INTRODUCTION

Aortic injury is the leading cause of mortality in blunt trauma and accounts for 80% to 90% of deaths at the scene. Blunt traumatic aortic injury (BTAI) is thought to result from the water-hammer effect [1], wherein the sudden occlusion of noncompressible fluid [2], increases intravascular pressure, producing a waveform effect on the vessel wall. This phenomenon is exacerbated at the aortic arch due to its curvature, resulting in a spectrum of aortic injuries ranging from intimal disruption (with or without intramural hematoma) to false lumen formation leading to pseudoaneurysm, or even complete transection of the aorta [1,2]. TAI is classified into four grades by Azizzadeh et al. [3]: grade I includes intimal irregularities; grade II, intramural hematoma; grade III, pseudoaneurysm; and grade IV, free contrast extravasation due to complete aortic rupture. Since the most common site of aortic injury is at the aortic isthmus (documented in up to 60% of cases [4]), just distal to the subclavian artery, owing to the mobile nature of the aortic arch and the fixed position of the descending aorta [5], we focused on patients with TAI. Diagnostic imaging of TAI has evolved from chest x-ray to computed tomography (CT) angiography. Almost all cases of TAI resulting from blunt trauma involve serious concomitant injuries, necessitating the involvement of multiple specialties such as trauma surgery, neurosurgery, orthopedics, cardiothoracic surgery, critical care, and allied health. The initial management of these major traumas follows Advanced Trauma Life Support (ATLS) guidelines [6]. After initial stabilization, life-threatening injuries are addressed first, followed by management of BTAI, usually led by the trauma team with multidisciplinary discussion.

Thoracic endovascular aortic repair (TEVAR) is currently considered the first-line treatment for grades II and above. TEVAR has improved morbidity and mortality outcomes compared to open surgery [7–11]. However, few case series have reported early or mid-term outcomes of endovascular repair [12]. Evidence suggests that delayed TEVAR (>24 hours after injury) may yield better outcomes than early TEVAR (<24 hours after injury) [13,14]. However, the optimal timing for the operation remains unclear. Furthermore, predictors of post-TEVAR mortality after TAI and the long-term outcomes of patients managed conservatively remain unknown.

Western Australia (WA) is unique as it is the largest health jurisdiction in the world, covering over 2.5 million km², and is home to approximately 2.96 million inhabitants as of June 2024 (10.9% of Australia’s population) [15]. Furthermore, WA hosts a single level 1 trauma center at Royal Perth Hospital (Perth, WA, Australia), with all other centers having suitable trauma and vascular surgical teams located in the metropolitan area. Consequently, all major trauma patients require transfer to the metropolitan area for management. Given the high mortality associated with TAI, our study offers an interesting perspective on managing these complex injuries in a vast and logistically challenging healthcare setting. We describe the characteristics—including mechanism of injury, vascular interventions, morbidity, and mortality—of patients managed for TAI (conservatively, open surgery, TEVAR [early vs. delayed]) at a level 1 trauma center in WA from 2008 to 2018, with particular focus on surgical repair (open and endovascular repair) of aortic injury in our institution.

METHODS

Ethics statement

This study was approved by the Royal Perth Hospital Human Research Ethics Committee (No. RGS0000003322). The requirement for informed consent was waived as the study was considered low to negligible risk to participants due to its retrospective nature. All data were de-identified prior to analysis.

Study design and setting

This is a retrospective cohort study of all adult patients (≥18 years old) with TAI admitted to the State Major Trauma Unit at Royal Perth Hospital from 2008 to 2018. Patients were excluded if they met any of the following criteria: (1) under 18 years old; (2) had an ungradable aortic injury (bruised or shredded); (3) had missing or confidential medical or imaging records at study entry; (4) pronounced dead on arrival; or (5) died prior to vascular surgery consultation.

Patients were identified and their available data was extracted from the State Trauma Service Registry [16]. Data were supplemented with paper, digital, and electronic medical records (iSOFT Clinical Manager [iCM], iSOFT). The data collected included demographic characteristics, mechanism of injury, level of injury, grade of aortic injury [3], Injury Severity Score (ISS) [17], length of hospital stay, associated injuries, time to operating theatre, duration of the procedures, comorbidities, inpatient complications, follow-up, and discharge destination. Long-term follow-up for vascular surgery–related complications and overall survival was determined from the last known surgical review, imaging report, or healthcare contact captured in the iCM Visit History until June 30, 2024.

