This study reported data on a group of patients with BTAI who visited Xijing Hospital during the last 10 years. The retrospective study data were extracted from hospital records based on the Chinese aortic dissection registry database, supplemented by the hospital cardiosurgery database and electronic medical records.
In our study, the male population was predominant (79.2%), with hypertension (37.5%) as the most common complication, traffic accidents as the most common injury mechanism (44.4%), and aortic isthmus (51.4) as the most common injury site. These basic patient characteristics were consistent with those of patients in other centers. However, compared with those in France and the United States, the age of patients in China in this study was significantly older than 54.2 ± 9.1 years (8,14,15,16,17).
This study applies the classic grading system (11) of the SVS. Compared with single-center studies in other countries (5,8), Grade III lesions accounted for a higher proportion of injuries in this study, which may be the most common type of BTAI in China. Further, this is closely associated with the following two facts (1). Although chest or back pain were found in 83.3% of patients in this study, the causes of pain are complex and diverse, and rib fractures, spinal injuries, pelvic fractures, and chest soft tissue injuries are prone to missed diagnosis or misdiagnosis (10,18). The main reason for the missed diagnosis was that orthopedic experts and ICU bedside doctors did not thoroughly examine the thoracic aorta injury and did not conduct aortic CTA examination or cross-sectional imaging to investigate vascular injury when the patient first visited the ED (10,11,19). In this study, 13 patients (18%) were treated in the local lower-level hospital for several weeks and months after trauma; however, symptoms did not show any improvement and no treatment required referral to cardiovascular surgery in our hospital. Emergency surgeons must understand the correlation between blunt thoracic trauma and BTAI, and based on the injury mechanism of patients with trauma, BTAI should be highly suspected. (2) Approximately 80% of patients with blunt aortic injury die before reaching the hospital, and most of those who survive the initial injury die without appropriate treatment (1,2,11,18,21), which may result in a deviation in the analysis population.
Based on the guidelines, Grade II–IV injuries should be treated via surgery. In this study, TEVAR was given priority for the treatment of patients with Grade II and III thoracic aortic injuries. Several previous studies have reported the beneficial results of endovascular repair on aortic trauma. Thomas M Scalea et al. used the American College of Surgeons National Trauma Databank (2003–2013) to identify adults with BTAI and found that TEVAR largely replaced open surgery, thereby reducing the mortality rate of BTAI by 50%. In both meta-analyses (24,25), endovascular intervention was associated with a significantly lower paraplegia rate and a lower mortality rate in traumatic aortic injury compared with open surgery. Endovascular intervention due to the avoidance of aortic clamping reduced intraoperative blood loss and did not require the use of postoperative anticoagulants, resulting in an increase in the use of this technology every year (23,26,27). Thus, open surgery and endovascular intervention in this study were not indicated for postoperative patients with paraplegia, and an effective conclusion cannot be drawn. A recent study published by Alexey Kamenskiy et al. reported that TEVAR in patients with BTAI may lead to accelerated expansion and reconstruction of the ascending aorta, increased left ventricular mass, and high incidence of hypertension. Therefore, long-term prevention of cardiovascular complications and follow-up or even lifelong detection for young patients should be implemented after the surgery. Al-Thani et al. reported that GCS and aortic injury grade in the ED were independent predictors of mortality in patients with BTAI. The 5-year survival rate after TEVAR was 94%, and the 5- and 10-year survival rates reported by Agostinelli et al. were 92% and 87%, respectively. The 5- and 10-year survival rates of TEVAR in this study were 97% and 84%, respectively, which were similar to the results of the two studies. The mean time required to perform TEVAR in this study was 41 ± 14.9 min, which was significantly shorter than that in other centers (80.5 ± 59.9 min)(30). No study has confirmed the difference between the time required to perform TEVAR and postoperative results; therefore, further studies are warranted in the future.
Recent studies have shown that the nonsurgical treatment of patients with low-grade (Grade I–II) BTAI does not lead to long-term aortic complications or require further intervention. Nonsurgical treatment can be safely used for Grade II BTAI (31,32). In this study, the imaging follow-up of a patient with type II aortic injury revealed that even though hematoma was absorbed earlier, the long-term results need to be further confirmed by further imaging follow-up. In the conservatively treatment group, the indication for surgery was not met due to extremely poor cardiopulmonary function or organ failure, and 5 of 8 deaths (62.5%) were reported due to the refusal of surgery by family members. Three patients died during hospitalization, and only two patients were followed up. The management of patients who opted for nonsurgical treatment also needs urgent relevant research and analysis. Overall, different surgical management strategies and inconsistent intensive care programs may lead to different mortality rates.