In the last twenty years, the endovascular treatment of TAI became the treatment of choice compared to “open” surgery, as it reduces mortality and morbidity (Urgnani F et al., 2009; Azizzadeh A et al., 2013; Erbel R et al., 2014; Mouawad NJ et al., 2020). Currently, there are studies with a small number of cases because the incidence of TAI is low, except for a few multicenter studies or work performed by trauma centers, which describe acute complications with medium-term follow-up after TEVAR. TEVAR for TAI treatment is feasible and safe also in patients with associated lesions and in young patients. Long-term results are scarce in the literature, but it is equally true that the late complications’ rate is relatively low (Azizzadeh A et al., 2013; Marcheix B et al., 2006; Orend KH et al., 2007; Marone EM et al., 2013; Lioupis C et al., 2012; Choi JH et al., 2021). Therefore, the most important findings of our study are the length of long-term follow-up and the absence of significant morphological changes of the native aorta determined by mechanical forces exerted by the endograft. The most recent guidelines (Zierler RE et al., 2018; Erbel R et al., 2014; Lee WA et al., 2011) recognize that TEVAR for TAI is associated with better immediate technical results than traditional surgery, especially immediately after the procedure, where survival is the main purpose of the intervention. However, the long-term durability and efficiency of this less invasive treatment over open surgical repair remain uncertain. Besides, a recent systematic review found no RCTs conducted to determine whether the use of TEVAR for the treatment of blunt TAI is associated with reduced mortality and morbidity when compared to conventional open repair (Pang D et al., 2019). Another comprehensive evidence is from a systemic review by Murad et al (Murad et al., 2011), which was based on 27 comparative observational nonrandomized studies with very low-quality evidence suggesting that, compared with the open repair or nonoperative management, endovascular repair of thoracic aortic transection is associated with better survival. There are two negative aspects related to the long-term follow-up of TEVAR for TAI. The first concern is the limited number of reported cases with long-term follow-up and the second is the low participation of patients in the follow-up (Urgnani F et al., 2009; Orend KH et al., 2007; Cheng YT et al., 2019; Hundersmarck D et al., 2020; Gennai S et al., 2020; Brenner M et al., 2017; Patel HJ et al., 2011; Riesenman PJ et al., 2012; Canaud L et al., 2008; Fernandez V et al., 2010). Furthermore, only a few of these studies specify the participation of patients in follow-ups with clinical visits and CT angiography. Instead, our study presents a collection of consecutive cases with long-term follow-up and with a low rate of withdrawal thanks to the close participation in medical and "imaging" visits. These are two key points because literature data enlightens that it’s difficult for authors to continue obtaining data from patients (only 30–65% of patients continues follow-up) (Patel HJ et al., 2011; Riesenman PJ et al., 2012). In our study, none of the patients came from a catchment area far from our centers. This logistical aspect and the patient recruitment capacity may have been the two decisive factors in achieving this result.
A long-term comparison, in terms of clinical outcome, between TEVAR and surgery is still absent. Patel (Patel HJ et al., 2011) reported that the risk of treatment failure was higher in the TEVAR group, but this had been determined only by re-treatment that occurred in the first year; after that, no long-term complications were observed. A retreatment rate of 5.8% was estimated in patients with a follow-up lasting longer than 3 years after treatment with TEVAR. This rate is higher than that of surgical treatments but is lower than that of TEVARs for non-traumatic diseases (Patel HJ et al., 2011; Canaud L et al., 2008; Orend KH et al., 2007; Urgnani F et al., 2009; Fernandez V et al., 2010; Marone EM et al., 2013). Endovascular treatment in these patients had excellent results and low mortality (Patel HJ et al., 2011). In our series, we have recorded a low rate of late complications. Because we had a wide range of endografts, we were able to treat virtually all diameters of the native aorta. Furthermore, hypovolemic shock affects the diameter of the descending aorta in trauma victims; therefore, the choice of the endograft was made taking this aspect into account. Prosthetic collapses were not treated because patients were clinically asymptomatic; at CT examination the prostheses presented a slight collapse in the most distal part, while they were open and well expanded in the proximal tract. The aortic tracts distal to prostheses were regularly opened without signs of ischemia of the splanchnic circle and lower limbs. The type I-A endoleak was not treated for the small size and the unfavourable anatomy of the aortic arch; monitoring over time with close follow-up was performed without evidence of progression.