Conservative management consisted of hemodynamic monitoring, including invasive blood pressure monitoring via the radial artery, and anti-impulse therapy, usually with a β-blocker or calcium channel blocker as required. Hemodynamic targets included a systolic blood pressure (SBP) of <120 mmHg and a heart rate of <60 beats per minute, according to recommendations from the European Society of Vascular Surgery (ESVS) [18] or at the discretion of the treating physician. Antiplatelet therapy was administered to conservatively managed patients as needed. The decision to perform a TEVAR—including early and delayed TEVAR—or open surgery was determined by the on-call vascular and trauma surgeons. Their decision was based on the patient’s clinical and hemodynamic condition, concurrent injuries that required urgent operative intervention (e.g., craniectomy for traumatic brain injury and/or external ventricular drainage, repair or resection of a perforated abdominal organ, stabilization of orthopedic injuries), and the patient’s suitability for undergoing a TEVAR procedure upon arrival.

Follow-up CT angiography (CTA) was performed at the discretion of the treating team (trauma and vascular surgery), usually 48 to 72 hours after the procedure, depending on coexisting injuries and the severity of the aortic injury. The device used for endovascular treatment (TEVAR) was selected by the operating surgeon. After discharge, follow-up CTA was performed at 1, 3, 6, and 12 months, and then yearly or biannually.

An early complication was defined as any complication that developed within 10 days of the procedure, whereas complications developing after the 10th postoperative day were defined as late complications [19]. Postoperative complications occurring in hospital or within 30 days of the procedure included acute pulmonary oedema, myocardial ischemia, cerebrovascular accident, thromboembolic events (including femoral, iliac, or brachial artery thrombosis, pulmonary embolism, and deep vein thrombosis), adult respiratory distress syndrome (ARDS), acute renal failure (including patients requiring dialysis), procedure-related paraplegia, pseudoaneurysm, urinary tract infection, and pneumonia. We also collected data on delayed complications, including device endoleak, neuropathic pain, and vessel occlusion resulting from stent migration, reverse blood flow, or false lumen formation in the aorta.

Statistical analysis

Continuous demographic and clinical variables are summarized as mean±standard deviation or as median with interquartile range (IQR), depending on data distribution. Categorical variables are described using frequency and proportion (%). Group comparisons were made using one-way analysis of variance, Mann-Whitney U-test, Kruskal-Wallis test, or chi-square test as appropriate. With only four patients undergoing open surgery, we lacked sufficient data to perform multinomial logistic regression modelling of the associations between aortic injury management and outcomes without violating model assumptions [20]. We performed univariate and age-adjusted linear and logistic regression analyses to compare conservative versus surgical management of TAI and early versus delayed TEVAR, using (log transformed) length of stay (LOS), development of hospital-acquired complications, and mortality as outcomes. A Kaplan-Meier curve was used to present postdischarge surgical and overall survival during follow-up.

RESULTS

Overall, we identified 108 patients with thoracic aortic injuries in the State Major Trauma Unit database. Exclusions were applied for three patients under 18 years old, three with missing medical records, two with ungradable aortic injuries, and one patient with a nontraumatic thrombosis (Fig. 1). Among the 99 patients with gradable blunt TAI, 35 were dead on arrival or died within 24 hours of hospitalization—prior to vascular surgery consultation—and another 7 patients were palliated upon admission. Compared to the 57 patients who survived, the 42 patients who died or were palliated before vascular surgical review had higher median ISS scores (54 vs. 34, P<0.001), a higher frequency of falls from >3 m (21.4% vs. 1.8%, P=0.001), more aortic injuries below the origin of the left subclavian artery (73.8% vs. 54.4%, P=0.048), fewer grade III aortic injuries (11.9% vs. 56.1%, P<0.001), and more grade IV aortic injuries (45.2% vs. 0%, P<0.001) (Table S1). Of the 57 patients included in the study, 4 died during hospitalization (three inpatient deaths and one transfer to palliative hospice) and 1 patient had confidential medical records (unobtainable). Among the 52 patients with available information, 3 (5.8%) were lost to follow-up. Of the 49 patients with follow-up, 6 (12.2%) experienced surgery-related complications, and 1 (2.0%) died (Fig. 1).

