Outcomes of routine surveillance of grade 1 blunt traumatic aortic injury.

Abstract

Blunt traumatic aortic injury (BTAI) can present with a wide range of severity from mild intimal injuries (grade 1) to rupture (grade 4). Although there is consensus that patients with grade 3 and 4 injuries should undergo immediate thoracic endovascular aortic repair (TEVAR), the optimal treatment strategy for milder injuries is less clear owing to the lack of data regarding the natural history of these injuries. Grade 1 injuries are typically treated with anti-impulse therapy and surveillance imaging. However, the efficacy of this approach remains unclear. Therefore, the aim of this study was to assess the outcomes of routine surveillance in grade 1 BTAI. Electronic medical records of all patients who presented to our institution with BTAI between 1999 and 2024 were reviewed retrospectively. Initial computed tomography (CT) scans were reviewed, and patients with grade 1 BTAI were included for further review. All initial follow-up studies were assessed and compared with the initial CT scan. A total of 542 patients were initially reviewed, of whom 165 (18%) presented with grade 1 BTAI. Of these patients, 162 (98%) were managed nonoperatively and 3 (2%) underwent immediate surgical intervention for BTAI. Two patients in the early part of our series underwent diagnostic thoracic aortography without further intervention, and one patient underwent repair of a common carotid injury in addition to TEVAR owing to multiple grade 1 injuries. Of these patients, 125 (77%) underwent repeat imaging at a median interval of 7 days (interquartile range, 3-8 days). The initial surveillance imaging showed absence of injury or improvement in 67 patients (54%), stable grade 1 BTAI in 55 (43%), progression to grade 2 BTAI in 1 patient (0.8%), and progression to grade 3 BTAI in 2 patients (1.6%). The three patients who showed progression of BTAI on repeat CT scan underwent further assessment with thoracic aortography and/or intravascular ultrasound examination. The patient with progression to grade 2 injury underwent assessment with intravascular ultrasound examination, which ruled out pseudoaneurysm formation, and no further intervention was performed. Of the two patients with progression to grade 3 injuries, one patient underwent thoracic aortography without further intervention because the injury appeared more consistent with grade 2, and the other patient underwent TEVAR. In our series of patients with grade 1 BTAI who underwent nonoperative management and surveillance imaging, the rate of progression of injury on CT scan was 2.4%. Only one patient (0.8%) ultimately underwent interval TEVAR. These findings suggest that the usefulness of serial imaging in mild BTAI is low in the setting of appropriate nonoperative management.