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.