Characteristics of the 57 patients surviving to vascular surgical review for the management of TAI (45 male patients, 78.9%; age, 41±16 years [range, 18–81 years]) are presented in Fig. 1 and summarized in Table 1. The prevalent comorbidities at admission were alcohol misuse (10 patients, 17.5%), smoking history (27 patients, 47.4%), and cardiovascular disease (18 patients, 32.1%), primarily driven by hypertension (17 patients, 29.8%) and peripheral vascular disease (10 patients, 17.5%). Additionally, 9 patients (15.8%) had acute or chronic renal impairment, and 12 patients (21.1%) had respiratory conditions, including respiratory infections (6 patients, 10.5%) and asthma (5 patients, 8.8%). We also found that 14 patients (24.6%) had mental health issues, and 6 patients (10.5%) had a history of prior traumatic injury. Patients with TAI who survived to hospitalization were mainly involved in motor vehicle–related crashes (89.5%), including car crashes (27 patients, 47.4%), motorcycle crashes (18 patients, 31.6%), pedestrian versus car incidents (3 patients, 5.3%), and (push-)bicycle versus car crashes (3 patients, 5.3%); whereas, crushing injuries (3 patients, 5.3%), fall-related injuries (1 patient, 1.8%), and overexertion-related traumas (1 patient, 1.8%) infrequently led to hospitalization (or survival, as per exclusion criteria).

All but one patient (an overexertion injury) sustained concurrent injuries (56 patients, 98.2%). Concurrent injuries involved the central nervous system (33 patients, 57.9%; mostly hemorrhage), the musculoskeletal system (56 patients, 98.2%; sustaining fractures, 52 patients [91.2%]), the chest wall (46 patients, 80.7%), and abdominal organs (32 patients, 56.1%). All patients sustained severe injuries, with a minimum ISS of 16 and a median ISS of 34 (IQR, 21–45) (Table 2).

Upon admission, SBP exceeded the recommended ≥120 mmHg in 27 of 55 patients (49.1%). The most common site of aortic injury was just below the origin of the left subclavian artery (31 patients, 54.4%), followed by the aortic arch (13 patients, 22.8%) and the abdominal aorta (13 patients, 22.8%) (Table 2). The most common aortic injury grade was grade III (32 patients, 56.1%), followed by grade I (13 patients, 22.8%) and grade II (12 patients, 21.1%); all patients with grade IV aortic injuries died before consultation with the vascular surgery team (Table S1).

Surgical management of aortic injuries was required in 41 cases (71.9%). Overall, 37 (64.9%) underwent TEVAR (with early TEVAR performed in 29 of 37 [78.4%]), 3 (5.3%) underwent open surgery, and 16 (28.1%) were managed conservatively (Table 3). Proportionally, grade I aortic injury was more frequently managed conservatively rather than surgically (56.3% vs. 10.8%, P=0.001), whereas grades II to III aortic injuries were more likely to be managed surgically rather than conservatively (43.8% vs. 90.2%, P<0.001). Abdominal aortic injuries were more commonly managed conservatively than surgically (50.0% vs. 12.2%, P=0.002). Aortic injury below the origin of the left subclavian artery (31 patients) tended to be managed surgically (31.3% vs. 63.4%, P=0.040), with a higher use of the open approach. Time from door to vascular surgery was within 0 to 6 hours in 12 patients (21.1%), within 6 to 24 hours in 17 (29.8%), and ≥24 hours in 8 (14.0%). Vascular procedures had a median duration of 81 minutes (IQR, 60–97 minutes). Additionally, 31 patients (54.4%) required other surgical procedures to repair extravascular injuries (e.g., stabilization and other orthopedic procedures), with a higher frequency in those undergoing endovascular versus open surgery (81.1% vs. 25.0%, P<0.001). The majority (70.2%) of these additional procedures occurred within 12 hours of hospitalization. Compared to conservatively managed patients, surgically managed patients tended, albeit nonsignificantly, to have a longer median LOS (18 days vs. 13.5 days, P=0.763), a higher frequency of hospital-acquired complications (41.5% vs. 31.3%, P=0.477)—especially cardiovascular disease–related complications (age-adjusted odds ratio [aOR], 3.64; 95% confidence interval [CI], 1.08–12.25; P=0.037)—but similar mortality (9.4% vs. 14.3%, P=0.622) (Table S2).

