Blunt traumatic injuries of thoracic aorta and supra-aortic trunks - a narrative review




Aortic injury, Blunt thoracic trauma, TEVAR, Thoracic aorta, Supra-aortic trunks


INTRODUCTION: Blunt thoracic aortic injuries (BTAI) are defined as a tear in the thoracic aorta caused by a high energy blunt trauma. The most common reported mechanism of injury is motor vehicle accidents, and it can be potentially lethal. The Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery (ESVS) guidelines recommend thoracic endovascular aortic repair (TEVAR) as the first line treatment for BTAI. Other controversies regarding BTAI management were reported in the literature, such as the best treatment for minimal aortic injuries with intimal tear, ideal stent graft oversizing, best timing for treatment and necessity to cover the left subclavian artery (LSA). The purpose of this review is to identify and analyze appropriate studies published so far about the management of BTAI.

METHODS: We performed a thorough electronic search of the literature using PubMed and Embase databases. We used the following combination of key words in our search strategy ((aortic injury) AND (blunt thoracic trauma)) AND (vascular surgery* OR treatment* OR TEVAR*). Articles not in English were excluded. The primary subject was results of endovascular treatment. Secondary subjects were indications and results of OSR, best timing for intervention, ideal graft oversizing, need for left subclavian artery (LSA) coverage, and management of BTAI grade I (intimal tear).

RESULTS: Data related to our primary and secondary subjects were extracted from the selected articles. TEVAR is considered the primary treatment for BTAI, if the patient has suitable anatomy, with good short and mid-term outcomes, with lower mortality and paraplegia rates at short and mid-term follow-up, compared to OSR. Despite good term results at short-term follow-up after TEVAR, long-term outcomes are still a concern. OSR is still a valid option in selected cases, and it should be considered for patients whose injury location is unsuitable for the endovascular approach. In most patients with BTAI, it is recommended around 10% of graft oversizing. However, a more aggressive approach with oversizing between 10-20% should be considered for patients with considerable hypotension and even >20% for patients presenting with severe hypotensive hemorrhagic shock. A necessity of LSA coverage has been reported in 30% of TEVAR for urgent treatment of BTAI, and it seems to be well tolerated. We should considered expectant approach with serial follow-up CT scans in patients with BTAI grade I injuries with asymptomatic intimal aortic tear.

CONCLUSIONS: This literature review reports and synthetizes published data about the management strategies for BTAI. TEVAR seems to be effective in the treatment of BTAI, with few complications and good outcomes at short and mid-term follow-up, and it should be the first-line treatment for these patients. OSR should be an option when a patient’s injury is not suitable for endovascular approach.


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Gaffey AC, Zhang J, Saka E, Quatromoni JG, Glaser J, Kim P, et al. Natural History of Nonoperative Management of Grade II Blunt Thoracic Aortic Injury. Annals of vascular surgery. 2020;65:124-9.

Teixeira PG, Inaba K, Barmparas G, Georgiou C, Toms C, Noguchi TT, et al. Blunt thoracic aortic injuries: an autopsy study. The Journal of trauma. 2011;70(1):197-202.

de Mestral C, Dueck A, Sharma SS, Haas B, Gomez D, Hsiao M, et al. Evolution of the incidence, management, and mortality of blunt thoracic aortic injury: a population-based analysis. Journal of the American College of Surgeons. 2013;216(6):1110-5.

Hiller RJ, Mikocka-Walus AA, Cameron PA. Aortic transection: demographics, treatment and outcomes in Victoria, Australia. Emergency medicine journal : EMJ. 2010;27(5):368-71.

Jahromi AS, Kazemi K, Safar HA, Doobay B, Cinà CS. Traumatic rupture of the thoracic aorta: cohort study and systematic review. Journal of vascular surgery. 2001;34(6):1029-34.

Sevitt S. The mechanisms of traumatic rupture of the thoracic aorta. The British journal of surgery. 1977;64(3):166-73.

Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. Journal of vascular surgery. 2011;53(1):187-92.

Azizzadeh A, Keyhani K, Miller CC, 3rd, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. Journal of vascular surgery. 2009;49(6):1403-8.

Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2017;53(1):4-52.

