By Erin Moore

Endovascular repair of traumatic thoracic aortic injury (TTAI) is associated with lower perioperative mortality and morbidity rates than open surgical repair, according to a study published in the April 2008 issue of the Journal of Vascular and Interventional Radiology. Canadian researchers found significant differences favoring thoracic endovascular aortic repair (TEVAR) on all measured variables.

TTAI generally occurs following a high-speed motor vehicle collision and is thought to account for 20 percent of vehicular accident deaths. Prior to 2003, when TEVAR was adopted into general practice, TTAIs were treated with open surgery. The surgical method is highly invasive and the combination of the significant mortality and morbidity rates with the frequent concomitant serious injuries makes it a challenge. TEVAR is a relatively new procedure without much documentation; the study authors thus set out to compare TEVAR with open surgery in the management of TTAI.

In this retrospective study, the authors identified patients from a provincial trauma registry who presented with acute, blunt TTAI between April 1995 and September 2006. One group -- 24 men and 12 women -- consisted of those who were treated surgically (either via the clamp-and-sew technique or partial left heart bypass, depending on physician preference), and the other group -- 21 men and 5 women -- was treated with TEVAR. Four surgical patients and no TEVAR patients died on the table; the technical success rate for TEVAR was 100 percent.

The 30-day mortality rates of the 2 groups were not significantly different. However, the 2 deaths that occurred in the TEVAR cohort were unrelated to the procedure, while all mortalities in the surgical cohort were intraoperative. All measured complications, including intrathoracic nerve damage, paraplegia, pneumonia, graft failure, and scarring, occurred significantly more frequently after surgery than after TEVAR. These results agree with the existing literature.

Although the authors say that more research is necessary due to the retrospective, historical data as well as the predominantly male study population, they assert: "the one drawback of TEVAR we found is that it is relatively more expensive. However, it avoids the most devastating complications associated with [surgery] -- namely neurological defects secondary to spinal cord ischemia -- and is a less time-consuming and less invasive procedure overall."

"This study adds to the growing, albeit still young, body of literature supporting the use of TEVAR in this acutely, critically ill population," said Dr. Ziv Haskal, Professor of Radiology and Surgery at the Columbia University Medical Center. "We have also learned that there are unique device issues related to TEVAR in an otherwise normal, non-atherosclerotic aorta that can lead to unusual later complications such as graft infolding. Without a doubt, TEVAR devices specifically designed for trauma applications will be developed, ones that may be more compliant and conforming to the adjacent normal aorta."

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Source: Chung J, Owen R, Turnbull R, et al. 2008. Endovascular repair in traumatic thoracic aortic injuries: Comparison with open surgical repair. Journal of Vascular and Interventional Radiology 19:479-486.

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