Discussion
BTAI is considered a surgical emergency and although it is a rare event following trauma, is associated with high mortality (4). The results of the investigations have shown that the most likely injury occurs in the proximal part of the descending aorta, followed by the ascending aorta, the aortic arch, and the middle and distal parts of the descending aorta. In about 15% of cases, the thoracic aorta may be injured in several places (10). The main mechanism of injury is rapid deceleration and mostly follows motor vehicle accidents. There are generally three approaches to treating BTAI. Conservative treatment, TEVAR and open surgery. High bleeding rate, neurologic events, higher mortality and longer recovery in open surgery have led to more popularity of TEVAR. But still, in cases where the anatomical conditions are not suitable for TEVAR and in some emergency cases, open surgery is indicated (1).
The patient of the present study had referred to our center due to multiple trauma after a car accident. In the investigations, grade III of BTAI along with nomortroperitoneum with the possibility of duodenal perforation were considered. According to the results of the studies, considering that BTAI usually occurs after high energy trauma, another serious injury may also be involved and it challenges the decision for treatment priority (4). Considering the grade of BTAI, we decided to perform surgery instead of conservative treatment. Also, according to the stable hemodynamics of the patient and the appropriate anatomical condition of the aorta, our option for the treatment of BTAI was TEVAR. In addition, due to the absence of symptoms of peritonitis we decided to postpone the abdominal surgery until after the aortic repair. Both surgeries were successfully performed for the patient, and the patient did not experience any complications after 3 months. In a study conducted on 275 patients with BTAI requiring surgery, the mortality rate in the group that underwent TEVAR was lower than open surgery (6). Minici et al.’s follow-up with an average of 80 months in 38 patients who underwent TEVAR for the treatment of BTAI, no serious postoperative complications were observed and zero percent mortality was reported, which shows the importance of TEVAR in the treatment of BTAI and is similar to the results of the present study (11). \RL The results of Al-Thani et al.’s 20-year experience showed that mortality in a group of BTAI patients who underwent open surgery or conservative treatment was significantly higher than the group who underwent TEVAR (9). Therefore, it seems that conservative treatment in the patient of the present study may be associated with increased mortality risk. On the other hand, in the absence of peritonitis symptoms, delayed abdominal surgery in patients with concomitant blunt abdominal injury may have other benefits. The results of Hsu et al.’s study showed that some cases of abdominal trauma with BTAI may be managed conservatively, but may require abdominal surgery after TEVAR (12). Lu et al reported that the incidence of intra-abdominal hemorhage after TEVAR is higher in patients who have BTAI and blunt abdominal injury at the same time, and also in these patients, TEVAR increases the risk of delayed abdominal surgery (13). Therefore, it will be possible to control intra-abdominal bleeding after TEVAR with delayed abdominal surgery, and on the other hand, the need for repeat laparotomy will be reduced.