Intraoperative Systemic Heparin for Treatment of Blunt Thoracic Aortic Injury with Concomitant Traumatic Brain Injury or Solid Organ Injury

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Introduction Transition of management of blunt thoracic aortic injuries (BTAI) to an endovascular first approach has significantly improved outcomes, with low observed aortic-related mortality. The safety and utility of intraoperative heparin for patients with concurrent traumatic brain injury (TBI) remains controversial. We sought to compare the impact of intraoperative systemic heparinization on outcomes after thoracic endovascular aneurysm repair (TEVAR) for patients with TBI and solid organ injury. Methods We reviewed all patients admitted with BTAI from 2005 through 2023 at a level 1 trauma center. Collected data included aortic injury grading, patient demographics and concomitant traumatic injuries. The primary outcome was progression of TBI after TEVAR. Additional outcomes included time to repair and aortic related mortality. Results In a cohort comprising 259 patients, 86 were managed with impulse control, 152 with TEVAR, and 21 with open repair of their aortic injury. Within the cohort, 84 patients (35%) had a concomitant brain injury, of which 34 (41%) underwent TEVAR. A total of 156 patients (66% of the total cohort) suffered a concomitant solid organ injury and 124 patients (80%) with a solid organ injury subsequently required a transfusion within 24 hours of arrival. Among these, 87 patients (70%) underwent TEVAR. Among patients with a brain injury undergoing repair, 25 patients (74%) had a concomitant solid organ injury. Among patients undergoing repair, 1 patient (3%) had an SVS grade 1 injury, 1 patient (3%) had a grade 2 injury, 31 patients (91%) had a grade 3 injury, and 1 patient (3%) had a grade 4 injury. While the majority of patients with TBI underwent repair with heparin (22 patients, 64.7%), heparin use was significantly less common among patients with a concomitant head injury (22 patients, 64.7%, vs. 102 patients, 86.4%, p=.004). Patients with a concomitant head injury were more likely to have an increased time to repair (31.2 ± 38 hours vs 161.3 ± 331 hours, p<.001). When evaluating the 34 patients with a head injury who underwent repair, 2 patients out of 12 (17%) undergoing repair without heparin had progression of their head injury versus 9 patients out of 22 (41%) undergoing repair with heparin (p=.004). Of 25 patients with both a brain and solid organ injury, 11 patients had heparin administered during TEVAR (44%) and no heparin-related complications were observed. One patient (4%) with a TBI suffered embolization of aortic thrombus with resulting stroke without heparin use, while four patients (3%) experienced similar embolic or thrombotic complications with heparin use (p=.926). There were no aortic related mortalities observed in the cohort. Conclusions Delayed TEVAR (>48 hours from time of repair) for stable BTAI is not associated with increased risk of aortic-related mortality. While use of systemic heparin during TEVAR for BTAI appears to be safe in selected patients with solid organ injury, use in TBI may be associated with increased risk of progression of TBI. Clinical expertise remains key to determine optimal management.

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