Given that TEVAR is no longer restricted to a cohort of older patients, the consequences of lifelong surveillance deserve special consideration, especially in younger patients treated for TAI (Grabenwöger M et al., 2012; Hiratzka LF et al., 2010; Zierler RE et al., 2018). As stated in the recommendations of the Society for Vascular Surgery (Zierler RE et al., 2018), it will be necessary to show that the benefits of surveillance after TEVAR are justified by the risks and costs over time. Complications prevail in the short term and include unsuccessful exclusion and endograft infolding. However, long-term device behaviour is still uncertain so that surveillance regimens in those patients may be relaxed yet not completely stopped (Khoynezhad A et al., 2015). According to recommendations of the Society for Vascular Surgery (Zierler RE et al., 2018) and previous recommendations by other international societies (Erbel R et al., 2014), radiological follow-up was performed with yearly lifelong CT-angiography. In young patients, follow-up made by CT is worrying about the annual cumulative exposure of ionizing radiation. A single CT scan of the chest exposes the patient to approximately 7 mSv of ionizing radiation (Larke FJ et al., 2011). A single exposure to 10 mSv of ionizing radiation causes cancer in one patient every thousand. In a 40-years-old patient (life expectancy of at least 30 years) who underwent annual chest CT follow-up, the cumulative dose will be approximately 210 mSv; this would significantly increase the risk of developing malignant conditions such as cancer and leukaemia (Miller LE et al., 2012). Hence, MRI has been proposed as a valid alternative in patients with endografts compatible with the magnetic field, associated with a chest radiograph. Rasche (Rasche V et al., 2011) evaluated 20 patients who underwent an endovascular procedure for TAI with CT and MRI. In this study, MRI performed for the evaluation of endoprostheses (MR-compatible) showed the presence of signal artefacts, up to complete signal voids, as the main limitation. Another limitation is the lack of long-term follow-up and complications. The authors concluded that MRI can give a global assessment of the complications of the thoracic endoprosthesis and proposed MRI as an "imaging" examination to identify complications related to TEVAR. However, given the limitations of a poor long-term follow-up period in the study, MRI was not proposed as a standard, but as a valid alternative. MRI plus chest radiograph can highlight endoleaks, alterations in the structure of the endoprosthesis and its dislocation over time (Urgnani F et al., 2009; Erbel R et al., 2014; Lee WA et al., 2011).
Knowledge of the long-term behaviour of devices is the main cause for concern, preventing the interruption of surveillance regimes. Morphological changes of the aorta due to age can still occur over the years, resulting in endograft-related complications (Forbes TL et al., 2010; Jonker FH et al., 2010). In our experience, we have not observed aortic morphological changes with a median follow-up duration of 80 months. In light of these late results, TEVAR may be considered effective and long-lasting.
Among TEVAR complications, the main ones described are the collapse and the poor positioning of the endograft resulting in endoleak. Our experience is in agreement with literature data, as we have found three endograft collapses and one endoleak during follow-up, resulting in 10.5% of procedure-related complications. The two main factors associated with an increased risk of long-term procedure-related complications are the mismatch between the endograft and aortic diameters and the bird-beak configuration, defined as a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch (Forbes TL et al., 2010; Marrocco-Trischitta MM et al., 2019). Furthermore, in our case series patients with the aforementioned procedure-related complications were clinically asymptomatic, like that of Jonker’s series (Jonker FH et al., 2010).
A classification scheme for grading the severity of the aortic injury has been proposed by Azizzadeh (Azizzadeh A et al., 2009): type I (intimal tear), type II (intramural hematoma), type III (pseudoaneurysm), and type IV (rupture). Clinical practice guidelines of the Society for Vascular Surgery for the endovascular repair of traumatic thoracic aortic injury (Lee WA et al., 2011) suggest expectant management with serial imaging for type I injuries. Riesenman (Riesenman PJ et al., 2012) opted for medical non-operative management in three cases with first degree lesions, but a pseudoaneurysm developed six months after the follow-up (one-third of cases). Marone (Marone EM et al., 2013) delayed four stable injury treatments, but then all TAIs were treated when patients showed signs of instability. More recent data show that TEVAR remains equivalent in outcomes to medical management for minimal injuries (DuBose JJ et al., 2021). The optimal management for minimal blunt traumatic TAI remains controversial. In our case history, we have immediately treated four cases of type I TAI in patients with severe chest pain. This approach can be criticized because it exposes the patient to the risks related to the endograft; however, complications related to the endograft are low and the purpose of treatment is survival, despite recent literature data would have modified our strategy. Further evidence is needed to establish the best treatment for type I TAI.
Limitations of the study are the lack of a control group to compare long-term outcomes of the open surgical repair, the retrospectivity of the analysis and the scarcity of data in the literature, necessary to evaluate the congruence and the consistency of the data presented.