Defining the criterion standard for detecting blunt traumatic aortic injuries: A systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND Contrast-enhanced computed tomography scan (CECT), angiography, transesophageal echocardiography (TEUS), and chest x-ray represent the most adopted diagnostic tests to detect blunt traumatic aortic injuries (BTAIs). This systematic review and meta-analysis of diagnostic test accuracy aim to identify the method with the best performance. METHODS The PubMed, Scopus, EMBASE, and Cochrane Library databases were screened up to January 28, 2024 (PROSPERO ID: CRD42023473041). Surgical exploration, autopsy, and discharge from the hospital after monitoring were set as reference standard. The risk of bias in individual studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Sensitivity analysis was conducted to detect sources of heterogeneity. Pairwise comparisons were conducted to detect the method with the best diagnostic performance. RESULTS After the exclusion of duplicates, 1,706 articles were initially screened. According to the Population (P), Index text (I), Reference standard (R), Target condition (T) framework and inclusion criteria, 77 studies were included in the qualitative and quantitative synthesis. The performance estimates of the different tests were as follows: angiography-16 studies, sensitivity (Sn) of 0.97 (95% confidence interval [CI], 0.90-0.99), specificity (Sp) of 0.99 (95% CI, 0.97-1.00), diagnostic odds ratio (DOR) of 3,751.23 (95% CI, 757.24-18,583), and area under the curve (AUC) of 1 (95% CI, 0.99-1); CECT-34 studies, Sn of 0.98 (95% CI, 0.94-0.99), Sp of 0.97 (95% CI, 0.94-0.99), DOR of 1,862.5 (95% CI, 426.5-8,133.7), and AUC of 1 (95% CI, 0.99-1.00); TEUS-16 studies, Sn of 0.94 (95% CI, 0.85-0.98), Sp of 0.99 (95% CI, 0.96-1.00), DOR of 1,421.5 (95% CI, 170.9-11,822.7), and AUC of 0.99 (95% CI, 0.98-1.00); and chest x-ray-11 studies, Sn of 0.87 (95% CI, 0.72-0.94), Sp of 0.56 (95% CI, 0.23-0.85), DOR of 8.2 (95% CI, 1.4-46.8), and AUC of 0.85 (95% CI, 0.82-0.88). CONCLUSION Angiography, CECT, and TEUS showed similar diagnostic performance in detecting BTAI. According to the Grading of Recommendations Assessment, Development and Evaluation methodology, in the case of multiple tests holding similar diagnostic performance, the choice may be based on the availability, ease of use, and further information provided. Therefore, CECT should represent the current reference standard for the screening and diagnosis of BTAI. Chest x-ray does not represent a reliable screening tool. LEVEL OF EVIDENCE Systematic Review and Meta-analysis; Level III.