Evolving role of endovascular techniques for traumatic vascular injury: A changing landscape?

BACKGROUND: Endovascular management of blunt aortic injury has dramatically reduced the morbidity and mortality associated with this specific injury. There remains a paucity of evidence quantifying the beneficial effects associated with endovascular (ENDO) techniques for other vascular injury types and little information regarding the impact ENDO techniques have had on the management of traumatic vascular injuries over time. METHODS: We performed a retrospective analysis of data from the National Trauma Data Bank over 2002 to 2006 and 2008 time periods (NTDB 7.2 and RDS 2008). Injured patients undergoing any arterial vascular repair procedure using ENDO or standard open techniques were determined using ICD-9-CM procedure codes. Abbreviated Injury codes were used to select patients who suffered subclavian, carotid, or thoracic aortic injury. Logistic regression was used to determine whether EARLY ENDO procedures (first 24 hours after injury) were independently associated with a lower risk of mortality. RESULTS: The percentage of ENDO procedures significantly increased over time irrespective of mechanism of injury. When aortic (thoracic), subclavian, and carotid arterial injuries were analyzed, a significant decrease in mortality over time was found. The percentage of ENDO procedures for all arterial injury subtypes significantly increased in the RECENT (2008) period. Seventy-five percentage of ENDO procedures occurred early (initial 24 hours) with 20%of those patients being hypotensive upon arrival (systolic blood pressure <90 mm Hg). For patients who had vascular procedures in the RECENT period, regression analysis revealed that early ENDO procedures were independently associated with a 35%reduction in mortality risk (odds ratio, 0.65; 95%confidence interval, 0.5- 0.8) after controlling for major confounders including mechanism of injury and presence of hypotension on arrival. CONCLUSION: ENDO procedures for arterial injury have increased over time while mortality for arterial injury subtypes has significantly decreased. Early ENDO procedures are common and are independently associated with a lower risk of mortality. These results suggest outcomes after vascular injury may benefit from ENDO expertise and that ENDO techniques should be incorporated into the early treatment algorithm of trauma patients with vascular injury, particularly those that require difficult operative exposure.