Midterm Outcomes of Nonoperative Management of Blunt Thoracic Aortic Injury: Systematic Review and Meta-analysis

Blunt thoracic aortic injury (BTAI) is one of the leading causes of death after trauma. Current guideline recommendations are primarily based on short-term outcomes, while longer-term outcomes are not well investigated. This study aims to investigate the safety of nonoperative management (NOM) for minor and more severe aortic injuries and the need for follow-up.

We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included studies from the forming of the databases till May 2025, evaluating the results of NOM on mid-term (≥12 months) or long-term clinical outcomes for patients with BTAI. Nine retrospective and observational studies comprising 438 patients were included. The overall methodological quality was moderate to low. Outcomes evaluated are aortic-related mortality, lesion evolution, aortic-related intervention and all-cause mortality.

Nine retrospective and observational studies comprising 438 patients were included. Of all patients, 29% had a Society of Vascular Surgery (SVS) grade I aortic injury, 27% grade II, 35% grade III, and 1% grade IV. After a mean follow-up of 37.7 months, no progression was observed in SVS grade I and II injuries. The pooled estimate for lesion progression in SVS grade III was 7% (95% confidence interval (CI): 0-14; I² = 23.2%). Lesion resolution occurred in 83% of SVS grade I and 50% of grade II injuries. Most grade III lesions (81%) remained stable (95% CI: 63-99; I² = 83.64%). The pooled rate of all-cause mid-term mortality was 3% (95% CI: 0-0.07), while this was 2% for aortic-related intervention (95% CI: 0-4).

This meta-analysis, including only retrospective and observational studies, shows that minor aortic injuries will remain stable or resolve with time and can be managed conservatively with appropriate surveillance. The risk of lesion progression for conservatively treated patients with SVS grade III is low.