Delayed thoracic endovascular aortic repair (TEVAR) for predominantly Grade III blunt thoracic aortic injury: a 12-year single-center experience

Introduction

Background

Blunt thoracic aortic injury (BTAI) is a life-threatening injury most commonly sustained after high-energy mechanisms, including motor vehicle collisions and falls from height. Although infrequent, BTAI is among the leading causes of death after blunt trauma; approximately 80% to 85% of patients die before reaching the hospital, and patients who survive to hospital presentation remain at risk for substantial early mortality (1,2). The aortic isthmus is the most common site of injury, owing to differential mobility between the relatively fixed arch and the descending thoracic aorta, which creates a fulcrum for deceleration-induced shear forces. BTAI encompasses a spectrum of injury, ranging from minor intimal disruption to full-thickness rupture. Contained injuries, including pseudoaneurysms, may initially be clinically occult but can progress to rupture and exsanguination.

Historically, emergent open repair was the mainstay for patients who survived to diagnosis. However, many patients with BTAI present with competing life-threatening injuries, including traumatic brain injury (TBI) requiring neurosurgical intervention, hemoperitoneum, severe respiratory compromise, or high-grade pelvic fractures. In such patients, delayed repair became a pragmatic strategy to permit stabilization and treatment of these injuries before definitive aortic intervention (3). During this interval, strict blood pressure (BP) and heart rate control with anti-impulse therapy is used to reduce aortic wall stress and limit injury progression while competing life-threatening injuries are addressed.

With the advent of endovascular repair, thoracic endovascular aortic repair (TEVAR) has become the preferred modality for repair-requiring BTAI (3,4). The 2011 Society for Vascular Surgery (SVS) guidelines classified BTAI into four grades: Grade I, intimal tear; Grade II, intramural hematoma; Grade III, pseudoaneurysm; and Grade IV, rupture. These guidelines recommended nonoperative management for Grade I injuries and repair for Grade II to IV injuries, with TEVAR preferred over open repair when anatomically feasible (4). More recently, the 2025 European Society for Vascular Surgery (ESVS) vascular trauma guidelines proposed a simplified 3-grade classification based on external aortic contour and rupture status, recommending nonoperative management for Grade 1 injuries, TEVAR for Grade 2 injuries based on high-risk features and timing considerations, and immediate repair for Grade 3 rupture (5). For consistency throughout this manuscript, all subsequent grading refers to the 2011 SVS classification (4).

Rationale

Subsequent evidence suggested that a similar delayed-intervention strategy may be safe for selected hemodynamically stable patients with Grade II injuries (6). For Grade III pseudoaneurysms, the updated SVS focused guidelines now suggest delayed TEVAR (>24 hours) in hemodynamically stable patients to allow management of associated traumatic injuries when needed; however, this recommendation is based on low-certainty evidence (Grade 2C). In unstable patients in whom the BTAI is suspected to be the primary driver of instability, the guidelines recommend urgent or emergent intervention (7). Therefore, although delayed TEVAR is increasingly supported in selected stable Grade III BTAI patients, the optimal timing of repair and the patient characteristics most suitable for delayed intervention remain incompletely defined.

Knowledge gap

Much of the existing literature is derived from multicenter registries, pooled datasets, or large administrative databases with variable institutional practices, anti-impulse protocols, operative thresholds, and follow-up patterns. These data sources often lack granular procedural and longitudinal outcome data specific to delayed TEVAR in Grade III BTAI (8-10). This limits the ability to define real-world perioperative outcomes, reintervention patterns, and midterm durability after delayed TEVAR in this subgroup.

Objective

To address this uncertainty, we present our single-institution experience with delayed TEVAR in a consecutive cohort of primarily Grade III BTAI patients over more than a decade, in accordance with STROBE guidelines (11). Our objective was to describe procedural details, perioperative outcomes, follow-up durability, and reinterventions after delayed TEVAR, thereby complementing registry-based analyses with granular single-center data. We present this article in accordance with the STROBE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-2025-1-94/rc).

