A Systematic Review Supporting the Development of the Society for Vascular Surgery Clinical Practice Guidelines on the Management of Blunt Thoracic Aortic Injury.

Abstract

Background: The writing committee (WC) from the Society for Vascular Surgery (SVS) has commissioned this systematic review to support the development of clinical practice guidelines (CPG) on the management of patients with blunt thoracic aortic injury (BTAI).

Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Pairs of independent reviewers selected and appraised studies addressing seven key questions identified by the SVS committee regarding the evaluation and management of BTAI patients. The certainty of evidence was assessed using the GRADE approach.

Results: We included 23 studies across seven key clinical questions. For Grade 1 and 2 injuries, TEVAR was associated with higher aortic-related mortality compared to non-operative management (RR 4.73, 95% CI: 1.19-18.68). Early (<24 hours) TEVAR was associated with higher mortality compared to delayed (>24 hours) intervention (RR 2.04, 95% CI: 1.45-2.86) with moderate certainty of evidence. There may be an increase in ischemic events when the left subclavian artery is covered and not revascularized, with low certainty of evidence. Intraoperative heparin use during TEVAR was associated with lower mortality (RR 0.41, 95% CI: 0.23-0.71) with low certainty of evidence. In patients with concurrent traumatic brain injury, early TEVAR (< 9 hours) was associated with higher mortality (12.9% vs 6.5%, p = 0.003) compared to delayed repair with low certainty of evidence. Analysis of imaging surveillance protocols suggested potential benefits of systematic follow-up. For Grade 2 injuries managed non-operatively, studies demonstrated favorable intermediate-term outcomes with most injuries resolving within 8 weeks.

Conclusion: This systematic review demonstrates a limited evidence base with high uncertainty for numerous patient-important outcomes. The evidence suggests benefits of delayed intervention when feasible, particularly for patients with concurrent injuries. Non-operative management may be appropriate for lower-grade injuries, while the timing of intervention and use of intraoperative anticoagulation may be important factors associated with outcomes in TEVAR. These findings of this evidence synthesis, along with individual patient factors and local expertise will inform the development of clinical practice guidelines.