History-
1557 - First case of blunt aortic injury described by Vessalius
1950's - First acute repair of BAI by DeBakey
1997 - First endovascular repair
Incidence-
In trauma registry-
Occurs in 0.3% of pedestrians, 0.1% of falls from height and in 1.4% of patients with pelvic fractures
BUT -
in autopsy series, occurs in 33% of MVC's of which 80% die at scene.
Of patients who reach hospital alive, 37% of deaths occur within 4 hours.
Anatomically-
93% of BAI occur at isthmus. This is due to an increase in intraluminal pressure in combination with rotational forces. The isthmus is the weakest portion of the thoracic aorta, having only 63% of the tensile strength of the descending aorta.
Delayed repair may offer survival benefit if BP is controlled and other life-threatening injuries are treated. This only applies to patients with NO extravasation on their CT.
Endovascular repair (EVAR) is good for high risk patients (ie other severe injuries or comorbidities) - it does not require general anesthesthia or thoracotomy and has minmal blood loss and lower incidence of paraplegia.
But what about the low risk patients?
Dr. Demetriades presented a lot of data from mostly small, mostly retrospective studies that showed a high risk of complications from EVAR - complications included stroke, stent collapse, endoleak and insertion site complications.
One concern is that BAI occurs rarely enough that many centers only see a handful each year. The complications of EVAR may be reduced by transferring patients to a center of excellence.
He proposed the following new standards of BAI treatment:
- Routine CT arch for all high risk patients
- Delayed repair acceptable in most cases
- Nonoperative management still a viable option
- EVAR better than open repair
- endovascular stents need improvements in device design, and long-term results still needed for EVAR.
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