Current expert-based opinions on endovascular treatment of blunt thoracic aortic injury: A state-of-the-art narrative review on indications,techniques,results,and challenges
Restricted accessReview articleFirst published online June, 2025
Current expert-based opinions on endovascular treatment of blunt thoracic aortic injury: A state-of-the-art narrative review on indications,techniques,results,and challenges
Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma which warrants prompt recognition with expedited management. Clinical manifestations of BTAI may not be straightforward to detect and may be misdiagnosed. Therefore, diagnosis of BTAI requires a high index of suspicion based on the mechanism of injury along with urgent transfer to centers with appropriate expertise and facilities.
Methods
We provide an expert-based narrative review on endovascular treatment of BTAI highlighting indications, techniques, results, and challenges.
Results
Multiple imaging modalities can be used including computed tomography angiography, transesophageal echocardiography, magnetic resonance imaging, and intravascular ultrasound. Whilst conservative pharmacological management can be a safe option in low-grade BTAI, thoracic endovascular aortic repair has become the gold-standard strategy in most cases, replacing open surgical repair. Nevertheless, it is important to account for patient demographics particularly age, severity of injury, choice of endograft including its type and size, and endovascular technique including landing zone and left subclavian artery revascularization.
Conclusions
Overall, TEVAR in BTAI has been shown to be an efficacious strategy with favorable early outcomes. In contrast, less is known on the long-term clinical outcomes of TEVAR in BTAI. Hence, despite the optimal early technical and clinical success rates, concerns remain about the need for long-term surveillance. The exact timing of follow-up and the integration of different modalities that can also investigate potential downstream cardiovascular effects remain hot topics for future research. Finally, industry should focus on developing more compliant endografts to improve the stiffness mismatch between the endograft and the aorta to optimize results.
ArbabiCNDuBoseJStarnesBW, et al.Outcomes of thoracic endovascular aortic repair in patients with concomitant blunt thoracic aortic injury and traumatic brain injury from the Aortic Trauma Foundation global registry [published correction appears in J Vasc Surg. 2022 Jun;75(6):2104]. J Vasc Surg2022; 75(3): 930–938. DOI: 10.1016/j.jvs.2021.09.028.
2.
RiambauVBöcklerDBrunkwallJ, et al.Editor's choice - management of descending thoracic aorta diseases: clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg2017; 53(1): 4–52. DOI: 10.1016/j.ejvs.2016.06.005.
3.
SmithJABoseSSarodeA, et al.Effect of intravascular ultrasound on clinical outcomes after thoracic endovascular aortic repair for blunt thoracic aortic injury. J Vasc Surg2022; 75(2): 448–454.e2. DOI: 10.1016/j.jvs.2021.08.061.
4.
WallaceGAStarnesBWHatsukamiTS, et al.Intravascular ultrasound is a critical tool for accurate endograft sizing in the management of blunt thoracic aortic injury. J Vasc Surg2015; 61(3): 630–635. DOI: 10.1016/j.jvs.2014.10.014.
5.
BrownSRStillSAEudaileyKW, et al.Acute traumatic injury of the aorta: presentation, diagnosis, and treatment. Ann Transl Med2021; 9(14): 1193. DOI: 10.21037/atm-20-3172.
6.
MouawadNJPaulisinJHofmeisterS, et al.Blunt thoracic aortic injury - concepts and management. J Cardiothorac Surg2020; 15(1): 62. DOI: 10.1186/s13019-020-01101-6.
AzizzadehAKeyhaniKMillerCC, et al.Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg2009; 49(6): 1403–1408. DOI: 10.1016/j.jvs.2009.02.234.
9.
QuirogaEStarnesBWTranNT, et al.Implementation and results of a practical grading system for blunt thoracic aortic injury. J Vasc Surg2019; 70(4): 1082–1088. DOI: 10.1016/j.jvs.2019.01.048.
10.
BadalamentiGFerrerCCalvagnaC, et al.Major vascular traumas to the neck, upper limbs, and chest: clinical presentation, diagnostic approach, and management strategies. Semin Vasc Surg2023; 36(2): 258–267. DOI: 10.1053/j.semvascsurg.2023.04.010.
11.
ArbabiCNDuBoseJCharlton-OuwK, et al.Outcomes and practice patterns of medical management of blunt thoracic aortic injury from the Aortic Trauma Foundation global registry. J Vasc Surg2022; 75(2): 625–631. DOI: 10.1016/j.jvs.2021.08.084.
12.
DuboseJJAzizzadehAEstreraAL, et al.Contemporary management of blunt aortic trauma. J Cardiovasc Surg2015; 56(5): 751–762.
13.
MohapatraALiangNLMakarounMS, et al.Risk factors for mortality after endovascular repair for blunt thoracic aortic injury. J Vasc Surg2020; 71(3): 768–773. DOI: 10.1016/j.jvs.2019.07.059.
14.
D'OriaMPipitoneMDDuBoseJ, et al.Development and validation of a risk prediction tool for in-hospital mortality after thoracic endovascular repair in patients with blunt thoracic aortic injury using the Aortic Trauma Foundation registry [published online ahead of print, 2023 Nov 1]. Ann Vasc Surg. 2023;S0890-5096(23). DOI: 10.1016/j.avsg.2023.09.076.
