Delayed Aortic Trauma Repair May Improve Survival

CINCINNATI—Patients who live through the first 24 hours of a blunt (non-penetrating) aortic trauma injury may have a better chance of long-term survival if repair to the damaged artery is delayed, surgeons at the University of Cincinnati (UC) say.

This finding is reported by Amy Reed, MD, assistant professor of surgery at UC, in the April edition of the Journal of Vascular Surgery.

The aorta is the main artery that carries oxygenated blood from the heart to be distributed throughout the body. A severe blunt thoracic injury, often the result of the sudden “deceleration” experienced in an auto accident, can jerk the aorta forward and back again, causing it to crack.

“The real problem is that most people die from blunt thoracic aortic trauma before ever reaching a hospital, and about 50 percent of those who do make it will die within a few hours,” explains Dr. Reed, a vascular surgeon.

“Unfortunately even if the aorta is repaired immediately,” she adds, “the patient almost always has other, equally life-threatening injuries that jeopardize their overall recovery and survival.”

Dr. Reed and her team wanted to know if there was a later time frame in which blunt thoracic aortic trauma injuries could be safely repaired, allowing surgeons to first address related—and often fatal—injuries.

If all three layers of the aorta rupture immediately, Dr. Reed explains, the patient dies almost instantly from blood loss. If the outer layer remains intact, however, a weakened area called a pseudoaneurysm can form—which temporarily contains the tear in the vessel, but can burst later.

“This gives us a window of opportunity to get blood pressure under control and prevent further damage to the body,” Dr. Reed explains. “Once the patient is stabilized, we can thoroughly assess the patient’s condition and begin addressing associated—and often just as life-threatening—injuries.”

“Creating this type of carefully controlled scenario allows us to come back and repair the aorta days, weeks, and sometimes even months later when the patient’s body is better able to tolerate it,” she adds.

Dr. Reed analyzed 51 cases of blunt thoracic aortic trauma treated at University Hospital—including the severity of accompanying injuries, time from trauma to repair, surgical method (open versus endovascular) and survival outcomes. Of the 24 patients who made it to the operating room, 13 (54 percent) were stabilized and then had successful delayed endovascular repair. Nine patients (38 percent) had immediate open repair, one of whom died during the procedure. Two patients (8 percent) had delayed open repair.

This data suggests that in some cases it is better to wait and repair the thoracic aortic injury with the minimally invasive (endovascular) technique, says Dr. Reed.

“If surgeons can take care of other injuries—such a bleeding liver or serious head injury—first and then safely address the thoracic aortic trauma injury when the patient is stabilized, there will be a better chance of surviving,” she says.

This approach also allows the surgeon to gather the ideal equipment and team to fix the injury.

Dr. Reed is a vascular surgery consultant to the around-the-clock trauma team at University Hospital, the only level-1 adult trauma center in Hamilton County, Ohio. The team—consisting of surgeons, physicians, residents, nurses, social workers and case managers—are specially trained to treat traumatic and critical-care injuries.

J. Keith Thompson, DO, Charles Crafton, Cindy Delvecchio and Joseph Giglia, MD, were coauthors on this UC-sponsored study.