and the timing of intervention in patients with blunt traumatic thoracic aortic
injuries (bTAI) are still debated. Recent evidence suggests a more conservative approach for patients with
lower grades of aortic injuries, specifically grade I and II [59,64] . A study published by the Aortic Trauma
Foundation Global Registry supports the use of medical therapy alone as the definitive treatment in patients
with grade I and II bTAI. The registry reported low overall intervention rates and no aortic-related deaths in
[65]
this group of patients .
Regarding the timing of intervention, a recent study analyzed the association between mortality and the
timing of repair. The study found that patients who underwent repair after 24 h had better survival
outcomes compared to those who underwent earlier intervention. This suggests that a delay in intervention
may be beneficial in terms of mortality .
[66]
It is important to consider individual patient factors, such as the severity of the aortic injury, hemodynamic
stability, associated injuries, and the overall clinical status, when determining the appropriate treatment
approach and timing for bTAI. A multidisciplinary approach involving vascular surgeons, trauma surgeons,
and other specialists is crucial in making these decisions and optimizing patient outcomes.