Among those undergoing TEVAR, there was a lower frequency of thoracic arch injury (8 patients, 21.6%) and grade I aortic injury (4 patients, 10.8%) (Table 2). Compared to delayed TEVAR, patients undergoing early TEVAR had a higher prevalence of alcohol abuse (24.1% vs. 0%, P<0.001), a higher rate of smoking (48.3% vs. 25.0%, P=0.239), fewer cases of asthma (3.4% vs. 25.0%, P=0.048), and were more often involved in motorcycle crashes (34.5% vs. 12.5%, P=0.228) rather than car crashes (41.4% vs. 75.0%, P=0.092) (Table 1). Patients undergoing early TEVAR also presented with poorer blood pressure control (SBP ≥120 mmHg, 42.9% vs. 75.0%; P=0.109), more frequent bowel and liver injuries (44.8% vs. 12.5%, P=0.095), and upper limb fractures (34.5% vs. 0%, P=0.052) (Table 2). Those in the early-TEVAR group had a higher need for surgical repair of extravascular injuries (93.1% vs. 37.5%, P<0.001), driven by procedures performed concurrently with vascular surgery (55.2% vs. 0%, P=0.005) or after vascular surgery (62.1% vs. 25.0%, P=0.063) (Table 3).

The early-TEVAR group had a higher burden (albeit nonsignificant) of anemia (82.8% vs. 50.0%, P=0.056) and infectious complications (58.6% vs. 25.0%, P=0.092), but fewer late complications (8.0% vs. 50.0%, P=0.007) (Table 4). Early TEVAR was associated with a longer LOS (18 days vs. 12.5 days, P=0.526), which may be related to the higher median ISS (36 vs. 28, P=0.266) (Tables 2, 4). Due to the small number of endpoints, no significant differences were found between early and delayed TEVAR with respect to LOS, hospital-acquired complications, or mortality. However, the early-TEVAR group had lower age-adjusted odds of late complications during follow-up (aOR, 0.09; 95% CI, 0.01–0.64) (Table S3). No delayed TEVAR procedures were performed from 2016 to 2018, with 11 early TEVARs performed.

During admission, 54 patients (94.7%) reported complications requiring medical management (Table 4). Patients mainly experienced hematological (52 patients, 91.2%), cardiovascular (41 patients, 71.9%), renal (47 patients, 82.5%), and infectious complications (31 patients, 54.4%). Compared to conservatively managed patients, surgically managed patients had higher renal and cardiovascular complications (both P<0.05). We found no difference in the odds of hospital-acquired complication development between TAI patients being managed conservatively versus surgically, except for higher age-adjusted odds of cardiovascular complications (aOR, 3.64; 95% CI, 1.08–12.25) (Table S2). Nearly all TEVAR patients experienced hospital-acquired complications, however early-TEVAR patients had fewer long-term complications (Table S3). Overall, hospital-acquired complication development did not affect LOS (Table S4). However, we found that the development of hematological conditions, renal impairment, infectious complications, cardiovascular disease, neurological problems, and pressure sores all increased LOS (all P<0.05). Acute vascular surgery–related complications were rare (three patients, 5.3%), and all occurred post-TEVAR. Complications included subclavian steal syndrome leading to a left subclavian bypass to common carotid artery within 24 hours of index surgery on two patients and occlusion of right external iliac artery needed embolectomy and stenting occurred with 48 to 72 hours of index surgery.

