Hospital setting of endovascular repair influences procedural outcomes in blunt traumatic aortic injury

Abstract

Background: Thoracic endovascular aortic repair (TEVAR) has become the mainstay of treatment for blunt thoracic aortic injuries (BTAI) over open repair. Since the arrival of TEVAR, hybrid operating rooms have emerged as highly specialized environments equipped to streamline endovascular and open cases. Procedure characteristics and outcomes may vary when TEVAR is performed in the setting of a standard operating room with a portable C-Arm vs in a hybrid operating room or interventional radiology (IR) suite with a fixed imaging system. The purpose of this study was to compare clinical characteristics and outcomes of TEVAR for BTAI across these settings. We hypothesize that cases performed with a C-Arm would lead to higher rates of complications.

Methods: The PROOVIT registry (PROspective Observational Vascular Injury Treatment) captures trauma-specific outcomes related to vascular injury across 14 trauma centers in the United States. The registry was queried for BTAI undergoing TEVAR from 2012 to 2021. Cases were categorized as having been performed in a standard operating room with portable C-Arm imaging (C-Arm), or in a fixed imaging suite (hybrid room [Hybrid] or IR). Procedural characteristics and complications (arterial access, reintervention, stroke) were collected and compared using univariate analyses.

Results: PROOVIT contained 199 TEVAR for BTAI: 82 C-Arm, 75 Hybrid, and 42 IR cases. There was no clear temporal trend in the setting TEVAR was performed. Demographics and mechanism of injury were similar between groups; Hybrid room procedures had higher median Injury Severity Score (ISS) (38; interquartile range [IQR], 14) than C-Arm (33; IQR, 15) and IR (29; IQR, 25; P = .02) and a higher proportion of cases with an Abbreviated Injury Scale head score of >3 (44% vs 28% C-Arm vs 24% IR; P = .06). Hybrid cases were most often delayed >6 hours from arrival (78% vs 48% vs 41%; P < .001), but C-Arm cases most frequently lasted >3 hours (34% vs 12% Hybrid vs 15% IR; P = .002). Use of C-Arm (P = .03) and time to TEVAR of <6 hours (P = .04) were predictors of complications. All strokes (n = 3) occurred in C-Arm cases (P = .04).

Conclusions: Despite technological advances, TEVAR for BTAI is still performed frequently in a standard operating room with C-Arm imaging, rather than with a fixed imaging system in a hybrid operating room or IR suite. C-Arm procedures take longer and have higher complication rates, including stroke. TEVAR for BTAI is conducted most safely using a fixed imaging system in a hybrid operating room setting.

Keywords: Blunt traumatic aortic injury; Hybrid operating room; Operating setting; Thoracic endovascular aortic repair; Trauma.