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Injury of thoracic trachea — Clinical Guidelines

Overview

Blunt thoracic aortic injury (BTAI) is a severe vascular emergency characterized by aortic damage due to blunt force trauma, often associated with high mortality rates. Thoracic endovascular aortic repair (TEVAR) is considered the gold-standard treatment for managing these injuries 1 4 7.

Diagnosis

Key Diagnostic Criteria: Widening mediastinum on chest X-ray, although unreliable; contrast-enhanced CT angiography is definitive 21.

Recommended Tests: Contrast-enhanced CT angiography is the standard for diagnosing BTAI, identifying intimal flaps, pseudoaneurysms, and extravasation 17 24.

Grading Systems: Society for Vascular Surgery (SVS) grading system is commonly used to assess injury severity 6 16.

Management

First-Line Treatment: Thoracic endovascular aortic repair (TEVAR) is recommended as the primary treatment 1 4 7.

Nonoperative Management (NOM): Considered safe for minor injuries but requires close follow-up 2.

Timing of Repair: Delayed elective repair often associated with lower mortality compared to urgent repair 6 13.

Left Subclavian Artery Coverage: Controversial; routine coverage may not be necessary for successful outcomes 9 12.

Special Techniques: TEVAR with fenestrations can preserve blood flow in supra-aortic branches 5.

Endovascular vs Open Repair: Endovascular repair shows equivalent survival outcomes compared to open repair 14.

Special Populations

Gender Differences: No significant difference in mortality between males and females undergoing TEVAR for BTAI 10.

Pediatrics and Elderly: Specific guidelines or studies focusing on these populations are not extensively covered in the provided abstracts.

Key Recommendations

Primary Treatment with TEVAR: Use thoracic endovascular aortic repair as the first-line treatment for blunt thoracic aortic injuries (Evidence: Strong 1 4 7).

Consider Delayed Repair: Opt for elective repair when feasible, as it is associated with lower mortality compared to urgent repair (Evidence: Moderate 6 13).

Evaluate Need for Left Subclavian Artery Coverage Individually: Routine coverage of the left subclavian artery may not be necessary; assess on a case-by-case basis (Evidence: Moderate 9 12).

Nonoperative Management for Minor Injuries: Nonoperative management can be considered safe for minor injuries with rigorous follow-up (Evidence: Moderate 2).

Use CT Angiography for Diagnosis: Rely on contrast-enhanced CT angiography for definitive diagnosis of BTAI (Evidence: Strong 17 24).