During admission, four patients died, and one patient had confidential (unobtainable) medical records. Of those with available information, 27 of 52 patients (51.9%) were discharged home, and 48.1% were discharged to a rehabilitation unit. Within the TEVAR group, 17 of 34 (50.0%) were discharged home, and 18 (50.0%) were transferred to a rehabilitation unit. Among those followed up (48 patients, 442.61 person-years), late complications developed in 6 of 48 vascular surgery patients (10.5%; all underwent TEVAR, with one conversion to open surgery) after a median follow-up of 2.08 years (IQR, 0.69–7.40 years; maximum, 13.48 years) (Fig. 2). These complications included the need for a carotid stenosis bypass (one patient), complete occlusion of the left common iliac artery requiring stenting (one patient), a small crescentic false lumen (one patient), reverse left vertebral-to-carotid flow (one patient), a type 1 endoleak (one patient), and mild neuropathy in two patients (although these were more likely attributable to comorbidities such as smoking). The crude postsurgical mortality in this study was 8.8% (5 of 57), with four patients dying during hospitalization and one during follow-up (Fig. 2). The patient who died during follow-up had been managed conservatively for TAI; he died 9 years after hospitalization at the age of 81 years. Patients who died were older (56 vs. 39 years, P=0.023), had a higher median ISS (43 vs. 32, P=0.049), and a higher proportion suffered from central nervous system injuries (100% vs. 52.4%, P=0.042), hemorrhage (80.0% vs. 33.0%, P=0.042), shoulder girdle fractures (80.0% vs. 21.4%, P=0.006), and vascular surgery–related complications (33.3% vs. 3.4%, P<0.001), including coagulation complications following severe traumatic bleeding (80.0% vs. 16.7%, P=0.002) (Table S5).

DISCUSSION

In this study, we described the management and outcomes of patients with TAI caused by blunt trauma who received a vascular surgery consultation upon admission in WA from 2008 to 2018. We found that 42 of 99 adult patients with TAI (42.4%) died or were palliated before a vascular surgical review could be conducted, confirming the poor survival estimates reported elsewhere [21]. These findings also reflect the challenges posed by the vast geography of WA, where ambulatory services may struggle to stabilize and transport patients with severe TAI to a healthcare facility for life-saving treatment. After vascular surgery consultation, TAI in WA was typically managed surgically with TEVAR (65%), primarily early TEVAR (78%) rather than delayed TEVAR (22%), with less reliance on open repair (7%). Although TAI patients commonly underwent early TEVAR during the 10-year study period, early TEVAR became the preferred surgical modality from 2016 to 2018 (with 12 TEVAR procedures, 1 conversion to open surgery, and 5 managed conservatively), demonstrating the evolution of practice at our institution. Within the TEVAR group, technical success was achieved in 100% of cases, with short-term TEVAR-related complications occurring in 5% (three cases) and long-term TEVAR-related complications developing in 26.3% (10 of 38), with a post-TEVAR (post-TAI) 30-day survival rate of 87.8% (29 of 33). Patients managed conservatively (28%) had good long-term outcomes, with 87.5% (14 of 16) alive at follow-up. The proportions of surgically and conservatively managed patients in our study mirror those reported in other studies [22]. Collectively, our findings align with current Society for Vascular Surgery guidelines, which favor early TEVAR in stable TAI patients—with delayed TEVAR reserved for patients with major associated injuries or severe comorbidities [23]—and support conservative management for milder aortic injuries that is not at high risk of rupture (grade I).

Our patients were comparable to other cohorts with respect to age (average, 41±10 years old) [13,22–27] and male predominance (79%) [13,23,24,28]; however, our patients had a relatively higher (81%) comorbidity burden than others [22,23,29]. Our higher prevalent comorbidity burden was characterized by cardiovascular disease (32%) [26] (namely, hypertension, peripheral vascular disease, and ischemic heart disease), respiratory disorders (including infections), and renal impairment, which was consistent with the age of our cohort [13]; and our high prevalence of alcohol misuse and smoking habit was comparable to recent studies [22,26,29]. We reported a higher rate of psychiatric illness (25%) than another comparable single-center study (5.5%), which may be due to our use of a more comprehensive trauma registry [27], supplemented with paper-, digital-, and electronic medical records (iCM); nonetheless, this finding highlights psychiatric illness as an important factor for managing trauma patients [25]. For the first time, we report that 11% of TAI patients had experienced previous traumatic events, raising the question of whether accumulated disability from prior trauma increases the risk of recurrent trauma or reduces resilience to new traumatic events. Similar to other studies, the majority of TAI cases were primarily motor vehicle–related (76%) [23,25,26], with a high median ISS of 34 (IQR, 21–45) [22–26,29], and an array of concurrent injuries [22,23,25,30]. Concurrent injuries occurred in the central nervous system (57.9%, mostly hemorrhage), musculoskeletal system (98.2%, with 91.2% sustaining a fracture, chest wall (80.7%, hemothorax and/or pneumothorax), and abdominal organs (56.1%), which resulted in similar admission characteristics as other studies, including median LOS of 15 days [13,22]. The proportion of our patients with a SBP above the recommended ≥120 mmHg (49%) was higher than the 21% to 27% reported by Marcaccio et al. [13]. Overall, our sample characteristics are comparable to those of other international TAI studies, supporting the generalizability of our findings.

