Endovascular repair for complicated Azzizadeh Grade III blunt traumatic aortic injury: a single-center cohort study of thoracic injuries with a separate abdominal subgroup

BACKGROUND: The optimal management of Azzizadeh Grade III blunt traumatic aortic injury (BTAI) is debated, with a clinical dilemma persisting particularly for hemodynamically stable patients. This study evaluates a risk-stratified protocol guiding intervention versus surveillance in a cohort that included both stable and unstable patients. METHODS: We retrospectively analyzed consecutive patients with Grade III BTAI (2014-2023) managed per a multidisciplinary protocol: thoracic endovascular aortic repair (TEVAR) for complicated thoracic injuries, and endovascular aortic repair (EVAR) for complicated abdominal injuries; surveillance for uncomplicated ones. Thoracic and abdominal injuries were analyzed separately. Hemodynamic stability was defined as systolic blood pressure ≥ 90 mmHg without vasopressor support. RESULTS: Among 36 patients (mean age 53.7 ± 16.3 years, 83.3% male), 30 had thoracic aortic injuries and 6 had isolated abdominal aortic injuries. Twelve patients (33.3%) were hemodynamically unstable on presentation, all of whom underwent urgent endovascular repair. Of the 30 thoracic injuries, 27 (90.0%) underwent TEVAR with 100% technical success and 96.3% 30-day survival; three patients did not immediately undergo TEVAR: two were planned for urgent repair but died preoperatively from overwhelming polytrauma, and only one highly selected patient was managed with non-operative surveillance and remained stable at 24 months. All 6 abdominal injuries underwent EVAR with 100% survival. 30-day overall survival was 91.7% (33/36). A thoracic "triad" (rib fracture, lung contusion, myocardial injury) was observed in 73.3% of thoracic cases. This finding represents a purely descriptive observation; because no trauma control group was included, the triad cannot be used for diagnosis, screening, or risk prediction. CONCLUSION: TEVAR/EVAR is safe and effective for the majority of Grade III BTAI with complicating features, achieving 96.3% 30-day survival in our thoracic cohort. Non-operative management was employed in only one highly selected patient, who remained stable at 24 months; two other patients who were planned for urgent TEVAR died preoperatively from polytrauma. This study cannot evaluate the safety, feasibility, or selection criteria for non-operative management of Grade III BTAI. Thus, although surveillance has been reported in isolated cases, this approach remains unvalidated and should not be broadly applied based on current evidence. The thoracic "triad" should prompt consideration of aortic imaging.