Today we are outlining the 13 recommendations from the 2026 Society for Vascular Surgery (SVS) guideline Management of Blunt Thoracic Aortic Injury (BTAI). BTAI is a potentially life-threatening complication of major trauma that typically occurs alongside other serious injuries. The 2026 update builds on the 2011 guideline and highlights evolving evidence to guide the timing of repair, patient selection, and overall management through a multidisciplinary approach. The 13 recommendations address key clinical questions related to diagnosis, management, and follow-up of BTAI.

View the full-text version for the most thorough explanation of these recommendations. 

Recommendations from the 2026 SVS BTAI Guideline

Should patients with minimal aortic injuries (grade 1 and 2 BTAI) be treated with nonoperative management alone or thoracic endovascular aortic repair (TEVAR)?

  • In patients with grade 1 and 2 BTAI (minimal aortic injury), we recommend definitive nonoperative management (NOM) over TEVAR or open repair. Grade 1 injuries require no routine follow-up imaging. We suggest grade 2 injuries undergo one follow-up computed tomography angiography (CTA) to ensure resolution.

Should patients with grade 3 BTAI undergo early or delayed TEVAR?

  • In patients with hemodynamically stable grade 3 BTAI, we suggest delayed TEVAR (>24 hours) to allow for management of other associated traumatic injuries if needed. In an unstable patient in whom there is a concern that the BTAI is the specific cause of the patient's instability, we recommend urgent (<24 hours) or emergent intervention. 

Do patients undergoing left subclavian artery coverage (zone 2) for TEVAR after BTAI require left subclavian revascularization?

  • Among patients requiring left subclavian artery (LSA) coverage for TEVAR after BTAI, we suggest that the decision regarding LSA revascularization be based on feasibility and factors such as a patent prior left internal mammary to coronary bypass, detection of a dominant left vertebral artery on preoperative or intraoperative imaging, or an aortic origin of the left vertebral artery.

What is the optimal role of intraoperative systemic anticoagulation in patients with BTAI undergoing TEVAR?

  • In patients with BTAI undergoing TEVAR, we suggest that intraoperative anticoagulation can be used at the surgeon's discretion after considering the risk of bleeding and thrombotic complications. 

What is the optimal imaging surveillance protocol for patients with BTAI after TEVAR or NOM?

  • In all patients with grade 1 BTAI treated nonoperatively, we suggest against routine surveillance imaging.
  • In patients with grade 2 BTAI treated nonoperatively, we suggest at least one follow-up surveillance imaging study. We suggest repeat imaging at 1 to 3 months after injury. 
  • In patients who had TEVAR for BTAI, we suggest postoperative surveillance imaging. 

What is the optimal treatment of BTAI patients with concomitant solid organ injury or traumatic brain injury?

  • In patients with grade 1 or 2 BTAI (minimal aortic injuries) and concomitant traumatic brain injury (TBI), we suggest against anti-impulse therapy for BTAI. Management of blood pressure should prioritize TBI over BTAI. 
  • In patients with grade 3 BTAI and concomitant TBI, we suggest that the decision to use anti-impulse therapy should be individualized based on collaborative management with other surgical and medical specialties. 
  • In patients with grade 3 BTAI and concomitant TBI or solid organ injury (SOI), we suggest that timing for TEVAR should be determined in a collaborative fashion in consultation with other stakeholders, including trauma and neurosurgery. 
  • In patients with grade 4 BTAI, we recommend emergent repair. 
  • For patients with BTAI and concomitant TBI or SOI, we suggest a collaborative approach for intraprocedural anticoagulation during TEVAR. Although current observational studies do provide some reassurance that heparinization is not associated with worse intracranial bleeding or neurologic outcomes, the certainty in this evidence is very low. Decisions about intraoperative anticoagulation in patients with TBI should be individualized based on multidisciplinary collaboration. 

What is the role of anti-impulse therapy in the NOM of BTAI?

  • In patients with grade 3 BTAI, we suggest anti-impulse therapy as a stabilizing measure until TEVAR is performed if the concomitant injuries do not preclude this approach. 

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