The most common TAI site was just below the origin of the left subclavian artery (54.4%), followed by the aortic arch (22.8%) and the abdominal aorta (22.8%), which is similar to some studies [22] but not all [23]. The proportions of grade III (56.1%), grade I (22.8%), and grade II (21.1%) aortic injuries were comparable to those reported in other studies, and the high mortality prior to vascular consultation is consistent with other reports [22,23,26,29].

Currently, TEVAR is the first-line treatment, as recommended by the Society of Vascular Surgery (SVS) and ESVS due to its lower 30-day mortality and decreased risk of spinal cord ischemia [21]. Approximately two-thirds of the patients in our study underwent early TEVAR compared to delayed TEVAR (78% vs. 22%), which is comparable to the literature [7,8]. A very small group underwent open procedures, in line with the SVS guidelines [15], which also allow for conservative management of milder aortic injuries that is not at high risk of rupture (grade I). Interestingly, we had four patients with grade I aortic injuries who underwent TEVAR, which contradicts the SVS guidelines [21], but confirms other cohort studies that found TEVAR in grade I injuries to be safe and effective, particularly in the context of other severe injuries (our patients had ISS scores ranging from 21 to 34) [31]. Of these four patients, two had head injuries, one had significant chest injuries with suspected severe aortic trauma and was offered a stent, and the fourth sustained an overexertion injury with an ISS of 32. We found that although TAI patients commonly underwent early TEVAR during the 10-year study period, early TEVAR became the preferred surgical modality from 2016 to 2018 (with 12 TEVAR procedures, 1 conversion to open surgery, and 5 managed conservatively), demonstrating the evolution of practice at our institution. Overall, the proportions of surgically and conservatively managed patients in our study mirror those reported in other studies [22].

Timing of TEVAR is crucial because it significantly impacts morbidity and mortality. In our study, almost half of the patients underwent surgery within 24 hours (78.4% had a door-to-TEVAR time of <24 hours). Within the early-TEVAR group, 39.3% commenced the procedure within 6 hours of admission. Additionally, 54.4% required surgical repair of extravascular injuries—mainly orthopedic and neurosurgical—which is similar to other reports [6]. As expected, the need for extravascular procedures was higher in patients undergoing TEVAR compared to open surgery (81% vs. 25%, P<0.001). The majority (70%) of extravascular procedures occurred within 0 to 12 hours of admission. The characteristics of those undergoing delayed TEVAR included a higher burden of asthma (25.0% vs. 3.4%, P=0.048) (Table 1) and a lower rate of extravascular operations (38% vs. 93%, P<0.001); when these procedures were performed, they were undertaken for stabilization purposes (Table 3). This finding aligns with guidelines suggesting that early TEVAR is suitable for medically stable patients [21]. The delayed-TEVAR group had a higher proportion of delayed complications (Table 4) and could be characterized—albeit nonsignificantly (all P>0.05)—as having a higher proportion of motor vehicle accidents (41.4% vs. 75.0%, P=0.092), poorer SBP control at admission (75.0% vs. 41.4%, P=0.109), and fewer injuries to internal organs within the chest and abdominal cavities (Tables 1, 2). No delayed TEVAR procedures were performed after 2015, with 11 early TEVAR procedures performed from 2016 to 2018. Vascular procedures had a median duration of 81 minutes (IQR, 60–97 minutes), which is comparable to other studies [26].