Scalea TM, Feliciano DV, DuBose JJ, Ottochian M, O'Connor JV, Morrison JJ. Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard. Journal of the American College of Surgeons. 2019;228(4):605-10.

Agostinelli A, Carino D, Borrello B, Marcato C, Volpi A, Gherli T, et al. Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience. Interactive cardiovascular and thoracic surgery. 2019;28(1):17-22.

van der Zee CP, Vainas T, van Brussel FA, Tielliu IF, Zeebregts CJ, van der Laan MJ. Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis. The Journal of cardiovascular surgery. 2019;60(1):100-10.

Tang GL, Tehrani HY, Usman A, Katariya K, Otero C, Perez E, et al. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. Journal of vascular surgery. 2008;47(3):671-5.

DuBose JJ, Charlton-Ouw K, Starnes B, Saqib N, Quiroga E, Morrison J, et al. Do patients with minimal blunt thoracic aortic injury require thoracic endovascular repair? The journal of trauma and acute care surgery. 2021;90(2):384-7.

Cheng YT, Cheng CT, Wang SY, Wu VC, Chu PH, Chou AH, et al. Long-term Outcomes of Endovascular and Open Repair for Traumatic Thoracic Aortic Injury. JAMA network open. 2019;2(2):e187861.

Mousa AY, Dombrovskiy VY, Haser PB, Graham AM, Vogel TR. Thoracic aortic trauma: outcomes and hospital resource utilization after endovascular and open repair. Vascular. 2010;18(5):250-5.

Estrera AL, Gochnour DC, Azizzadeh A, Miller CC, 3rd, Coogan S, Charlton-Ouw K, et al. Progress in the treatment of blunt thoracic aortic injury: 12-year single-institution experience. The Annals of thoracic surgery. 2010;90(1):64-71.

Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. The Journal of trauma. 2008;64(3):561-70; discussion 70-1.

Steuer J, Björck M, Sonesson B, Resch T, Dias N, Hultgren R, et al. Editor's Choice – Durability of Endovascular Repair in Blunt Traumatic Thoracic Aortic Injury: Long-Term Outcome from Four Tertiary Referral Centers. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2015;50(4):460-5.

Karmy-Jones R, Ferrigno L, Teso D, Long WB, 3rd, Shackford S. Endovascular repair compared with operative repair of traumatic rupture of the thoracic aorta: a nonsystematic review and a plea for trauma-specific reporting guidelines. The Journal of trauma. 2011;71(4):1059-72.

Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review. Journal of vascular and interventional radiology : JVIR. 2008;19(8):1153-64.

Jonker FH, Verhagen HJ, Mojibian H, Davis KA, Moll FL, Muhs BE. Aortic endograft sizing in trauma patients with hemodynamic instability. Journal of vascular surgery. 2010;52(1):39-44.

Muhs BE, Balm R, White GH, Verhagen HJ. Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture. Journal of vascular surgery. 2007;45(4):655-61.

Fabian TC, Richardson JD, Croce MA, Smith JS, Jr., Rodman G, Jr., Kearney PA, et al. Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. The Journal of trauma. 1997;42(3):374-80; discussion 80-3.

Hemmila MR, Arbabi S, Rowe SA, Brandt MM, Wang SC, Taheri PA, et al. Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair? The Journal of trauma. 2004;56(1):13-23.

Stafforini NA, Singh N, Hemingway J, Starnes B, Tran N, Quiroga E. Reevaluating the Need for Routine Coverage of the Left Subclavian Artery in Thoracic Blunt Aortic Injury. Annals of vascular surgery. 2021;73:22-6.

Matsumura JS, Lee WA, Mitchell RS, Farber MA, Murad MH, Lumsden AB, et al. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. Journal of vascular surgery. 2009;50(5):1155-8.




How to Cite

Baldaia L, Antunes LF, Silva M, Silva E, Nunes C, Oliveira VC, Silva J, Fonseca M. Blunt traumatic injuries of thoracic aorta and supra-aortic trunks - a narrative review. Angiol Cir Vasc [Internet]. 2023 Aug. 15 [cited 2023 Dec. 1];19(2):39-41. Available from:



Review Article