Thoracic Endovascular Repair (TEVAR) for Blunt Traumatic Thoracic Aortic Injury: Long-Term Results.

doi:10.21203/rs.3.rs-1450003/v1

Background:

Blunt traumatic thoracic aortic injury (TAI) is a critical injury with high mortality and an uncertain prognosis. In the last twenty years, thoracic endovascular repair (TEVAR) has become the treatment of choice compared to surgery, as it reduces mortality and morbidity. To date, a few studies evaluated long-term clinical and radiological follow-up of TEVAR for blunt traumatic TAI. The main concerns related to long-term follow-up relate to late endograft-related complications, morphological changes in the aorta and the consequences of life-long surveillance in terms of cumulative radiation dose.

Results:

Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of 4 procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft’s diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up.

Conclusions:

The consequences of lifelong surveillance deserve special consideration in younger patients treated with thoracic endovascular repair (TEVAR) for blunt traumatic thoracic aortic injury (TAI). Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up.

Thoracic endovascular repair (TEVAR)

blunt traumatic thoracic aortic injury (TAI)

long-term follow-up

procedure-related complications

MRI.

In 1557, the first thoracic aortic injury (TAI) was described by the Flemish anatomist Vesalius in a patient fallen from a horse. This pathology has been described mostly since 1900 as a consequence of road trauma (Steenburg SD et al., 2008). TAI represents approximately 94% of all traumatic aortic lesions. Aortic rupture leads to high mortality and it is usually the result of deceleration and torsion from car accidents, precipitation from great heights and sports injuries. In most cases (80–90%), these are full-thickness lesions of the aortic wall, which result in rapid bleeding with the death of the patient at the accident scene or during transport to the hospital. In the other cases (10–20%), the lesions are incomplete or contained by adventitial or peri-adventitial tissue, allowing patients to arrive in a trauma centre. These lesions, if untreated, can develop into complete rupture or pseudoaneurysms. Pseudoaneurysms are at high risk of rupture and are often diagnosed as occasional findings. In survivors, the lethality rate increases by 1–2% every hour afterwards and only 2% of the untreated patients survive beyond four months (Steenburg SD et al., 2008; Ho XN et al., 2019; Irace L et al., 2012). TAI is a "critical" injury with high mortality and an uncertain prognosis. The prognosis of the polytraumatized patients with TAI becomes worse if multiple injuries (abdominal, neurosurgical, bone or thoracic) are associated. If possible, the patient should be referred to a trauma centre. Patients need stabilization of vital functions and fast identification and treatment of the most serious and potentially fatal injuries. CT is the gold standard in the management of polytraumatized patients, if stable or stabilized. Until a few years ago, only open surgery with extracorporeal circulation was used. This treatment is characterized by high morbidity, especially for subsequent anticoagulation therapies and coagulopathies in the polytraumatized hemorrhagic patients (pulmonary contusions, multiple fractures, limb injuries, cranial lesions, internal organs fractures such as liver, kidney, bladder etc.). In the last decade, open surgery has been replaced by endovascular treatment (TEVAR) with excellent immediate results (mortality reduction and few cases of major complications such as paraplegia, stroke or renal failure) (Ait Ali Yahia D et al., 2015; Lee WA et al., 2011; Carmona AF et al., 2012). This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic TAI, through long-term clinical and diagnostic follow-up. CT, MRI and chest radiographs have been used in the diagnostic follow-up.