Methods

Diagnosis and timing of repair

The diagnosis of BTAI was confirmed in all patients using computed tomographic angiography (CTA) at initial presentation. Aortic injuries were classified according to the SVS Aortic Injury Scale based on admission imaging (4). Emergent repair was performed in cases of hemodynamic instability attributable to the aortic injury, active contrast extravasation suggestive of impending rupture, or evidence of distal ischemia, including absent peripheral pulses or organ malperfusion. In patients with concomitant life-threatening injuries, priority was given to stabilization and management of these conditions prior to aortic intervention. Similarly, patients with significant cardiac comorbidities underwent repair only after appropriate medical optimization. For patients selected for delayed repair, defined as repair performed more than 24 hours after presentation, anti-impulse therapy with continuous beta-blocker infusion was instituted with multidisciplinary consultation. The goal was to maintain systolic BP at ≤100 mmHg and/or mean arterial pressure (MAP) at ≤80 mmHg to minimize shear stress on the injured aortic wall. Adjunctive measures included analgesia with acetaminophen and intravenous opioids as needed to ensure adequate pain control and limit sympathetic stimulation. Routine bed rest was not mandated as part of the protocol, but was implemented in patients with concomitant injuries requiring immobilization.

Endovascular repair technique and operative setting

Endovascular repair of BTAI was performed in a hybrid operating room. All cases were performed with at least one board-certified vascular and board-certified cardiothoracic surgeon present and under general anesthesia. Spinal monitoring with somatosensory evoked potential (SSEP) and/or motor evoked potential (MEP) was used. Use of spinal drainage was at the discretion of the operating surgeon. Preoperative antibiotics were administered. Intravenous heparin was then given, and activated clotting times were maintained within the therapeutic range. Preoperative CTA and intravascular ultrasound (IVUS), if needed, were used for evaluation of proximal and distal landing zone diameter and grafts were appropriately selected to achieve no more than 10% oversizing. In patients with concomitant TBI, intervention was deferred until the ability to provide systemic anticoagulation was obtained from the neurosurgical team. Access to the common femoral artery was initially obtained via surgical cutdown in most early cases, and was later transitioned to percutaneous access. In all patients, the lesion location in relation to the left subclavian artery (LSA) was assessed. Left carotid-to-subclavian bypass using a prosthetic graft was performed as a first-stage operation in patients requiring LSA coverage prior to thoracic branch endograft availability. Adenosine was used in earlier cases and temporary percutaneous intravenous pacing in later cases to induce transient circulatory arrest and minimize the risk of stent-graft migration during deployment. Completion angiography was obtained in every patient to assess final stent position, graft patency, and the presence of endoleaks by the operating surgeon(s).

Outcome measures

Operative details, including access site, operative technique, intraoperative complications, endoleaks, LSA coverage or revascularization status, and need for reintervention, were obtained from operative records. In-hospital outcomes, including access-site complications, paraplegia, stroke, reintervention, and extremity claudication, were collected through chart review. Follow-up data, including surveillance CTA findings, access-site complications, extremity claudication, endoleaks, reinterventions, graft patency, graft migration, and mortality, were recorded at intervals ranging from 1 to 24 months.

Follow-up compliance was calculated using the number of surviving delayed-TEVAR patients eligible for each time point as the denominator. Unless otherwise specified, outcome analyses for delayed TEVAR included all 27 delayed repairs, including one chronic Grade III case; time-to-repair analyses were restricted to the 26 acute cases with delayed repairs.

The primary outcomes were 30-day mortality and technical success. Time from diagnosis to intervention was recorded as a key timing variable. Secondary outcomes included open conversion, intraoperative and postoperative complications, endoleaks, reinterventions, hospital length of stay, intensive care unit length of stay, graft patency, graft migration, and late mortality. Technical success was defined as successful endograft deployment with exclusion of the aortic lesion at completion of the index procedure, including after adjunctive angioplasty or additional stent-graft placement when required. Outcome analyses were limited to patients undergoing delayed TEVAR, whereas all patients were included in descriptive cohort analyses.

Statistical analysis

Data were analysed using IBM SPSS Statistics version 26 (IBM Corp, Armonk, NY) (12). Given the descriptive nature of the study, only descriptive statistics were used; no comparative or inferential analyses were performed. Data were summarized using means with standard deviations or medians with ranges for continuous variables and counts with percentages for categorical variables. Missing data were not imputed. Analyses were conducted using available-case/complete-case methods, with denominators adjusted to reflect the number of patients with available data for each variable.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Westchester Medical Center, New York Medical College (No. L-10,170), and individual consent for this retrospective analysis was waived.

