Professor and Chief, Division of Vascular Surgery University of California Davis Health Sacramento, California
Objectives: Grading blunt thoracic aortic injuries (BTAI) is a key determinant for reporting and treatment of this condition, but provides no guidance for the safety of intraoperative heparin for patients with concurrent traumatic brain injury (TBI). We sought to compare the impact of intraoperative systemic heparinization on outcomes after thoracic endovascular aneurysm repair (TEVAR) for patients with TBI. We also compared University of Washington (UW) and Society of Vascular Surgery (SVS) grading systems.
Methods: We reviewed all patients admitted with BTAI from 2011 through 2021. Collected data included injury grading, demographics and concomitant traumatic injuries. Our primary outcome was progression of TBI after TEVAR. Additional outcomes included time to repair, mortality, and concordance of the two BTAI grading systems.
Results: The cohort comprised 174 patients after excluding three who died upon arrival. The mean age was 46 ± 19 years, 68% were men, and the median ISS was 34 (IQR 26- 45). Median door to repair time was 19 hours (IQR 11-39 hours) and 79% received systemic heparin. Strong agreement was observed between the scoring systems (kappa=.84). BTAI treatment was aligned with guidelines for 87%-89% of patients. Repair was required for 63% of patients (all TEVAR). Time to repair was delayed for TBI patients (TABLE I; p=.002). Heparin was used in a majority of TBI patients, but was used less frequently than for those without TBI (TABLE I; p<.001). Overall mortality was 8% (12.5% with BTAI observed vs. 5.5% with BTAI treated, p=.09) with no BTAI-related deaths. Repair delayed >48 hours did not decrease mortality (5.0% vs. 5.6%; p=.9). Vascular complications occurred in 8.2% of those receiving TEVAR with an overall re-operation rate of 4.5%. Progression of TBI was not associated with severity of BTAI by either grading system. Progression of TBI after TEVAR was not impacted with intra-operative systemic heparin use (4.6% with vs. 6.7% without, p=.87). Mean follow-up after TEVAR was 7.9 ± 11.7 months; 97.0% of repaired patients had resolution of the injury.
Conclusions: Use of systemic heparin during TEVAR for BTAI appears to be safe in selected patients with TBI, without progression of TBI. UW BTAI grading system accurately captures patients requiring surgical intervention compared with the SVS grading system. Clinical expertise remains key to determine optimal management.
