Introduction
The most common cause of death in young people is trauma (1). Perforation of the duodenum due to trauma usually occurs after high energy abdominal trauma and it has a very low incidence especially in adults, although its mortality is about 30% (2). If the intensity of the trauma is high, the possibility of damage to other parts of the body, including the chest, increases. Although blunt thoracic aortic injury (BTAI) occurs only in 0.3% of severe traumas, BTAI is the most common cause of death after head injury following trauma (1,3). Only 20% of patients who experience BTAI reach the hospital alive, and about half of survivors die within the first 24 hours (4). BTAI is divided into four categories by the Society of Vascular Surgery (SVS). Grade I, intimal tear; Grade II, intramural hematoma; Grade III, pseudoaneurysm; and Grade IV, free rupture (5). Grade I and II are usually treated conservatively. But higher grades require surgery. Unfortunately, despite progress in treatment, many cases of grade IV die (1). The surgical approach in BTAI includes open surgery and thoracic endovascular aortic repair (TEVAR). During the last decade, TEVAR has replaced open surgery as an effective first-line treatment for BTAI (6). Despite the preference of vascular surgeons for TEVAR, the timing of TEVAR for the treatment of BTAI has been controversial. In some studies, it has been suggested that it is better to perform TEVAR electively, and in other studies, there was no significant difference between the time of performing it (7,8). In addition, the results of a 20-year review have shown that a conservative approach to BTAI has been associated with increased mortality (9). Deciding on the time of treatment becomes more important when there is an concomitant injury that requires immediate treatment. In this study, we report a rare case of BTAI with perforation of the duodenum, and according to the patient’s clinical conditions, we decided to prioritize the repair of the aorta instead of the duodenum, and the TEVAR approach instead of open surgery to repair the aorta.