Results

Patient characteristics

A total of 30 consecutive patients with a mean age of 41±19 years (range, 19–86 years) were operated at Westchester Medical Center for BTAI. Five patients (16.7%) were older than 65 years, and the majority were male (22/30, 73.3%). The most common mechanism of injury was motor vehicle trauma, accounting for nearly three-quarters of cases, followed by falls in 5 patients (16.7%) and pedestrian injuries in 2 patients (6.7%). The mean Injury Severity Score (ISS) was 32.7±10.2, and the mean Trauma and Injury Severity Score (TRISS) for blunt trauma was 0.70±0.27.

One noteworthy case involved a patient with a remote motor vehicle collision in 1976 who presented three decades later, in 2006, with chest pain and was diagnosed with a chronic descending thoracic aortic pseudoaneurysm as a delayed manifestation of BTAI. This case was classified as chronic BTAI and, given its delayed presentation, was included in overall cohort analyses but excluded from time-to-repair calculations.

Demographic, preoperative and clinical data for all patients who presented to us with severe BTAI are summarized in Table 1. The pattern and location of BTAI in this cohort are summarized in Table 2.

The majority of aortic injuries (60%, n=18) were located at the aortic isthmus, with 11 patients (36.6%) demonstrating involvement of the descending thoracic aorta. Of the 30 patients comprising the total BTAI cohort, 28 (93.3%) had acute Grade III injuries, 1 (3.3%) had chronic Grade III BTAI, 1 (3.3%) had a Grade IV injury, and 1 (3.3%) had a Grade II injury.

The total cohort comprised 30 patients with BTAI, as illustrated in Figure 1. Based on timing of intervention, patients were stratified into emergent (<24 hours) and delayed TEVAR groups. The emergent repair cohort included 3 patients: 2 with acute Grade III injuries and 1 with a Grade IV injury. The remaining 27 patients constituted the delayed TEVAR cohort, including 25 with acute Grade III BTAI, 1 with chronic Grade III BTAI, and 1 with acute Grade II injury.

Figure 1 Patient selection, stratification, and follow-up in the BTAI cohort. BTAI, blunt thoracic aortic injury; TEVAR, thoracic endovascular aortic repair.

The mean pseudoaneurysm size among patients undergoing delayed TEVAR was 2.2±0.8 cm in its largest dimension. Patients undergoing emergent repair were excluded from subsequent outcome analyses.

Associated injuries

All patients with BTAI who underwent TEVAR sustained additional injuries. The most common associated injuries were orthopedic, including extremity and pelvic fractures, which occurred in 23 (76.6%) patients. More than half of these patients required operative intervention prior to TEVAR. Neurologic injuries were present in 21 (70%) patients, with a third of them requiring operative management such as craniotomy/craniectomy or placement of multimodality invasive monitoring catheters. Intra-abdominal injuries were identified in 15 (50%) patients, a third of which required emergent intervention in the form of exploratory laparotomy and/or angiographic embolization for solid organ injury prior to aortic repair (Table 3).

Operative management

TEVAR was performed in all 30 patients. Among the acute BTAI cohort (n=29), 26 underwent delayed repair, whereas 3 required emergent TEVAR (<24 hours) due to hemodynamic instability in 2 patients with Grade III injury and 1 patient with Grade IV injury presenting with hemothorax.

Among patients with acute BTAI undergoing delayed TEVAR (n=26; 1 Grade II and 25 Grade III), the median time to repair was 19 days (range, 2–152 days); the patient with chronic BTAI was excluded from this calculation.

Two patients required the deployment of two stent grafts, both to treat intraoperative type I endoleaks noted on completion angiography, which resolved following the additional coverage. In one case, partial coverage of the left common carotid artery origin occurred, necessitating carotid stenting to preserve cerebral perfusion. The remaining patients required a single stent graft.

Device selection was determined by time period, anatomical measurements, device availability, and surgeon preference. The GORE^® TAG^® stent graft (W. L. Gore & Associates, Flagstaff, AZ, USA) was used in 4 cases. Talent™ stent grafts (Medtronic, Santa Rosa, CA, USA) were deployed in 9 patients, while the Medtronic™ Valiant™ device was used in 10 patients. Cook Alpha™ stent grafts (Cook Medical, Bloomington, IN, USA) were used in 2 patients, and Relay^® stent grafts (Bolton Medical, Sunrise, FL, USA) were used in 2 patients.

