STS: Endovascular Stents Effectively Repair Aortic Trauma Injury

SAN DIEGO, Jan. 31 -- Endovascular stents appear to have advantages over open surgery for repairing traumatic aortic rupture among critically injured patients, researchers said here.

Compared with standard open surgery, thoracic aortic stents decreased blood loss, improved recovery, and eliminated the need for anticoagulation, reported Sina L. Moainie, M.D., of the University of Maryland's R. Adams Cowley Shock Trauma Center in Baltimore, and colleagues, at the Society of Thoracic Surgeons meeting.

Aortic rupture is the second leading cause of death from blunt trauma and typically occurs during the rapid deceleration of a car accident. It is an uncommon injury but frequently fatal with most patients dying before arrival at the emergency room.

The researchers retrospectively examined outcomes of 22 consecutive traumatic aortic injury cases treated with open left heart bypass surgery and the same number treated off-label with a Gore TAC aortic endograft. These grafts are FDA-approved for aneurysm of the descending thoracic aorta but not for aortic transection.

The findings were:

• Operative time was significantly shorter with stenting (132.09 minutes versus 268.76 minutes, P=0.00001).
• Blood loss was far less for endovascular stents compared with open surgery (mean 170.45 mL versus 1,871.43 mL, P=0.0001).
• Likewise, 24-hour blood transfusion volumes were significantly lower (2.64 units versus 7.95 units, P=0.002).

Surrogate outcome measures also reflected that patients had easier recovery after an endovascular stent procedure rather than open surgery. The investigators also found:

• The length of stay was more than 10 days shorter with stents (mean 16.47 days versus 27.75 days, P=0.01).
• Tracheostomy with stenting was less than a quarter that of open surgery (9.09% versus 42.86%, P=0.005).

Survival to hospital discharge was identical between groups (85.0%) even though the stent group had lower predicted survival based on severity and mechanism of injury, physiologic parameters and age (73.44% versus 84.85%).

Joseph S. Coselli, M.D., of Baylor in Houston, the discussant, said endovascular stents may prove "quite valuable in the management of patients in institutions and situations where open operation for traumatic lesions across the thoracic aorta have ? frequently poor results."

Such patients may include those in high-risk groups who are at increased risk for bleeding from anticoagulation medication used during open bypass surgery, said Frederick L. Grover, M.D., of the University of Colorado Health Sciences Center in Denver, who moderated the session.

"The particular group of patients that it might be a good place to start would be those patients at particularly high risk for the open procedure," he said. "That's usually the group of patients who have other major injuries such as brain injuries, major intra-abdominal or pelvic injuries with a lot of bleeding where even a little bit of heparin for the left heart bypass to help with the open procedure could potentially increase the risk to the patient."

He said patients with major pulmonary contusions may be candidates as well.

However, Dr. Grover cautioned that long-term follow-up is needed.