Study design

The Institutional Review Board approval and informed written consent from each patient have been obtained. This study is a multi-centre (Circolo Hospital and Macchi Foundation of Varese, Italy - Mater-Domini University Hospital of Catanzaro, Italy), retrospective analysis of prospectively collected data of consecutive patients with TAI, who had undergone, from November 2000 to October 2020, thoracic endovascular aortic repair. Inclusion criteria, met by all patients, are I) blunt traumatic thoracic aortic injury (TAI); II) treated with thoracic endovascular aortic repair (TEVAR); III) evaluation by a multidisciplinary team of vascular surgeons, interventional radiologists and anaesthetists; IV) age ≥ 18 years. Exclusion criteria are: I) missed clinical and radiological follow-up after 6 months since the endovascular treatment; II) death after TEVAR of associated traumatic injuries (intracerebral haemorrhage, abdominal haemorrhage, etc.). In all cases, a computed tomography (CT) angiography and a total body CT scan (multislice CT Lightspeed Plus, GE, Milwaukee, USA; Aquilion 64, Toshiba, Tokyo, Japan) were performed after trauma to identify associated cerebro-thoraco-abdominal vascular lesions, to evaluate the feasibility of the endovascular procedure, to choose the endoprosthesis and to select the most favourable vascular access. Classifications by Ishimaru and Criado (Criado FJ et al., 2002; Ishimaru S et al., 2004) were used to describe aortic anatomy, defining the five possible landing zones of the thoracic aorta during the endovascular repair. A different treatment is intended for each zone. The treatment of Zone 0, the most proximal, involves the complete transposition of the epiaortic vessels with aorto-anonymous and left aorto-carotid by-pass, and eventually a carotid-subclavian by-pass. The treatment of Zone 1, the intermediate, requires a carotid-carotid by-pass and possibly carotid-subclavian by-pass. Zone 2, more distal, can be treated both with carotid-subclavian by-pass and with intravascular treatment if subclavian theft can be carried out. Zone 3 and Zone 4 can be treated with endovascular treatment.

Treatment

The endovascular procedure was performed in dedicated angiographic suites. After surgical exposure of the common femoral artery, in most cases, a retrograde approach and insertion of the endoprosthesis were performed. In the cases of iliac arteries obstruction or small vessel diameter, vascular access by common iliac artery or abdominal aorta was used. In patients with a chronic history of TAI, heparin sodium (100 IU/Kg) has been administered in the arterial lumen systematically, to maintain an activated clotting time > 250 s. In cases of acute trauma, heparin treatment was applied during surgery after exclusion of associated visceral haemorrhages. In all cases, general anaesthesia was performed with cardio-respiratory monitoring and short-term antibiotic prophylaxis (cefazoline 2g or vancomycin 1g). From the contralateral femoral side or a brachial/radial access, a pigtail catheter was advanced for angiography. The endografts were delivered over a stiff guidewire and deployed at the thoracic aorta level by fluoroscopic monitoring in anterior left-angled projection. The implanted endografts were Medtronic Talent, Medtronic Valiant, Medtronic Valiant Captivia, Gore Tag, Gore Excluder, Gore C-Tag and Cook Zenith TX2. We have overestimated the diameter of the prosthesis by 20% compared to CT-angiography measurements. During procedures, controlled hypotension (90 mm/hg) was maintained to avoid the endograft dislodgement during the release and a final angiography was carried out to evaluate the correct endograft position and the absence of endoleaks. After endoprosthesis’ positioning, we assessed the subclavian artery’s revascularization by Doppler-US examination to exclude any sign of ischemia. Post-procedural complications (incomplete endoprosthesis’ sealing or endoleaks) were immediately treated and, if needed, left subclavian artery (LSA) embolization were performed. Eventually, associated vascular lesions, like traumatic splenic injury, were treated simultaneously to ensure the best treatment and prognosis. When it has been possible, after resolution of vascular lesions associated with trauma, a dual anti-platelet therapy (in most cases, acetylsalicylic acid 100 mg/day plus clopidogrel 75 mg/day) has been administered at least for 1 year after endovascular treatment.

Follow-up

Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter, according to recommendations of Society for Vascular Surgery (Zierler RE et al., 2018). A different schedule was used according to previous recommendations by other international societies (Erbel R et al., 2014). In all cases, a clinical and radiological follow-up was performed every year after endovascular treatment.