The mean operative time for the entire cohort was 284±119 minutes. With the introduction of a hybrid operating room during the latter part of the study period, operative times demonstrated a downward trend. To evaluate this, cases were divided into two equal groups based on chronology. The first group, comprising the initial 15 cases performed during the first six years, had a mean operative time of 337±130 minutes. In contrast, the subsequent 15 cases performed in the later six years demonstrated a shorter mean operative time of 241±101 minutes, a reduction likely attributable to the availability of the hybrid operating room.

None of the patients in this series required conversion to an open procedure. Coverage of the LSA occurred in 16 of 27 (59.2%) patients with delayed repair. Of these, 8 patients underwent prophylactic left carotid-subclavian bypass prior to TEVAR. Additional indications for revascularization included prior coronary artery bypass with the left internal mammary artery (LIMA) in 1 patient, and severe underlying coronary artery disease in 2 patients, where preservation of LIMA inflow was considered important for potential future coronary revascularization. Among the 8 patients who underwent LSA coverage without bypass, 2 were deferred due to cervical spinal instability. One of these subsequently developed symptomatic left upper extremity claudications after spinal stabilization and required delayed carotid-subclavian bypass. The remaining 7 patients remained asymptomatic on follow-up. Technical success was achieved in all cases, with complete exclusion of the aortic lesion at the end of the procedure and no intraoperative deaths.

Early/intraoperative endoleaks

On completion angiography, endoleaks were identified in 7 of 27 (25.9%) patients with delayed repair. Five patients had type I endoleaks; three were successfully treated with balloon angioplasty, and two required placements of an additional stent graft. Type II endoleaks were observed in 3 patients, including 1 who also had a concomitant type I endoleak. Two patients demonstrated backflow from the covered LSA, both of whom underwent coil embolization at approximately 3 months of follow-up. In one patient, slow filling of the pseudoaneurysm sac was seen from an unidentified branch vessel, which resolved spontaneously on subsequent imaging.

A summary of intraoperative findings and management is provided in Table 4.

Postoperative in-hospital outcomes

The mean hospital length of stay was 38±24 days, with a mean intensive care unit stay of 30±24 days. One patient (3.7%) developed a groin access complication related to percutaneous closure, requiring surgical exploration and primary repair of the common femoral artery. No patient required an unplanned return to the operating room during the index hospitalization, and no cases of graft failure or migration were observed in the in-hospital period.

Postoperative complications occurred in 6 of 27 patients (22.2%). Five complications were unrelated to either the BTAI or TEVAR and included deep vein thrombosis (DVT), sepsis, ventilator-associated pneumonia, acute kidney injury requiring hemodialysis, and hypertensive crisis managed conservatively. The remaining patient experienced loss of distal pulses in the limb used for device delivery within 24 hours postoperatively. Urgent angiography revealed no flow-limiting lesion, and systemic anticoagulation was initiated with subsequent restoration and maintenance of palpable pulses after discontinuation of anticoagulation, without further sequelae. No patient suffered ischemic stroke, paraplegia, or bowel ischemia during the hospitalization. Follow-up CTA was obtained in all patients prior to discharge. All-cause mortality in the delayed TEVAR cohort was 3.7% (1/27). The single death occurred in a delayed TEVAR patient on post-operative day 47, with extensive multisystem trauma whose family elected comfort measures following a prolonged hospitalization of over 60 days. Importantly, no deaths were directly attributable to the BTAI itself or to the TEVAR procedure, either early or delayed.

The postoperative data has been summarized in Table 5.

Follow-up compliance and duration

Clinical outcomes were evaluated over a 24-month follow-up period and included mortality, graft failure, graft migration, endoleaks, readmissions, and reinterventions. As noted above, one patient died in-hospital, leaving 26 patients eligible for follow-up.

Among the 26 surviving patients who underwent delayed TEVAR, 20 (76.7%) returned for follow-up at 1 and 3 months after discharge. Of the 26 patients eligible for early follow-up, one had an insufficient duration of surveillance at the time of analysis at 6 months, leaving 25 patients eligible for evaluation at 6, 12, and 24 months.

