Physician’s Weekly: online CME courses, articles on hypertension, arthritis

Blunt aortic injury is a leading cause of death in motor vehicle crashes, ranking second only to head injuries after such accidents. Blunt trauma injuries to the aorta typically occur after sudden deceleration in vehicular crashes, specifically due to changes in velocity of 20 mph or more, an impact to the side of the vehicle, and/or the intrusion of walls into the vehicular compartment of 15 inches or more. The abrupt deceleration can cause a tear or rupture at the junction of the aortic arch and the descending aorta.

Up to 80% of patients with blunt aortic injuries die before they ever reach the hospital. Other studies have shown that blunt aortic injury patients who survive their initial trauma and are treated with traditional open surgery have a 30% mortality rate and 8% rate of paraplegia. Traditional methods of open surgical repair require open thorocotomy and clamping of the aorta, which can result in reduced flow to the spinal cord. Advanced methods of open surgical repair include use of the left atrial to femoral bypass and femoral vein to femoral artery bypass circuits. These improvements, when used in selected patients, have reduced the risk of paraplegia but are not universally applied.

Endovascular Grafting

Endovascular grafting is an emerging minimally invasive technique that is performed to repair blunt traumatic aortic injuries. When compared with open surgery, endovascular grafting may offer a less invasive, more effective approach to repairing tears. Rather than opening the chest, a catheter is inserted into an artery in the leg. Using an angiogram, the catheter is guided through blood vessels to the site of the injury. A self-expanding, tube-like endograft is subsequently deployed, creating a new lining that seals the artery. This technique appears to repair the aortic injury effectively and is associated with less blood loss, shorter operating times, and faster recovery times than open surgeries. Several investigations retrospectively comparing endovascular and open repair have found that endograft recipients have lower morbidity, mortality, and paraplegia rates when compared with open surgery recipients.

Important Considerations

There are technical limitations associated with endografting, and most are the result of difficult injury locations and specific aortic anatomies. Injuries that occur adjacent to a sharp bend in the aorta or to a narrow thoracic aorta present challenges for physicians wishing to use endovascular grafting. New endografts currently under investigation will hopefully address these anatomic pitfalls.

The main challenge for surgeons performing endovascular repair for blunt traumatic aortic injuries who are already experienced in endografting techniques for aneurysms is patient selection. When making decisions on whether or not to use endografts, surgeons should base their course of action on injury location and anatomy to ensure optimal outcomes.

The treatment for blunt aortic injury has evolved considerably over the past 50 years, and the hope is that endovascular grafting will become a more widely used method to treat these serious injuries. Although, long-term data on the performance of endografts is lacking, younger patients who have already undergone aortic repair will provide an opportunity to evaluate the efficacy of the technique over a significant period of time.

David G. Neschis, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.