Statistical analysis

Data were maintained in an Excel spreadsheet (Microsoft Inc, Redmond, Wash) and the statistical analyses were performed on a per-protocol basis, using SPSS software (SPSS, version 22 for Windows; SPSS Inc, Chicago IL, USA). Kolmogorov-Smirnov test and Shapiro-Wilk test were used to verify the normality assumption of data. Categorical data are presented as frequency (percentage value). Continuous normally distributed data are presented as mean ± standard deviation. Continuous not normally distributed data are presented as median (interquartile range: 25th and 75th percentiles - IQR). A P-value of < 0.05 was considered statistically significant for the aforementioned tests.

During the study interval (November 2000 - October 2020), a total of 38 patients (63% male; average age 37.5 years) with TAI underwent thoracic endovascular aortic repair. One patient was excluded from the study because he had a < 6 months follow-up and two patients were excluded from the study because they died after treatment of associated traumatic injuries.

32 of the 38 patients underwent diagnostic CT immediately after the trauma, while 6 underwent CT during the weeks/months after. The other 6 patients had unrecognized post-traumatic aortic lesions: one of them underwent a CT scan for the onset of recent chest pain, while in the other five cases patients were asymptomatic (Figs. 1 and 2). The clinical presentation was chest pain in 14 patients (36.8%), dyspnea in 4 patients (10.5%) and hemorrhagic shock in 15 patients (39.5%). 10.5% of the patients had associated vascular lesions, while 84.2% of the patients had associated non-vascular lesions. The median value of hemoglobin count at clinical onset was 9.1 g/dl. Population data are reported in Table 1.

Table 1

Population data.
Variables		All patients (n = 38)
Age (years) – mean		37.5 (± 16.2)
Sex (M/F)		24 (63%) / 14 (37%)
Symptoms (Yes/No)		33 (86.8%) / 5 (13.2%)
Clinical presentation
	Asymptomatic	5 (13.2%)
	Chest pain	14 (36.8%)
	Dyspnea	4 (10.5%)
	Hemorrhagic shock	15 (39.5%)
Associated vascular lesions (Yes/No)		4 (10.5%) / 34 (89.5%)
Associated non-vascular lesions (Yes/No)		32 (84.2%) / 6 (15.8%)
Hemoglobin (g/dl) – median		9.1 (7.1–12.6)

At CT-angiography, 65.8% of the lesions were pseudoaneurysm, 15.8% of the lesions were dissection and 18.4% of the lesions were rupture of the thoracic aorta. According to Criado/Ishimaru classifications (Criado FJ et al., 2002; Ishimaru S et al., 2004), the 38 thoracic aortic lesions were localized in 7 cases (18.4%) at the distal arch (zone 2) and in 31 cases (81.6%) at the descending aorta (zone 3 and 4). CT-angiography enabled the accurate measurement of the morphological characteristics of the aortic lesions (average length 40.1 mm; average maximum diameter 35 mm; average distance from brachiocephalic trunk 164.5 mm), fundamental for the choice of the endoprosthesis and for planning the endovascular procedure. Lesion data are detailed in Table 2.

Table 2

Lesion data
Variables		All patients (n = 38)
Type of thoracic aortic injury (TAI)
	Pseudoaneurysm	25 (65.8%)
	Dissection	6 (15.8%)
	Rupture	7 (18.4%)
Site, according to Criado/Ishimaru classification
	Distal arch – 2	7 (18.4%)
	Descending aorta – 3/4	31 (81.6%)
Lesion length (mm) – mean		40.1 (± 11.9)
Lesion maximum diameter (mm) - mean		35 (± 8.1)
Distance from brachiocephalic trunk (mm) - mean		164.5 (± 21.5)

