Contemporary Management of Blunt Thoracic Aortic Injury

Objective: To determine contemporary management practices for BTAI among trauma and vascular surgeons. Methods: A survey of EAST, AAST and SVS membership regarding BTAI care was conducted. Results: 404 respondents included trauma (52.5%), vascular (42.6%) and other specialty providers (4.5%) primarily from North American (90.6%) academic teaching institutions (71.0%) / ACS Level I trauma centers (58.9%). Most respondents managed 1-5 BTAI annually (71.6%). Preferred diagnostic modality was CTA (99.8%), after which respondents stated they preferred to utilize personal knowledge of the literature and experience (50.5%), the SVS guidelines (27.4%) or institution specific guidelines (12.8%) to guide subsequent management. Respondents primarily agreed on the treatment of intimal tears (SVS G1) with medical management. For intramural hematoma (SVS G2), management choice was divided between medical (46.6%) and TEVAR (46.3%). Both groups defined TEVAR as treatment of choice for hemodynamically stable patients with pseudoanuerysm (SVS G3) (93.5%) and rupture (SVS G4) (82.2%), although more trauma surgeons preferred open repair (20.4%) than vascular counterparts (4.1%) in stable G4 patients. Preferred medical management goals varied between MAP (37.3%) and SBP (62.3%) targets. Preferences also varied in adjuncts for open repair [Left heart bypass 56.5%; Clamp and Sew 46.1%; CSF drainage 48.5%] and TEVAR [percutaneous puncture for arterial access 58.4%; open vascular exposure 65.5%, IVUS 36.1%, CSF drainage 28.9%]. Outpatient follow-up timing (2 weeks 37.0%, 1 month 37.2%) and initial type (clinical exam 36.6%, CTA 48.3%) also varied. Conclusions: Survey of trauma and vascular surgeons illustrates controversy regarding SVS G2 treatment, surgical adjuncts and follow-up. Additional study is required to identify optimal BTAI management.