Seal the bleed or wait to proceed? Resuscitation and early vs. delayed timing for thoracic endovascular aortic repair in blunt thoracic aortic injury.

BACKGROUND

In patients with blunt thoracic aortic injury (BTAI) undergoing thoracic endovascular aortic repair (TEVAR), the relationship between resuscitation (defined by markers such as lactate, base excess (BE), and need for transfusion) and TEVAR timing is not well defined. Several studies suggest repair after 24 ​h is associated with decreased mortality. The impact of related injuries and their competing need for resuscitation and intervention on the timing of TEVAR is not well defined. This study aims to compare patients who underwent early versus delayed TEVAR and determine mortality-related predictors. We hypothesize that the timing of TEVAR is not associated with mortality after accounting for covariates, including markers of resuscitation.

METHODS

A single-center, retrospective (2017-2023) review of patients with BTAI and TEVAR was performed. Resuscitation markers [lactate, base excess (BE)], transfusions, and outcomes were collected. Patients were stratified by TEVAR timing. A multivariable logistic regression (MLR) was performed for mortality.

RESULTS

93 patients underwent TEVAR and met inclusion criteria. There were 23 (25 ​%) patients in the delayed and 70 (75 ​%) in the early cohorts. There was no difference in demographics, initial vital signs, or concomitant TBI or SOI between cohorts. The delayed group had more immediate operative intervention for associated injury (52 ​% vs. 21 ​%,p ​= ​0.01) and were more likely to be resuscitated to a lactate of 2 or BE -2 before intervention (95 ​% vs. 60 ​%,p ​= ​0.002). The grade of injury was significantly different (p ​= ​0.01) between delayed and early groups: I (1 ​% vs. 0 ​%), II (43 ​% vs 13 ​%), III (56 ​% vs 71 ​%), and IV (0 ​% vs. 14 ​%). Death was most commonly from the sequela of traumatic thoracic aortic coarctation (n ​= ​3, 33 ​%) and multisystem organ failure (n ​= ​3, 33 ​%). MLR found that PRBC transfusion within the first 24 ​h (AOR 1.18, 95 %CI 1.06-1.30,p ​= ​0.02) was associated with mortality after adjusting for covariates, including time to TEVAR and grade of injury.

CONCLUSION

The timing of TEVAR was not related to outcomes. Early PRBC transfusion predicts mortality. Timing of TEVAR should depend on the patient's condition rather than a fixed time point.