Follow-up compliance rates were 56% (14/25) at 6 months, 52% (13/25) at 12 months, and 44% (11/25) at 24 months. The mean follow-up duration was 24±33 months, and the median follow-up was 6 months (range, 0–108 months).

The follow-up data, together with long-term complication profile has been summarized in Table 6.

Early (≤3 months) complications and reinterventions

Four patients (20%) required reintervention during early follow-up, out of 20 presenting for follow-up. At 1 month, 1 patient (5%) developed severe left upper extremity claudication following LSA coverage; prophylactic carotid-subclavian bypass had been deferred due to an unstable spinal injury. After stabilization, a bypass was performed uneventfully with complete resolution of symptoms.

At 3 months, 3 patients (15%) required intervention for type II endoleaks originating from the LSA. Two had been identified intraoperatively, while one was newly diagnosed. All were successfully treated with coil embolization.

Late outcomes

One additional type II endoleak was detected at 24 months, arising from a carotid-subclavian bypass through the subclavian vessel, and was successfully treated with coil embolization. The late endoleak rate was 0% at 6 and 12 months, and 9.1% (1/11) at 24 months. Beyond endoleak management, one additional patient presented with recurrent left upper extremity claudication at 24 months follow-up; diagnostic angiography revealed no arterial abnormality, and no intervention (other than CTA) was performed.

Overall reintervention rates were 20% (4/20) at 3 months, with no new reinterventions at 6 and 12 months, and 18% (2/11) at 24 months. Endograft patency was 100% across all evaluable patients at 6, 12, and 24 months, with no instances of graft migration or device failure observed during follow-up. No postdischarge mortality was observed.

Discussion

Key findings

In this single-center series of 30 consecutive BTAI patients treated with TEVAR, most injuries were severe, with 90% classified as acute Grade III and all patients presenting with concomitant traumatic injuries. Among the 27 patients managed with delayed TEVAR, technical success was achieved in all cases, with no intraoperative deaths, no conversion to open repair, and no in-hospital stroke, paraplegia, bowel ischemia, graft failure, or graft migration. Delayed repair was associated with acceptable early outcomes despite high injury burden, including one all-cause in-hospital death unrelated to BTAI or TEVAR. During follow-up, endograft patency remained 100% among evaluable patients, with no late device-related complications or mortality; however, follow-up attrition was substantial, and reinterventions were primarily related to type II endoleaks from the LSA or symptoms after LSA coverage.

Comparison with existing literature & explanation of findings

Historically, immediate open repair was favored for BTAI because of concern for rapid progression and rupture, supported by early reports showing high prehospital and early in-hospital mortality (1). Subsequent experience demonstrated that aggressive anti-impulse therapy could stabilize selected patients during a delay to repair, laying the foundation for delayed repair strategies (13). With the adoption of TEVAR, repair-related morbidity decreased substantially, and TEVAR became the preferred modality for repair-requiring BTAI (3,4). Early experience with TEVAR reinforced the long-standing preference for prompt repair, as reflected in the Eastern Association for the Surgery of Trauma (EAST) guidelines, which recommended repair whenever feasible except in poor surgical candidates or patients with competing life-threatening injuries (14). Although the 2011 SVS guidelines recommended urgent TEVAR within 24 hours for Grade II–IV injuries, later evidence suggested that low-grade injuries may often be observed safely, shifting the controversy toward the optimal timing of repair for Grade III pseudoaneurysms and not the need for intervention (4,15).

Demetriades et al highlighted an increase in average time to repair over successive decades, reflecting a gradual shift toward delayed repair (3,16). Registry-based and multicenter studies have reported lower in-hospital mortality after delayed TEVAR compared with early TEVAR. Marcaccio et al. reported lower mortality after delayed TEVAR than early TEVAR among stable patients (5.4% vs. 11.9%); early repair was associated with higher adjusted odds of mortality (adjusted odds ratio, 2.39) (8). In a large National Trauma Data Bank (NTDB) analysis of 2,821 patients, Alarhayem et al found that mortality was more than twofold higher among patients repaired within 24 hours compared with those repaired after 24 hours (9.8% vs. 4.4%). This survival advantage persisted across injury-severity strata and after adjustment for concomitant extrathoracic injuries (9).

