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Outcomes of Deliberate Nonoperative Management for Blunt Thoracic Aortic Injury in Trauma
Anthony D Caffarelli, Hari R. Mallidi, Paul M. Maggio, David A. Spain, Mary Anne Purtill, Michael P. Fischbein, *Robert C. Robbins, Phillip E. Oyer, *Bruce A. Reitz, *D. Craig Miller, *R. Scott Mitchell
Stanford University, Stanford, CA
Objective
Blunt thoracic aortic injury in trauma has traditionally been managed as a surgical emergency. Treatment options have consisted of urgent and delayed open repairs and more recently endovascular stent graft repairs. However with improved imaging capabilities, a broader spectrum of aortic injuries are now detectable, including many injuries consisting of only a partial intimal disruption. In this study, we review our experience with a deliberate, nonoperative management for blunt thoracic aortic injury.
Methods
From January 2001 to May 2008, a retrospective chart review with selective longitudinal follow-up was conducted. All patients admitted to our Level I trauma center that were confirmed to have the diagnosis of blunt aortic injury and survived disposition from the emergency department had their hospital course reviewed. Surveillance imaging with CT angiogram was performed to evaluate the aortic injuries. Nonoperative patients were then reviewed and analyzed for (1) in-hospital survival and interval survival as determined through patient interviews and review of the Social Security Death Index (SSDI), (2) evolution of aortic injury, and (3) possible failure of nonoperative management
Results
During the study period, 54 patients (39 males, 15 females) with an average age of 46 years (range 18-82) were identified with 28% presenting to our emergency department and 72% transfered from outside hospitals. Of the 54 patients, 24 underwent operative management (9 open vs. 15 endovascular stent graft repairs) while 30 patients underwent nonoperative management with anti-impulse therapy. From 2001 to 2004, 20 patients underwent operative repair while 5 underwent nonoperative management. From 2005 to 2008, 4 patients underwent operative repair while 25 underwent nonoperative management. Average Injury Severity Score (ISS) for all patients was 33.9 ± 10.4; with no significant difference between nonoperative vs. operative patients (31.9 ± 10.2 vs. 36.4 ± 10.2; p = 0.91). Of the 30 nonoperative patients, in-hospital survival was 90% (27 patients) with no aortic deaths in the remaining 3 patients. Post-discharge follow-up has shown an interval survival of 96.7% with one non-aortic death (13 patients confirmed alive, while 13 patients not listed in the SSDI). Two patients failed nonoperative management: one for increasing pseudoaneurysm size and underwent open repair; another underwent endovascular stent graft repair for unclear reasons. Serial imaging was performed in all patients (average of 97 days, median 30 days) with 50% having longitudinal imaging studies > 30 days post injury and 15% had imaging > 100 days post injury. Five patients had complete resolution of their aortic injuries.
Conclusions
This experience suggests that deliberate nonoperative management of select aortic injuries may be a reasonable alternative in the multi-trauma patient; however, serial imaging and long-term follow-up will be necessary to detect treatment failures.
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