Aortic and cardiovascular remodelling after thoracic endovascular aortic repair for blunt traumatic aortic injury in younger patients: A narrative review of physiological and clinical outcomes

Blunt traumatic aortic injury (BTAI) is severe, often fatal in younger populations due to high-energy deceleration mechanisms. Thoracic endovascular aortic repair (TEVAR) has revolutionised BTAI treatment, surpassing the previously standard open surgical repair in mortality and complication rates. Despite its success, concerns arise regarding TEVAR's long-term effects, especially in younger BTAI patients. Key physiological changes following TEVAR include alterations in aortic size, shape, compliance and flow dynamics, leading to loss of the Windkessel effect and a consequent increased pulse wave velocity and decreased radial strain, which can contribute to the development of hypertension. These alterations also predispose patients to changes in cardiovascular flow (increased reverse systolic flow, reduced maximum velocity and altered helical flow), potentially increasing the risk of left ventricular dysfunction and coronary artery disease. Physiological changes also increase the likelihood of complications such as graft migration. Clinical outcomes of TEVAR for BTAI have generally been favourable, with significant reductions in mortality and cerebrovascular accident rates compared to open surgical repair. However, long-term complications, including the need for re-interventions, remain a concern, though studies suggest these are infrequent. The durability of TEVAR in younger patients, who may experience decades of device use, poses unique challenges, particularly due to the natural progression of aortic morphology over time. Therefore, adapting TEVAR to the physiological needs of younger BTAI patients is essential. Developing more compliant endografts and using shorter stents with improved materials can help minimise structural and haemodynamic changes and enhance cardiovascular outcomes, supporting the long-term health of this vulnerable population.