The endovascular procedures were performed in urgency regime in 12 cases (31.6%) and emergency regime in 20 cases (52.6%). The other 6 patients (15.8%) had unrecognized post-traumatic aortic lesions, treated in elective regime. In 34 patients (89.5%) vascular access by the common femoral artery was used; in two cases (5.3%) the common iliac artery was used and in the other two cases (5.3%) a direct abdominal trans-aortic access. 37 patients have been treated with a single endoprosthesis, while in one case two endoprostheses have been used due to a distal type I endoleak. A total of 39 endografts have been used. Preoperative CT-angiography measurements have been used to choose the correct size of the endoprosthesis (average diameter 28.1 mm - average length 115.2 mm) to cover the aortic lesions in all their extension and to have adequate proximal and distal landing zones. In 9 patients (23.7%) the origin of the left subclavian artery was intentionally covered. In one case, the embolization of the left subclavian artery was performed with a “vascular-plug” by brachial access, for a type II endoleak at the post-procedural angiography. In 9 patients some adjunctive procedures were carried out: 2 splenectomies performed before TEVAR, while 4 bone stabilizations and 3 thoracic drainages were performed after the endograft deployment. The median duration of the endovascular procedure was 72.5 minutes, with a median fluoroscopy time of 42 minutes. Endovascular procedure data are detailed in Table 3.

Table 3

Endovascular procedure data
Variables		All patients (n = 38)
Intervention regime
	Elective	6 (15.8%)
	Urgency	12 (31.6%)
	Emergency	20 (52.6%)
Vascular access site
	Common femoral artery	34 (89.5%)
	Common iliac artery	2 (5.3%)
	Abdominal aorta	2 (5.3%)
Number of Endograft used (1/2)		37 (97.4%) / 1 (2.6%)
Endograft length (mm) - mean		115.2 (± 21.6)
Endograft diameter (mm) - mean		28.1 (± 3.9)
Left subclavian artery coverage (Yes/No)		9 (23.7%) / 29 (76.3%)
Procedure duration (min) - median		72.5 (30)
Fluoroscopy time (min) - median		42 (19)

Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure (such as malposition, dislocation, aortic or iliac-femoral axis laceration) were observed. The median duration of diagnostic follow-up was 80 months (IQR, 68.2 months). In all cases, the aortic hematoma and hemothorax were completely solved. A total of 4 procedure-related complications

(10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses (Figs. 3 and 4) of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. One of the collapses occurred 1 month after the procedure, while the second and the third were identified at the 6-months and at the 1-year follow-up. Type Ia endoleak was identified at the 6-months follow-up (Figs. 5 and 6). No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft’s diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up (Figs. 7 and 8). In all cases, CT-angiography examinations were performed at the follow-up. All patients discharged from the hospital were still alive at the time of their last follow-up. Outcomes and follow-up data are detailed in Table 4.

Table 4

Outcomes and follow-up data.
Variables		All patients (n = 38)
Procedure-related complications (Yes/No)		4 (10.5%) / 34 (89.5%)
Type of procedure-related complications
	Endoleak	1 (2.6%)
	Infolding	3 (7.9%)
Follow-up duration (months) - median		80 (68.2)
TAI-related death at follow-up (Yes/No)		0 (0%) / 38 (100%)
Use of MRI at follow-up (Yes/No)		20 (52.6%) / 18 (47.4%)
Use of Chest Radiograph at follow-up (Yes/No)		34 (89.5%) / 4 (10.5%)
Use of CT at follow-up (Yes/No)		38 (100%) / 0 (0%)

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.

Thoracic endovascular repair (TEVAR) is a safe and effective treatment for blunt traumatic thoracic aortic injury (TAI). The consequences of lifelong surveillance deserve special consideration, especially in younger patients treated for TAI, making MR-angiography plus chest radiograph a valuable alternative to CT-angiography who deserves dedicated comparative study to consolidate its use in clinical practice. Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up.

IQR

Interquartile range

LSA

left subclavian artery

RCTs

Randomized controlled trials

TAI

thoracic aortic injury

TEVAR

thoracic endovascular aortic repair

Ethics approval and consent to participate

Approval by the ethic committee of Magna Graecia University and written informed consent by patients were obtained.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors’ contributions

RM and DL conceived the study concepts and design. RM, DL, MP and GC performed literature research and assisted in data collection. RM, DL and AMI were in charge of manuscript editing. MP performed the statistical analysis using the provided database. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

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Thoracic Endovascular Repair (TEVAR) for Blunt Traumatic Thoracic Aortic Injury: Long-Term Results.

Status:

Version 1

Abstract

Figures

Background

Methods

Study design

Treatment

Follow-up

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Status:

Version 1