Delayed Repair is Associated With Lower Stroke Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

Current societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that delayed repair was associated with lower mortality following TEVAR for BTAI. However, these studies lacked accurate data on aortic injury grade and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative (VQI) registry, which includes more granular anatomic and outcome data, to examine the impact of early (≤24 hours) vs delayed (>24 hours) TEVAR for BTAI. Patients undergoing TEVAR for BTAI in the VQI between 2013 and 2022 were included, excluding those with Society for Vascular Surgery (SVS) grade 4 aortic injury. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbities, medication use, SVS aortic injury grade, coexisting injuries (injury severity score), Glasgow coma score (GCS), and prior aortic surgery into a regression model to compute propensity scores for assignment to early or delayed repair. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion, and annual center and physician volumes. Of 1016 patients, 102 (10%) underwent delayed TEVAR. Compared with the early repair group, the delayed group had a higher proportion of patients with grade 1 aortic injuries (delayed vs early; 15% vs 9.5%; P = .056), but a lower proportion of those with grade 2 aortic injuries (15% vs 23%; P = .056). Coexisting injuries were comparable between the two groups. Patients who underwent delayed repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). Following inverse probability weighting, delayed repair was associated with lower postoperative stroke (1.0% vs 3.0%; odds ratio, 0.10; 95% confidence interval [CI], 0.01-0.91; P = .042) (Table). There was no association between timing of repair and perioperative mortality (delayed vs early: 3.9% vs 6.6%; odds ratio, 1.1; 95% CI, 0.27-4.7; P = .90) or 5-year mortality (5.8% vs 12%; hazard ratio, 0.95; 95% CI, 0.21-4.3; P > .9) following risk-adjustment. In patients with BTAI undergoing TEVAR, delayed TEVAR resulted in more patients being able to receive heparin and was associated with lower odds of postoperative stroke, relative to early TEVAR. Perioperative mortality and 5-year mortality were similar between the groups. These findings support the idea that delaying TEVAR in patients with BTAI without extravasation could result in improved outcomes.TablePerioperative outcomes following TEVAR for BTAI stratified by early (≤24 hours) vs delayed (>24 hours) repairDelayed (n = 102)Early (n = 914)P-valueDelayed vs early adjusteda outcomesUnadjusted rates, %Odds ratio95% confidence intervalP-valuePerioperative death3.96.6.391.10.27-4.7.90 Aortic-related mortality2.93.212.40.53-11.30Any complication1932.0110.540.23-1.8.20Stroke1.03.0.350.100.01-0.92.042Acute kidney injury1217.250.810.28-2.3.70Postoperative dialysis03.2.13NANA–Spinal cord ischemiab1.00.211.960.26-14.7.50Bowel ischemia1.01.110.250.03-1.90.24Leg ischemia01.5.38NANA–Pulmonary complications6.718.0050.360.12-1.05.061Cardiac complications01.9.25NANA–Reintervention during index admission2.02.110.360.06-2.1.30BTAI, Blunt thoracic aortic injury; TEVAR, thoracic endovascular aneurysm repair.aPropensity weighted for age, gender, race, anemia (preoperative hemoglobin <10 gm/dL), comorbidities, medication use, Injury Severity Score category, aortic injury grade, Glasgow Coma Score, transfer status, prior aortic surgery and adjusted for left subclavian artery involvement, center, and physician volumes in the regression models.bRisk-adjusted model also includes length of aortic coverage (average number of zones between the distal sealing and proximal sealing zone). Open table in a new tab