Blunt thoracic aortic injury (BTAI) management
Type
ModificationConfidence
92%
Created
Apr 15, 2026
Evidence
1 source
Rationale
The ESVS 2026 guideline (PMID 41448425) supersedes the 2017 ESVS guideline Riambau V, Bockler D, Brunkwall J, et al for all claims in this section. Per the stale guideline replacement instructions, Riambau V, Bockler D, Brunkwall J, et al has been replaced with European Society for Vascular Surgery (ESVS) in each location where it supported the same claim, rather than co-citing both. The existing citation key European Society for Vascular Surgery (ESVS) was already listed among the chapter's existing keys, confirming this is the correct key to use. No content was removed; only the citation attribution was updated to reflect the current guideline evidence.
Evidence
These 2025 ESVS clinical practice guidelines provide comprehensive and up to date advice to physicians and patients on the management of diseases of the mesenteric and renal arteries and veins.
Content Changes
<!-- type: classification --> **Injury grading** - **Grade I:** Intimal tear - **Grade II:** Intramural hematoma - **Grade III:** Pseudoaneurysm - **Grade IV:** Rupture [@neschis2008] <!-- type: treatment --> **Initial management (all grades)** - **Anti-impulse therapy** (typically beta-blockade) to reduce aortic wall stress while planning definitive management of blunt thoracic aortic injury (BTAI). [@neschis2008] [@isselbacher2022] **Definitive management** - **Thoracic endovascular aortic repair (TEVAR)** is generally preferred for **grade II–IV** BTAI when anatomy is suitable [@riambau2017][@esvs2025] [@isselbacher2022] [@wagner2025]. - **Grade I** injuries and select **Grade II** injuries (specifically intramural hematomas) are often managed non-operatively with strict hemodynamic control and interval imaging, as meta-analysis data indicates low rates of disease progression and aortic-related mortality in these cohorts [@riambau2017][@esvs2025] [@romijn2025]. - In stable patients with major concomitant injuries, **delayed repair** may be appropriate to optimize physiology and reduce perioperative risk; long-term cohort data supports the safety and efficacy of this individualized timing [@neschis2008] [@riambau2017][@esvs2025] [@prendes2026]. **Technical considerations** - **Sizing/oversizing:** avoid excessive oversizing in young, small aortas. [@riambau2017][@esvs2025] - **Left subclavian artery (LSA) coverage:** may be required for an adequate proximal seal; selective revascularization is recommended in higher-risk situations (e.g., left internal mammary artery (LIMA) graft, dominant left vertebral, dialysis access, upper extremity ischemia risk). [@matsumura2009] - **Spinal cord ischemia (SCI) mitigation:** minimize coverage length where feasible and avoid sustained hypotension. [@riambau2017][@esvs2025] <!-- type: surveillance --> **Surveillance** - **Computed tomography angiography (CTA)** surveillance after TEVAR is recommended to assess endoleak, migration, and device-related complications (typical schedule: early post-op and interval follow-up based on institutional protocol). [@isselbacher2022] [@neschis2008]