Larger registry-based evidence has produced more nuanced findings. In a Vascular Quality Initiative (VQI) analysis of 1,016 patients, Yadavalli et al. demonstrated no significant differences in perioperative or 5-year mortality between urgent/emergent (≤24 hours) and elective TEVAR. Notably, elective repair, which accounted for approximately 10% of cases, was associated with lower rates of postoperative stroke and pulmonary complications, suggesting potential perioperative benefits despite the absence of a mortality difference (17). These mixed findings were synthesized by Liu et al. in a meta-analysis of 13 studies including 5,690 patients. Early repair was associated with higher in-hospital mortality compared with delayed repair (odds ratio, 1.99; 95% confidence interval, 1.53–2.58), whereas delayed repair was not associated with an increased risk of stroke. Early repair was associated only with shorter intensive care unit (ICU) stay and ventilator duration. Subgroup analyses suggested that the mortality difference was primarily observed in Western cohorts, whereas no significant mortality difference was identified in the Chinese subgroup, possibly reflecting differences in trauma systems, patient selection, or resource allocation (18). In contrast to larger registry analyses, our study provides procedure-level detail describing outcomes after delayed repair in a carefully selected cohort. Our findings are consistent with this evolving evidence base, demonstrating acceptable perioperative and midterm outcomes after delayed TEVAR in predominantly Grade III injuries.

This shift is reflected in the updated SVS clinical practice guidelines, which now suggest delayed TEVAR beyond 24 hours in hemodynamically stable patients to allow prioritization of concomitant injuries, while reserving urgent or emergent repair for patients in whom the aortic injury is the primary driver of instability (7). This represents an important change from the 2011 recommendation favoring urgent repair for Grade III injuries and supports individualized, multidisciplinary timing decisions, particularly in patients with concomitant TBI or solid organ injury. The guidelines also suggest anti-impulse therapy as a stabilizing measure until TEVAR, when not precluded by competing injuries (7). The importance of individualized timing is particularly evident in patients with concomitant TBI. Zambetti et al. found that, among patients with concomitant TBI, early TEVAR was associated with higher mortality than delayed TEVAR (19). However, the Aortic Trauma Foundation (ATF) registry analysis by Arbabi et al. found no significant differences in mortality or stroke across emergent, urgent, and delayed TEVAR groups among patients with TBI (20). These divergent findings reinforce the need for patient-specific sequencing rather than a uniform timing threshold.

Delayed repair allowed prioritization of severe concomitant injuries, which are common in this population. In our series, patients frequently presented with neurologic, abdominal, or orthopedic injuries requiring intervention or stabilization before aortic repair. This approach is consistent with damage-control principles, allowing resuscitation and operative sequencing before definitive repair. When combined with aggressive BP and heart rate control, delayed TEVAR may reduce the additive physiologic burden of intervention in patients with multisystem trauma.

In accordance with the 2011 SVS guidelines, we favored preemptive LSA revascularization before TEVAR when clinically feasible in patients requiring LSA coverage to obtain an adequate proximal seal zone (4). The updated SVS focused guidelines now suggest an individualized approach to LSA revascularization, based on feasibility and patient-specific factors such as prior patent LIMA coronary bypass graft, dominant left vertebral artery, or anomalous aortic origin of the left vertebral artery (7). In our series, carotid-subclavian bypass was performed in 8 of 16 patients requiring LSA coverage. Consistent with prior trauma-focused series, all but 1 patient in our cohort who underwent LSA coverage without preemptive revascularization remained asymptomatic during follow-up, and none developed acute perioperative upper extremity ischemia (21-23). However, Romagnoli et al. cautioned against routine LSA coverage without revascularization, reporting higher rates of spinal cord ischemic events among patients in whom the LSA was covered without preservation of flow (24). Therefore, contemporary evidence increasingly supports selective revascularization or preservation of LSA flow in anatomically suitable patients. The emergence of branched thoracic endoprostheses may further alter the management of LSA coverage in BTAI by enabling proximal seal while preserving branch-vessel perfusion (25).