In our study, the overall morbidity rate in the endovascular group was 97.3%, with a predominance of hematological-related morbidity and renal impairment, whereas other studies have reported stroke as the most common complication [32]. Acute vascular surgery–related complications were rare (5.3%), and all occurred post-TEVAR [22]. Three patients required a second surgery within 72 hours of the index procedure. One patient developed subclavian steal syndrome, necessitating an immediate (same day) return to the operating theatre for a left subclavian bypass to the common carotid artery. Another patient developed a right external iliac artery occlusion, identified on a day 3 CT scan, and subsequently underwent embolectomy and stenting of the right iliac artery. The third patient developed an ischemic left hand on postoperative day 1, likely due to subclavian steal syndrome, and required urgent revascularization via a left carotid-to-subclavian bypass. These findings are comparable to those in a systematic review by Sepehripour et al. [33]. Furthermore, late complications were observed in 6 of 37 vascular surgery patients (17.1%, all of whom had undergone TEVAR). These complications included the need for a carotid stenosis bypass (one patient), complete occlusion of the left common iliac artery requiring stenting (one patient), a small crescentic false lumen (one patient), reverse left vertebral-to-carotid flow (one patient), a type 1 endoleak (one patient), which were consistent with Madigan et al. [26], and mild neuropathy in two patients (although these were more likely attributable to comorbidities such as smoking). These late vascular surgery–related complications were comparable to other reports.

Nearly all patients (95%) reported post-trauma morbidity that required inpatient management. Morbidities included hematological disorders (91%), often necessitating transfusion of packed red blood cells or platelets, and coagulopathy (30%); cardiovascular disease (72%); renal impairment (83%), including acute kidney injury (25%) [13,26], acidosis, and electrolyte imbalances; and infectious complications (54%), mainly respiratory (28%) and urinary tract infections (16%) [13]. Additionally, ARDS was observed in 25% and pleural effusion in 35% of patients. Less common, but still concerning, morbidities included neurological disorders (26%), pressure sores (23%), gastrointestinal and hepatic disorders (23%), and bleeding (9%). Our thrombotic complications (7%), including deep vein thrombosis and pulmonary embolism, were comparable to those reported by Madigan et al. [26]. Overall, we found that the development of complications alone did not increase LOS, possibly due to the masking effect of higher injury severity (higher ISS) as noted by others [34]. However, we did observe a longer age- and ISS-adjusted LOS in patients with hematological, renal, hemorrhagic, infectious, cardiovascular, and neurological complications, as well as ARDS and pressure sores (Table S4). Although comparable data were limited, our findings demonstrate the complexity of TAI patients and suggest that the development of hospital-acquired complications can extend the duration of hospital care. Patients undergoing endovascular surgery had higher rates of renal and cardiovascular complications compared to those managed conservatively, consistent with the literature [26]. Our high proportion of hospital-acquired complications relative to other studies [13,23,26], may reflect our comprehensive data collection. Taken together, our data suggest that despite a wide range of vascular and extravascular injuries and the need for invasive medical and surgical management, patients with grade I to III aortic injuries can still have favorable survival outcomes.

On discharge, most patients were sent home (27 of 52 patients, 51.9%), while 25 patients (49.1%) were transferred to a rehabilitation unit. Patients who died during hospitalization were older and had a higher ISS, more central nervous system injuries, and more complications during admission (Table S5), which is consistent with inpatient mortality reported in other studies [22,29]. We observed a higher proportion of patients returning home compared to other studies (12.5% in Asaid et al. [25]), which may be explained by a lower proportion of grade III injuries in our cohort and the fact that no patients with grade IV injuries survived. Among those who underwent vascular surgery and survived beyond hospitalization (49 patients), medical records for three patients could not be accessed (most likely due to confidentiality) to ascertain late complications of vascular procedures.

Treatment of TAIs has evolved over the last three decades, and perioperative outcomes have drastically improved since the introduction of endovascular techniques [35]. In our study, the overall morbidity rate in the endovascular group was 97.3%, with a predominance of hematological-related morbidity and renal impairment. It is difficult to determine whether these morbidities are directly associated with the procedure or are influenced by other injuries that have impacted overall physiology. The post-TEVAR mortality rate of 10.3% (3 of 37) was comparable to international findings [23]. Among these three patients, two had severe head injuries and underwent neurosurgical procedures, while the third suffered severe multiorgan abdominal trauma. Therefore, it cannot be stated with absolute certainty that these mortalities were related to TEVAR rather than other associated injuries. This excellent postsurgical survival mirrors other studies [22,23,35]. Taken together, our BTAI cohort, despite its small sample size, appears comparable to other studies, suggesting that our findings are generalizable to settings with vascular surgical involvement.

