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.