Invited commentary

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Patients with traumatic aortic rupture (TAR) were traditionally treated by conventional open repair. A major improvement in open repair was the introduction of distal aortic perfusion as opposed to the “clamp and sow” technique. It resulted in better survival and fewer complications such as paraplegia.

Dr Verdon and his team should be congratulated for publishing personal experience with a standardized technique, which involves distal perfusion and results in excellent outcome with low mortality and morbidity given the severity of the patients' injuries.

Nowadays, the discussion on treating TAR patients focuses on the choice between conventional open repair and endovascular repair. What does this study add to that discussion?

It shows that excellent results can be achieved by open repair. A point of concern is the fact that it describes personal experience of a single surgeon. Very often, excellent results reported by a dedicated team can not be achieved in other settings. Also, we must consider selection bias. The author describes only those patients treated by open surgery. Surgery may have been delayed because of the poor physical condition of the typical multi-trauma patient, deeming him/her unfit for open repair. Especially in these patients, injuries to other organs such as multiple fractures, pulmonary contusion, brain damage, and intra abdominal bleeding might interfere with open aortic surgery. It is not reported how often patients could not be operated on and if these patients have died prior to surgery.

In comparison, the potential benefit of endovascular treatment of TAR is that it is a fast and relatively simple transfemoral procedure that is performed with the patient in supine position. The endovascular procedure can be combined with other life saving emergency procedures and there is usually no need to delay aortic repair if the endovascular technique is chosen. Short term results are good with low morbidity and mortality rates. Therefore, nowadays, many trauma centers prefer endovascular repair over open surgery. Despite early successes, there are, of course, issues to be solved among which are long term durability and optimalization of graft design.

This study does not intend to answer the question which technique is better and, because of the selection issue, will probably not change the strategy of those involved in caring for TAR patients. What it does is show us what can be achieved by an optimized protocol for open repair. This is relevant, since not all patients can be treated with an endovascular graft. Those patients are best treated by an experienced team doing an open procedure. This study describes the targets for open repair in terms of mortality and morbidity in those selected patients.