15.
PrendesCFStanaJSchneidwindKD, et al.Blunt traumatic thoracic aortic injuries: a retrospective cohort analysis of 2 decades of experience. Interact Cardiovasc Thorac Surg2021; 33(2): 293–300. DOI: 10.1093/icvts/ivab067.
16.
OkadomeJMorishigeNSukehiroY, et al.Effectiveness of thoracic endovascular aortic repair for blunt thoracic aortic injury. Ann Thorac Cardiovasc Surg2023; 29(3): 133–140. DOI: 10.5761/atcs.oa.22-00095.
17.
TeraaMHazenbergCEHoubenIB, et al.Important issues regarding planning and sizing for emergent TEVAR. J Cardiovasc Surg2020; 61(6): 708–712. DOI: 10.23736/S0021-9509.20.11571-4.
18.
PiazzaMSquizzatoFXodoA, et al.Determination of optimal and safest proximal sealing length during thoracic endovascular aortic repair. Eur J Vasc Endovasc Surg2021; 62(3): 423–430. DOI: 10.1016/j.ejvs.2021.05.012.
19.
FarberMAKrishnasastryKVDesaiN, et al.Five-year outcomes with conformable GORE TAG endoprosthesis used in traumatic aortic transections. Ann Thorac Surg2022; 113(5): 1536–1542. DOI: 10.1016/j.athoracsur.2021.05.054.
20.
PatelHJAzizzadehAMatsumotoAH, et al.Five-year outcomes from the United States pivotal trial of valiant Captivia stent graft for blunt aortic injury. Ann Thorac Surg2020; 110(3): 815–820. DOI: 10.1016/j.athoracsur.2019.12.028.
21.
StarnesBWDwivediAGigliaJ, et al.Updated outcomes from the TRANSFIX study to evaluate endovascular repair of blunt thoracic aortic injuries with the Zenith Alpha thoracic device. J Vasc Surg2020; 71(6): 1851–1857. DOI: 10.1016/j.jvs.2019.05.070.
22.
MorisakiASohgawaEFujiiH, et al.Fenestrated endovascular repair with debranching technique for blunt traumatic isthmus injury. Ann Vasc Dis2018; 11(4): 565–568. DOI: 10.3400/avd.cr.18-00088.
23.
AntonelloMMenegoloMMaturiC, et al.Intentional coverage of the left subclavian artery during endovascular repair of traumatic descending thoracic aortic transection. J Vasc Surg2013; 57(3): 684–690. DOI: 10.1016/j.jvs.2012.08.119.
24.
RomagnoliANPatersonJDuaA, et al.Cover with caution: management of the left subclavian artery in TEVAR for trauma. J Trauma Acute Care Surg2023; 94(3): 392–397. DOI: 10.1097/TA.0000000000003832.
25.
D'OriaMManiKDeMartinoR, et al.Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke. Interact Cardiovasc Thorac Surg2021; 32(5): 764–772. DOI: 10.1093/icvts/ivaa342.
26.
YoonWJManiKWanhainenA, et al.Anatomic feasibility of off-the-shelf thoracic single side-branched endograft in patients with blunt traumatic thoracic aortic injury. J Vasc Surg2021; 74(5): 1456–1463.e2. DOI: 10.1016/j.jvs.2021.04.047.
27.
XenosESAbediNNDavenportDL, et al.Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg2008; 48(5): 1343–1351. DOI: 10.1016/j.jvs.2008.04.060.
28.
KhoynezhadAAzizzadehADonayreCE, et al.Results of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Vasc Surg2013; 57(4): 899–905.e1. DOI: 10.1016/j.jvs.2012.10.099.
29.
KhoynezhadADonayreCEAzizzadehA, et al.One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Thorac Cardiovasc Surg2015; 149(1): 155–161.e4. DOI: 10.1016/j.jtcvs.2014.09.026.
30.
GennaiSLeoneNMezzettoL, et al.Systematic review and meta-analysis of long-term reintervention following thoracic endovascular repair for blunt traumatic aortic injury. J Vasc Surg2023; 78(2): 540–547.e4. DOI: 10.1016/j.jvs.2023.01.196.
31.
GennaiSLeoneNAndreoliF, et al.Influence of thoracic endovascular repair on aortic morphology in patients treated for blunt traumatic aortic injuries: long term outcomes in a multicentre study. Eur J Vasc Endovasc Surg2020; 59(3): 428–436. DOI: 10.1016/j.ejvs.2019.05.008.
32.
MandigersTJBissaccoDDomaninM, et al.Cardiac and aortic modifications after endovascular repair for blunt thoracic aortic injury: a systematic review. Eur J Vasc Endovasc Surg2022; 64(2-3): 176–187. DOI: 10.1016/j.ejvs.2022.05.004.
33.
MohapatraALiangNLMakarounMS, et al.Improved outcomes of endovascular repair of thoracic aortic injuries at higher volume institutions. J Vasc Surg2020; 73(4): 1314–1319. DOI: 10.1016/j.jvs.2020.08.034.
