Impact of trauma center volume on treatment strategies and outcomes of blunt traumatic aortic injuries

Objective: Management of blunt traumatic aortic injuries (BTAIs) has changed significantly over time. There is now increasing support for medical management of minimal aortic injuries (MAIs; Grades I and II) and thoracic endovascular aortic repair (TEVAR) in more severe injuries (Grades III and IV). Data on real-world management of BTAIs, from medical therapy to surgical intervention, remains limited. Available literature predominately focuses on outcomes after intervention, rather than the spectrum of BTAI care that includes medical management. Furthermore, it remains unclear whether the trauma center volume influences the management and the outcome of patients with BTAIs.We aim to investigate the impact of trauma center volume and temporal treatment patterns on outcomes of patients with BTAIs encompassing medical management and surgical intervention. Methods: The Aortic Trauma Foundation international prospective multicenter registry was retrospectively analyzed to examine the impact of trauma center volume and temporal treatment patterns on outcomes of patients with BTAIs from 2014 through 2024. Exposures included medical management, thoracic endovascular aortic repair (TEVAR), and open repair, stratified by trauma center volume, and over time. The primary outcomes were treatment modality, in-hospital mortality, 30-day mortality, and aortic-related in-hospital mortality. Secondary outcomes included perioperative complications such as stroke, spinal cord ischemia, cardiac, pulmonary, acute renal failure, extremity ischemia, and access site complications. Results were stratified according to high- or low-volume trauma center status and temporal trends. Results: Among 1061 patients with BTAIs from 48 international centers, there was no significant difference in baseline patient demographics or presenting hemodynamics between those treated at high-volume trauma centers (HVCs) vs low-volume trauma centers (LVCs). The average age of the cohort was 43.5 years, and 75.9% were male. Patients evaluated at HVCs had more concomitant injuries, as determined by a higher overall Injury Severity Score (ISS; 35.1 vs 33.8; P < .001). Society for Vascular Surgery (SVS) Grade I injuries were more common at HVCs (32.7% vs 18.0%; P < .001), whereas SVS Grade III injuries were the most common overall. TEVAR was more frequently performed (LVC, 64.9% vs HVC, 55.6%; P = .002) and were more likely to be conducted emergently at LVCs compared with HVCs. There was an increase in the use of medical management for low-grade BTAIs over time at all centers. Discrepancy in TEVAR utilization was particularly pronounced for MAIs (SVS Grade I and II), with LVCs treating 32.3% of these injuries, compared with 12.4% at HVCs (P < .001). Notably, this correlated with higher in-hospital mortality (16.9% vs 12.2%; P = .029), aortic-related mortality (7.4% vs 2.8%; P < .001), and longer hospital lengths of stay (20.3 vs 16.4 days; P ≤ .001), in patients treated at LVCs compared with HVCs. Conclusions: Management of BTAIs at LVCs is associated with higher rates of in-hospital, aortic-related mortality, and access-related complications. These outcomes appear to be associated with a higher rate of TEVAR compared with medical management for MAIs at LVCs. These findings support medical management of MAIs and suggest that patients with BTAIs may have better outcomes when managed at HVCs.