Our study also highlights a common challenge in trauma populations: follow-up attrition, which limits accurate long-term outcome assessment. In our cohort, 6 of 26 eligible survivors did not return for 3-month follow-up, corresponding to 23.1% attrition, which increased to 56% by 24 months. Similarly, Kidane et al. reported loss-to-follow-up rates of up to 25% among patients undergoing endovascular repair in a systematic review of BTAI management strategies (26). These findings underscore the need for structured surveillance strategies to reduce attrition and improve the quality of long-term outcomes data.

Limitations

This study has several limitations. First, it represents a single-center, retrospective experience with a relatively small sample size, which inherently limits generalizability. Second, long-term follow-up was incomplete, with attrition over time that may bias durability assessments. Third, our cohort included only patients undergoing delayed TEVAR; the absence of a contemporaneous early-repair control group introduces inherent selection bias, as only hemodynamically stable patients were eligible for delayed intervention, thereby limiting causal inference and generalizability of the observed outcomes.

Additionally, the predominance of Grade III injuries in this cohort reflects selection bias inherent to the study design, as only patients undergoing operative intervention were included; higher-grade injuries are more likely to require repair and are therefore overrepresented compared to the broader BTAI population, in which lower-grade injuries are often managed nonoperatively.

The definition of delayed repair (>24 hours) in this study differs from that used in prior literature, and the prolonged time-to-intervention observed in some patients in our cohort may limit comparability with previously reported delayed repair strategies. Furthermore, this study is not designed to determine the optimal timing of TEVAR in BTAI. Patients undergoing emergent repair represent a distinct clinical subset with greater physiologic instability and possibly higher injury severity, introducing additional selection bias that limits valid comparison.

Finally, the 12-year study period spans significant advancements in endovascular technology, perioperative management, and multidisciplinary trauma care, introducing potential temporal heterogeneity. Due to limited granularity of earlier records, we were unable to perform a formal temporal subgroup analysis or provide detailed year-wise comparisons to assess the impact of these changes on outcomes. Accordingly, our findings should be interpreted as descriptive, demonstrating feasibility in a selected cohort rather than providing definitive guidance on optimal timing or treatment strategy.

Implications and actions needed

For Grade III BTAI, the practical implication of these findings is the need for structured decision-making rather than reflexive repair based on time from injury alone. In hemodynamically stable patients, multidisciplinary pathways should integrate vascular surgery, trauma surgery, critical care, neurosurgery, orthopedic surgery, and interventional radiology to determine when concomitant injuries should take priority and when aortic repair should proceed. During any delay to TEVAR, patients require strict anti-impulse therapy, close hemodynamic monitoring, and interval imaging or clinical reassessment to identify progression, instability, or high-risk imaging features that would justify earlier intervention. When LSA coverage is required, teams should proactively evaluate the need for revascularization or branch-vessel preservation based on anatomy and ischemic risk. Finally, trauma programs should implement dedicated surveillance systems, including follow-up scheduling before discharge, patient navigation, reminder workflows, and coordination with regional providers, to reduce attrition and improve long-term assessment of endograft durability.

Conclusions

In this single-center retrospective experience, delayed TEVAR for carefully selected, hemodynamically stable patients with predominantly Grade III BTAI was feasible and associated with acceptable perioperative outcomes, including no aortic- or device-related mortality, no stroke or paraplegia, and encouraging midterm durability among patients with available follow-up. These findings are consistent with contemporary evidence and the updated SVS clinical practice guidelines supporting delayed TEVAR in stable patients when concomitant injuries require prioritization. Given the single-center design, small cohort size, absence of an early-repair comparator, and incomplete follow-up, these results should be interpreted as descriptive rather than definitive evidence of superiority. Larger multicenter studies with standardized imaging surveillance are needed to refine patient-selection criteria, clarify optimal timing, and assess long-term durability.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-2025-1-94/rc

Data Sharing Statement: Available at https://asj.amegroups.com/article/view/10.21037/asj-2025-1-94/dss