References

1 Surkhi AO, Jubouri M, Alsarayrah AI, Jubouri YF, Akasheh HM, Alaraj RSN et al.. Evaluating the Clinical Profile of Thoracic Endovascular Aortic Repair in Blunt Thoracic Aortic Injury: A Systematic Review and Meta-Analysis. Annals of vascular surgery 2026. link 2 Romijn AC, Zlatanovic P, Jovanovic A, Ricco JB, Davidovic L, Jongkind V. Midterm Outcomes of Nonoperative Management of Blunt Thoracic Aortic Injury: Systematic Review and Meta-analysis. Annals of vascular surgery 2026. link 3 D'Alessio I, Monzio-Compagnoni N, Salinetti G, DuBose J, Starnes BW, Quiroga E et al.. The Role of Gender in Blunt Thoracic Aortic Injuries. Annals of vascular surgery 2026. link 4 Nana P, Spanos K, Behrendt CA, Brodis A, Haulon S, Kölbel T. A Systematic Review on Thoracic Endovascular Repair Outcomes in Blunt Thoracic Aortic Injuries. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists 2025. link 5 Wang Y, Wang B, Qiu C. TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm: Case report and systematic review. Vascular 2025. link 6 Yadavalli SD, Summers SP, Rastogi V, Romijn AC, Marcaccio CL, Lagazzi E et al.. The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury. Journal of vascular surgery 2024. link 7 Minici R, Serra R, Ierardi AM, Petullà M, Bracale UM, Carrafiello G et al.. Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results. Vascular 2024. link 8 D'Oria M, Pipitone MD, DuBose J, Azizzadeh A, Miller CC, Starnes BW et al.. Development and Validation of a Risk Prediction Tool for In-hospital Mortality After Thoracic Endovascular Repair in Patients with Blunt Thoracic Aortic Injury Using the Aortic Trauma Foundation Registry. Annals of vascular surgery 2024. link 9 Romagnoli AN, Paterson J, Dua A, Kauvar D, Saqib N, Miller C et al.. Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma. The journal of trauma and acute care surgery 2023. link 10 Rastogi V, Romijn AC, Yadavalli SD, Marcaccio CL, Jongkind V, Zettervall SL et al.. Males and females have similar mortality after thoracic endovascular aortic repair for blunt thoracic aortic injury. Journal of vascular surgery 2023. link 11 Hundersmarck D, van der Vliet QMJ, Winterink LM, Leenen LPH, van Herwaarden JA, Hazenberg CEVB et al.. Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. European journal of trauma and emergency surgery : official publication of the European Trauma Society 2022. link 12 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. link 13 Alarhayem AQ, Rasmussen TE, Farivar B, Lim S, Braverman M, Hardy D et al.. Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era. Journal of vascular surgery 2021. link 14 Erben Y, Trejo G, Brownstein AJ, Jean RA, Ziganshin BA, Carino D et al.. Endovascular thoracic aortic transection repair has equivalent survival to open repair after blunt thoracic aortic injury. International angiology : a journal of the International Union of Angiology 2018. link 15 Tanizaki S, Maeda S, Matano H, Sera M, Nagai H, Nakanishi T et al.. Blunt thoracic aortic injury with small pseudoaneurysm may be managed by nonoperative treatment. Journal of vascular surgery 2016. link 16 Harris DG, Rabin J, Kufera JA, Taylor BS, Sarkar R, O'Connor JV et al.. A new aortic injury score predicts early rupture more accurately than clinical assessment. Journal of vascular surgery 2015. link 17 Ait Ali Yahia D, Bouvier A, Nedelcu C, Urdulashvili M, Thouveny F, Ridereau C et al.. Imaging of thoracic aortic injury. Diagnostic and interventional imaging 2015. link 18 Tong X, Gu P, Yu D, Guo F, Lin X. An endovascular treatment of a thoracic aortic injury caused by a misplaced pedicle screw: Case report and review of the literature. Journal of the Formosan Medical Association = Taiwan yi zhi 2015. link 19 Estrera AL, Miller CC, Guajardo-Salinas G, Coogan S, Charlton-Ouw K, Safi HJ et al.. Update on blunt thoracic aortic injury: fifteen-year single-institution experience. The Journal of thoracic and cardiovascular surgery 2013. link 20 Patel HJ, Hemmila MR, Williams DM, Diener AC, Deeb GM. Late outcomes following open and endovascular repair of blunt thoracic aortic injury. Journal of vascular surgery 2011. link 21 Nzewi O, Slight RD, Zamvar V. Management of blunt thoracic aortic injury. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2006. link 22 Hoffer EK, Karmy-Jones R, Bloch RD, Meissner MH, Borsa JJ, Nicholls SC et al.. Treatment of acute thoracic aortic injury with commercially available abdominal aortic stent-grafts. Journal of vascular and interventional radiology : JVIR 2002. link61870-3) 23 Wall MJ, Hirshberg A, LeMaire SA, Holcomb J, Mattox K. Thoracic aortic and thoracic vascular injuries. The Surgical clinics of North America 2001. link80013-x) 24 Patel NH, Stephens KE, Mirvis SE, Shanmuganathan K, Mann FA. Imaging of acute thoracic aortic injury due to blunt trauma: a review. Radiology 1998. link 25 Timberlake GA, Kerstein MD, McSwain NE. Penetrating thoracic aortic injuries: rare but potentially salvageable sequelae of urban warfare. Southern medical journal 1989. link 26 Walls JT, Curtis JJ, Boley T. Sarns centrifugal pump for repair of thoracic aortic injury: case reports. The Journal of trauma 1989. link

Injury of thoracic trachea