Outcomes Following Endovascular Versus Open Management of Carotid Artery Injuries in the National Trauma Data Bank

INTRODUCTION: The treatment of traumatic carotid injuries has evolved over time, particularly with advancements in endovascular techniques. We analyze contemporary management of blunt and penetrating carotid injuries, and compare outcomes following endovascular and open repair. METHODS: The National Trauma Data Bank (2017-2023) was queried for carotid injuries in patients aged ≥16 managed with endovascular or open repair. Baseline characteristics, associated injuries, and in-hospital outcomes were compared between groups, and further stratified by blunt versus penetrating mechanism. Additional sub-group analysis was performed for patients with concomitant traumatic brain injury (TBI). Primary outcomes were stroke and mortality, and multivariable analysis was performed to identify independent predictors of stroke and composite stroke-mortality. RESULTS: Of 3,339 carotid injuries, 54.5% were treated endovascular and 45.5% open. Patients who underwent endovascular repair of carotid injuries (ENDO) suffered from predominantly blunt trauma (81%), and those who underwent open repair (OPEN) had mostly penetrating trauma (66%; P<0.001). ENDO patients were more likely to have high injury severity (ISS≥15; 74% vs. 69%; P<0.001), longer time to intervention (41h vs. 3h; P<0.001), and interfacility transfer (30% vs. 23%; P<0.0001). The most common ENDO modalities were stenting (60%), embolization (18%), and angioplasty (5.6%); OPEN patients were managed with primary repair (31%), interposition/bypass (27%), ligation (9.7%), and patch angioplasty (4.7%). On unadjusted analysis, ENDO patients were more likely to suffer stroke (31% vs. 26%; P=0.025), with no mortality difference (14% vs. 12%; P=0.2). Among penetrating injuries, there was no difference between ENDO vs. OPEN groups for stroke (24% vs. 25%; P=0.9) or mortality (14% vs. 14%; P=0.9). For blunt injuries, ENDO patients had greater mortality (14% vs. 9.0%; P=0.004) but not stroke (33% vs. 29%; P=0.2). On multivariable analysis, neither operative approach nor injury mechanism were independently associated with stroke or stroke-mortality. Predictors of stroke were male gender (OR 0.67; 0.49-0.92; P=0.012), smoking (OR 1.50; 1.09-2.06; P=0.012), and hypertension (OR 1.74; 1.20-2.52; P=0.004). Predictors of stroke-mortality included concomitant TBI (OR 2.49; 1.69-3.68; P<0.001), hypertension (OR 1.71; 1.20-2.44; P=0.003), cardiac complication (OR 2.43; 1.52-3.91; P<0.001), and ISS≥15 (OR 2.03; 1.43-2.90; P<0.001). CONCLUSIONS: Carotid trauma carries significant morbidity, with over a quarter of patients experiencing stroke and 12-14% dying during hospital admission. Mechanism or operative approach do not seem to predict stroke or stroke-mortality, which appears to be driven by overall injury burden.