According to the most recent consensus of the Society for Vascular Surgery (SVS) the use of TEVAR is supposed to follow some guidelines that the committee suggested on the basis of a systematic review and meta-analysis of the literature including 7768 patients from 139 studies [29]. As it was said before, only observational studies, case series and unsystematic observations or expert opinion are available to date; thus, using the GRADE system, all of the following indications should be regarded as Grade 2, Level C statements:

Despite TEVAR is associated with a lower risk of complications compared to open repair, there remains a number of controversial issues:

Airways trauma is a life-threatening condition which may be a result of blunt and penetrating injuries to the neck and chest [53]. Therefore, prompt diagnosis is mandatory for the survival of these patients, also because the presence of concomitant severe injuries and unspecific symptoms may delay the diagnosis and lead to early fatal outcome or late sequela such as airway stenosis and recurrent pulmonary infections [54]. The treatment of these patients provides an adequate ventilation and then the repair of the airways injury with a smaller impact on the respiratory function and the quality of life of the patients [55].

Blunt chest trauma causes an abrupt increase in intrathoracic airways pressure. If this happens against a closed glottis, the trachea and major bronchi can be injured secondary to the increased pressure.

The incidence of tracheobronchial injuries (TBI) among trauma patients with thoracic injuries, including those that died immediately, is estimated at 0.5–2% [56, 57]. The mortality from traumatic TBIs has decreased from 36% before 1950 to 9% in 2001 [53]. Laceration of the mediastinal pleura and/or bronchial injuries may allow air to enter in the pleural cavity; pneumothorax occurs in 17–70% of the patients with TBIs [58] and in 30–40% of all patients with a blunt chest trauma [59]. The most common cause is a rib fracture that lacerates the lung, but it also may be caused by rupture of a preexisting bleb at the time of impact [59]. Finally, hemothorax is seen in approximately 50% of patients who sustain blunt chest trauma [60]. Bleeding into the pleural space can originate from injury to the pleura, chest wall, lung, diaphragm, or mediastinum.

Concerning the approach to the patient with thoracic trauma, the airway in a neurologically intact patient is easily assessable: the injured patient who is alert and able to speak normally is maintaining a patent airway. However, especially in polytrauma patient, this must be carefully monitored as facial fractures with associated bleeding or edema, emesis, or foreign bodies can eventually compromise airway patency. The symptoms and signs of TBI depend on the site and the severity of the injury and most of them are not specific for this kind of injury.

Subcutaneous emphysema is the most common finding in TBI occurring in up to 87% of the patients [61]. Dyspnea, tachypnea, and respiratory distress are found in 59–100% of the patients [62], while hemoptysis can be seen in up to 74% of the cases [63].

Clinical signs of pneumothorax can be subtle and difficult to elicit in a patient who has multisystem trauma [60]. Detection of even a small, asymptomatic pneumothorax is important because up to one third can develop into a tension pneumothorax with potential cardiopulmonary decompensation [64].

The most common findings in chest X-rays are subcutaneous emphysema, pneumomediastinum, and pneumothorax.

Subcutaneous emphysema signs include: tracheal deformity, a defect in the tracheal contour, an endotracheal tube out of place, and the tube’s cuff over-inflated and protruding beyond the edge of the tracheal wall [65].

Radiographic signs of a pneumothorax can be subtle, and the appearance differs based on the patient position at the time that the radiograph was performed. In the supine position, air collects within the anterior costophrenic sulcus, which extends from the seventh costal cartilage to the 11th rib at the midaxillary line [64]. This appears radiographically as abnormal lucency in the lower chest or upper abdomen, an abnormally wide and deep costophrenic sulcus (the “deep sulcus” sign), a sharply outlined cardiac or diaphragmatic border, depression of the hemidiaphragm, or as a “double diaphragm” sign that is seen when air outlines the dome and anterior insertion of the diaphragm [66].

The appearance of hemothorax on a chest radiograph depends on the amount of blood that has collected in the pleural space and patient position. Plain radiography of the upright chest may be adequate to establish diagnosis by showing blunting at the costophrenic angle or an air–fluid interface if a hemopneumothorax is present. If the patient cannot be positioned upright, a supine chest radiograph may reveal apical capping of fluid surrounding the superior pole of the lung. In the acute trauma setting, the portable supine chest radiograph may be the first and only view available from which to make definitive decisions regarding therapy [60, 67]. When the size of a hemothorax reaches approximately 200 mL, an upright chest radiograph demonstrates blunting of the costophrenic angle. With progressive increase in size, a meniscus-sign will be seen: a concave upward sloping of fluid in the costophrenic angle. In contrast, a straight air–fluid level on the upright chest radiograph indicates a hemopneumothorax. A large hemothorax can opacify the hemithorax completely and cause contralateral shift of the mediastinum as the result of mass effect [68].