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 from the Society for Vascular Surgery has commissioned this systematic review to support the development of clinical practice guidelines on the management of patients with blunt thoracic aortic injury. 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 Society for Vascular Surgery committee regarding the evaluation and management of patients with blunt thoracic aortic injury. The certainty of evidence was assessed using the GRADE approach. Results: We included 21 studies across seven key clinical questions. For Grade 1 and 2 injuries, thoracic endovascular aortic repair (TEVAR) was associated with higher aortic-related mortality compared with nonoperative management (relative risk [RR], 8.11; 95% confidence interval [CI], 1.25-52.57. Early (<24 hours) TEVAR was associated with higher mortality compared with 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 = .003) compared with delayed repair with low certainty of evidence. Analysis of imaging surveillance protocols suggested potential benefits of systematic follow-up. For Grade 2 injuries managed nonoperatively, studies demonstrated favorable intermediate-term outcomes with most injuries resolving within 8 weeks. Conclusions: 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. Nonoperative management may be appropriate for lower-grade injuries, whereas 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.