John W. York, Ginger L. Manos, Brent L. Johnson, Chris G. Carsten, Spence M. Taylor, David L. Cull, Bryan C. Morse, Stephen C. Lowe
Surgery, University Medical Center-Greenville Hospital System, Greenville, SC.
OBJECTIVES: Traditionally, blunt thoracic aortic injuries (BTAIs) have been regarded as surgical emergencies due to the perceived imminent risk of rupture and death. Due to an observed aortic stability, our group has adopted a policy of planned observation and surveillance for patients with BTAI. The aim of this study was to evaluate the intermediate outcomes of this non-operative, observational strategy.
METHODS: A retrospective analysis of all patients with BTAI was performed at a single institution with a Level I trauma center. Aortic injuries identified by CT scan were classified as pseudoaneurysm (n=13, 76%), intimal injury (n=2, 12%), intra-mural hematoma (n=1, 6%), and localized dissection (n=1, 6%). Each patient was treated with medical anti-impulse therapy (systolic BP<140mm; heart rate<90bpm) in a monitored setting. CT scans were obtained at intervals during the in-hospital period and following discharge. Overall intervention-free survival and freedom from rupture was evaluated using Kaplan-Meier life table analysis.
RESULTS: A total of 65 patients were identified with BTAI who survived their initial injury and were admitted to our institution. Seventeen patients were selected for surveillance of their BTAI with serial CT scans for a median follow-up of 22.6 months (range –1-128 months) and elective repair when indicated. Two patients (11%) in the observational group received open thoracic aortic repair. Otherwise, there was no significant increase in size of the injured aorta or other aortic associated morbidity during follow-up. The 5-year intervention-free survival and 5-year freedom from rupture was 78% and 100% respectively.
CONCLUSIONS: Our intermediate outcomes indicate that BTAI in stable patients is not a surgical emergency. Indeed, many patients with BTAI can be spared surgical intervention, and when indicated, can safely undergo elective repair. These findings support a non-operative approach to BTAI and that medical therapy should be the initial management of choice.
AUTHOR DISCLOSURES: C. G. Carsten, Nothing to disclose; D. L. Cull, Nothing to disclose; B. L. Johnson, Nothing to disclose; S. C. Lowe, Nothing to disclose; G. L. Manos, Nothing to disclose; B. C. Morse, Nothing to disclose; S. M. Taylor, Nothing to disclose; J. W. York, Nothing to disclose.
Posted April 2012