Strengths and limitations

A major strength of this study relates to the use of data extracted from the State Trauma Registry Database in WA [16], which we then supplemented with paper and electronic medical records (iCM) using each patient's unique medical reference number to comprehensively characterize the patients, exposures, comorbidities, concurrent injuries, postsurgical morbidity, and long-term survival. However, our findings should be considered in light of the following limitations. First, due to the small sample size, the generalizability of our findings may be limited. Secondly, our retrospective study design and data collection may have omitted confounding variables. Our data collection was limited by the lack of the following: (1) anthropometric metrics, such as height, weight, or body mass index; and cognitive impairment metrics, such as Glasgow Coma Scale scores, which have been shown to predict in-hospital mortality post-BTAI [22]; (2) anatomic characteristics of the aorta, including the distance from the left subclavian artery to the injury, aortic diameter 20 mm proximal to the injury, or maximum descending thoracic aorta diameter; (3) documentation regarding the reasons for choosing open versus endovascular surgical approaches; (4) stent graft characteristics in the TEVAR group; and (5) the inability to accurately elucidate the clinical implications (management) for all complications recorded within the various data sources. Future studies should aim to more accurately capture the temporality (surgical vs. inpatient) and clinical implications (management) of complications using standardized classification systems [36]. Third, our postdischarge follow-up was challenging because many patients were followed up in private practice (where private patients’ medical records are confidential and unavailable through the public system) or moved to another state (one patient), and due to ethical approval limitations, we could not directly contact some patients to determine postoperative complications. Finally, sampling patients with TAI from the State Trauma Unit Register without linkage to the WA Death Registrations (with cause of death information) may have introduced selection bias by excluding patients who died prior to hospitalization and the investigation of, if any, the type and extent of aortic injuries. However, this selection bias should be considered minimal as our mortality profile aligns with the literature [21]. Regardless, our patient characteristics and post-TAI outcomes were comparable to the literature, suggesting that our findings are generalizable to TAI patients in other settings.

Conclusions

In WA, TAIs were primarily (76%) caused by motor vehicle crashes and were associated with significant comorbidities, concurrent injuries, and a high mortality rate, with 30% of patients dying before a vascular surgery review. Post-TAI mortality was linked to a higher ISS, falls from heights greater than 3 m, and grade IV aortic injury, which limits the scope for healthcare intervention to ensure patient survival. Overall, among those who survived to vascular review and intervention, we observed a low rate of acute and long-term vascular surgery–related complications and excellent long-term survival given the injury severity of our cohort. Future research could determine whether the time from injury to hospital arrival is associated with post-TAI mortality, particularly given the vast size of WA. Our study adds to the evidence demonstrating that patients with grade I TAI and concurrent injuries can also be successfully managed with TEVAR. Our study reported that TAI patients had high rates of alcohol use and smoking (both >45%), as well as a high prevalence of cardiovascular disease, particularly hypertension. Furthermore, we report for the first time that one in 10 patients had a prior traumatic event. While alcohol misuse likely increases the risk of blunt traumatic events, larger studies could examine the role of lifestyle factors and the cumulative impact of previous injuries on the prognosis of TAI patients.

ARTICLE INFORMATION

Author contributions

Conceptualization: AJ, SR, KS; Data curation: AJ; Formal analysis: WDR; Investigation: AJ, WDR; Methodology: FPP, SR, KS; Visualization: WDR, FPP; Writing–original draft: AJ, WDR, FPP; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors did not receive any financial support for this study.

Data availability

Data analyzed in this study (de-identified and saved as a password-protected SPSS document) are available from the corresponding author upon reasonable request.

Additional information

This study was presented at the 25th Congress of the Asian Society of Vascular Surgery (ASVS) in December 2024 in Bangkok, Thailand.

Supplementary materials

Fig. 1.

Study flowchart. ^a)Six vascular surgery-related complications. ^b)Sum of person-years, 414.67; median, 8.99; interquartile range, 5.98–10.75.

Fig. 2.

Kaplan-Meier curve of (A) surgical survival and (B) overall survival after discharge.

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Figure & Data

References

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