Outcomes in Grade II Blunt Thoracic Aortic Injury

2011 Society for Vascular Surgery guidelines recommend surgical management for all > grade I blunt thoracic aortic injuries (BTAI). An update to these guidelines in 2026 recommends nonoperative management (NOM) for grade II injury. Previous work from the Aortic Trauma Foundation (ATF) database has combined grade I and II BTAI for analysis. We sought to analyze outcomes specifically for grade II injuries to determine if current outcomes represented in the ATF are in line with guideline updated NOM of grade II injuries.

ATF data from 2014 to 2025 was retrospectively analyzed for demographics and outcomes based on treatment strategy. Outcomes of 30-day mortality, hospital length of stay, ventilator days, in-hospital mortality, and aortic related in-hospital mortality were determined for patients with grade II injuries with outcomes stratified for NOM vs TEVAR. Aortic injury anatomic characteristics, concomitant traumatic injuries, time from admission to repair, and procedural and access related complications were also compared between groups.

There were 114 grade II injuries with NOM in 36.8%, TEVAR in 62.3%, and open repair in 0.9%. Patients with grade II BTAI with NOM vs TEVAR had no significant differences in hospital length of stay (p=0.832), ventilator days (p=0.933), in-hospital mortality (p=0.177), 30-day mortality (p=0.534), or aortic related in hospital mortality (p=1.00). Injuries selected for TEVAR were larger and anatomically more extensive, while NOM patients more often had intracranial hemorrhage or contusion; ten TEVAR patients (14.1%) were treated after failure of medical management, with no deaths in this subgroup.

In agreement with updated 2026 guidelines, we found that TEVAR provides no short-term 30-day mortality benefit over NOM in patients with grade II BTAI. However these groups were demographically disparate with the TEVAR group significantly younger than NOM patients. This data should spur longer term follow-up and cost effectiveness studies for management of grade II BTAI.