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Reduced Mortality, Paraplegia, And Stroke With Stent Graft Repair Of Blunt Aortic Transections: A Modern Meta-Analysis

Gale L Tang¹, Hassan Y Tehrani², Eduardo Perez³, Christopher Otero³, Mariano Arosemena³, Kushagra Katariya², Domenico Calcaterra³, Grayson H Wheatley, III⁴, Mark K Eskandari.^1
1Northwestern Memorial Hospital, Chicago, IL; ²Artemis Health Institute, Gurgaon, Haryana, India; ³Jackson Memorial Hospital, Miami, FL; ⁴Arizona Heart Institute, Phoenix, AZ.

OBJECTIVES: In recent years, there have been numerous reports of endovascular repair of traumatic thoracic aortic transections (TTAT). Stent grafting has become the first-line approach to TTAT in some trauma centers due to a perceived decrease in morbidity and mortality rates over standard open repair which typically requires a thoracotomy with or without the use of partial cardiopulmonary bypass. We sought to review contemporary outcomes of patients undergoing endovascular repair of TTAT (endoTTAT) as compared to those undergoing open repair (openTTAT) to determine if current reported results support first-line use of endoTTAT.

METHODS: A systematic review of retrospective, non-randomized studies (>5 cases/report) involving TTAT published and listed in PubMed between 2001 and 2006 was performed. Periprocedural outcomes between endoTTAT and openTTAT were analyzed. Mean follow-up was 22 months for endoTTAT (reported for 17 of 23 studies) and 59 months for openTTAT (reported for 3 of 9 studies). Data analyzed includes patient age, injury severity score (ISS), technical success, mortality, paraplegia, and stroke rates. Procedure specific complication rates were also examined. For statistical analysis T-tests were used.

RESULTS: An analysis of 32 papers reporting on 555 procedures was performed. Among the 308 patients treated with endoTTAT and the 247 patients managed with openTTAT there were no statistical differences in regards to mean age (40 yrs vs 38 yrs, P < 0.39), ISS (39.7 vs 35.9, P < 0.3) or technical success rates of the procedure (95.4% vs 98.8%, P = 0.35). In contrast, mortality was statistically significantly lower in the endoTTAT group (7.1% vs 15.8%, P = 0.0026) as were paraplegia (0% vs 5.2%, P < 0.0001) and stroke (0.6% vs 6.6%, P < 0.011) rates. The most common procedure-related complications for each technique were iliac artery injury during endoTTAT and recurrent laryngeal nerve injury after openTTAT.

CONCLUSIONS: To date, no large multi-center prospective randomized trial comparing endoTTAT and openTTAT has yet to be published in the world literature. This meta-analysis of pooled data serves as a surrogate demonstrating a significant reduction in mortality, paraplegia, and stroke rates in patients who undergo endoTTAT, however the long-term durability of endoTTAT remains in question.