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-2025-1-94/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-2025-1-94/coif). A.S. serves as an unpaid editorial board member of AME Surgical Journal from August 2025 to July 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Westchester Medical Center, New York Medical College (No. L-10,170), and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the noncommercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. PARMLEY LF, MATTINGLY TW, MANION WC, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17:1086-101. [Crossref] [PubMed]
2. Al-Thani H, Hakim S, Asim M, et al. Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital. Eur J Trauma Emerg Surg 2022;48:4079-91. [Crossref] [PubMed]
3. Demetriades D, Velmahos GC, Scalea TM, et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma 2008;64:1415-8. [Crossref] [PubMed]
4. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011;53:187-92. [Crossref] [PubMed]
5. Wahlgren CM, Aylwin C, Davenport RA, et al. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. Eur J Vasc Endovasc Surg 2025;69:179-237. [Crossref] [PubMed]
6. Golestani S, Dubose JJ, Efird J, et al. Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury. J Am Coll Surg 2024;238:1099-104. [Crossref] [PubMed]
7. DuBose J, Kundi R, Curi MA, et al. The Society for Vascular Surgery clinical practice guideline on the management of blunt thoracic aortic injury: Focused update. J Vasc Surg 2026;83:1281-1290. [Crossref] [PubMed]
8. Marcaccio CL, Dumas RP, Huang Y, et al. Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury. J Vasc Surg 2018;68:64-73. [Crossref] [PubMed]
9. Alarhayem AQ, Rasmussen TE, Farivar B, et al. Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era. J Vasc Surg 2021;73:896-902. [Crossref] [PubMed]
10. Romijn AC, Rastogi V, Proaño-Zamudio JA, et al. Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis. Ann Surg 2023;278:e848-54. [Crossref] [PubMed]
11. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 2014;12:1495-9. [Crossref] [PubMed]
12. IBM Corp. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp; 2019.
13. Pate JW, Fabian TC, Walker W. Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995;19:119-25. [Crossref] [PubMed]
14. Nagy K, Fabian T, Rodman G, et al. Guidelines for the diagnosis and management of blunt aortic injury: an EAST Practice Management Guidelines Work Group. J Trauma 2000;48:1128-43. [Crossref] [PubMed]
15. Sandhu HK, Leonard SD, Perlick A, et al. Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries. J Vasc Surg 2018;67:389-98. [Crossref] [PubMed]
16. Demetriades D, Velmahos GC, Scalea TM, et al. Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study. J Trauma 2009;66:967-73. [Crossref] [PubMed]
17. Yadavalli SD, Summers SP, Rastogi V, et al. The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury. J Vasc Surg 2024;79:229-239. [Crossref] [PubMed]
18. Liu M, Yu L, Yu D, et al. A meta-analysis of the timing of endovascular repair for blunt thoracic aortic injury: Safety and efficacy of early vs. delayed treatment. Am J Surg 2025;249:116564. [Crossref] [PubMed]
19. Zambetti BR, Huang DD, Lewis RH Jr, et al. Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury. J Am Coll Surg 2021;232:416-22. [Crossref] [PubMed]
20. Arbabi CN, DuBose J, Starnes BW, et al. Outcomes of thoracic endovascular aortic repair in patients with concomitant blunt thoracic aortic injury and traumatic brain injury from the Aortic Trauma Foundation global registry. J Vasc Surg 2022;75:930-8. [Crossref] [PubMed]
21. DuBose JJ, Leake SS, Brenner M, et al. Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study. J Trauma Acute Care Surg 2015;78:360-9. [Crossref] [PubMed]
22. McBride CL, Dubose JJ, Miller CC 3rd, et al. Intentional left subclavian artery coverage during thoracic endovascular aortic repair for traumatic aortic injury. J Vasc Surg 2015;61:73-9. [Crossref] [PubMed]
23. Kruger JL, Balceniuk MD, Zhao P, et al. Left Subclavian Artery Coverage is Not Associated with Neurological Deficits in Trauma Patients Undergoing Thoracic Endovascular Repair. Ann Vasc Surg 2022;86:408-16. [Crossref] [PubMed]
24. Romagnoli AN, Paterson J, Dua A, et al. Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma. J Trauma Acute Care Surg 2023;94:392-7. [Crossref] [PubMed]
25. Chou EL, Lu E, Dake MD, et al. Initial Outcomes of the Gore TAG Thoracic Branch Endoprosthesis for Endovascular Repair of Blunt Thoracic Aortic Injury. Ann Vasc Surg 2024;104:147-155. [Crossref] [PubMed]
26. Kidane B, Plourde M, Chadi SA, et al. The effect of loss to follow-up on treatment of blunt traumatic thoracic aortic injury. J Vasc Surg 2015;61:1624-34. [Crossref] [PubMed]