The use of systemic heparin during thoracic endovascular aneurysm repair (TEVAR) for blunt thoracic aortic injuries (BTAI) appears to be safe in selected patients with traumatic brain injury (TBI), a new study presented at the 2022 Vascular Annual Meeting (VAM) indicated. The finding was a central conclusion from data delivered by Rafael Lozano, MD, a general surgery resident at the University of California Davis Medical Center, Sacramento, California, at the Boston gathering (June 15–18).
In an effort to compare the impact of intraoperative systemic heparinization on post-TEVAR outcomes for patients with TBI, researchers reviewed all patients admitted with BTAI from 2011 through 2021. Collected data included injury grading, demographics and concomitant traumatic injuries. The study’s primary outcome was progression of TBI after TEVAR.
The cohort comprised 174 patients (mean age=46 years; 68% men; median injury severity score [ISS]=34)—after excluding three who died upon arrival. Median door-to-repair time was 19 hours and 79% of the study population received systemic heparin. In addition, BTAI treatment was aligned with guidelines for 87–89% of patients. Repair (all TEVAR) was required for 63% of patients and time to repair was delayed for TBI patients.
Heparin was used in the majority of TBI patients—but was used less frequently than for those without TBI. Overall mortality was 8% (12.5% with BTAI observed vs. 5.5% with BTAI treated) with no BTAI-related deaths. Repair being delayed by more than 48 hours did not decrease mortality (5% vs. 5.6%). Vascular complications occurred in 8.2% of those receiving TEVAR, with an overall re-operation rate of 4.5%.
Progression of TBI was not associated with severity of BTAI by either grading system, the study found. Progression of TBI after TEVAR was also not impacted by intraoperative systemic heparin use (4.6% with vs. 6.7% without). Mean follow-up after TEVAR was 7.9 months and 97% of repaired patients experienced resolution of their injury.
Based on these findings, the researchers conclude that the use of systemic heparin during TEVAR for BTAI appears to be safe in selected patients with concomitant TBI, without causing TBI progression. Finally, they note that clinical expertise remains key in determining optimal management of these patients.
Senior author Matthew Mell, MD, professor and chief of vascular surgery at UC Davis, outlined what he believes are the clinical implications of the findings in an interview with Vascular [email protected] in Boston.
“The main significance is we think it’s safe to heparinize trauma patients for TEVAR, even if they have a head injury,” he said “Our practice has been to wait 12–24 hours to make sure the head injury is stable, and it appears that when that practice is followed, giving heparin is safe.
“These injuries are complex and nuanced. It’s really important to make these decisions as a multidisciplinary team. This, we hope, will contribute the literature, that will allow people to be a little more comfortable to treat these with heparin.”