Endovascular Repair of Thoracic Aortic Lesions Using Infrarenal Devices: Lessons Learned and Continued Applications

Endovascular repair of thoracic aortic injury: current thoughts and technical considerations

Thoracic aortic traumatic injury is a highly morbid event. Mortality and paraplegia rates after emergent open repair remain high. Now, however, thoracic aortic endografting for trauma (TAET) is commonly used. It is appealing due to reduction of operative stress for the multiply injured trauma victim. This minimizing of stress and risk is secondary to avoidance of thoracotomy, single-lung ventilation, aortic cross-clamping, and the more complex anesthetic techniques required. Early and midterm results from TAET delineate improved outcomes, yet access and aortic constraints continue to challenge TAET. Questions regarding longer-term durability of endografts in younger patients remain unanswered. Broader application of TAET within endovascular programs is challenged by appropriate imaging, operating suite inventories, and the logistics and personnel required for TAET. Currently developed thoracic endograft devices are not ideal for TAET due to platform size and graft diameter. This is changing, however, as new modifications have been developed and trials are ongoing. In light of these collective factors, the management paradigm for traumatic aortic injury is beginning to favor TAET.

Endograft Malapposition in the Distal Aortic Arch Resulting in Functional Coarctation

The application of thoracic endografts to thoracic aortic injuries is often limited by the available diameters of these devices. Abdominal aortic endografts have been successfully used in the thoracic aorta to overcome sizing limitations. A case is presented of a patient who underwent endovascular exclusion of a thoracic aortic transection with an abdominal aortic endograft iliac limb. The repair was complicated by endograft malapposition to the lesser curvature of the aortic arch and the development of a functional coarctation. The endovascular repair was successfully salvaged through the use of a balloon-expandable stent to improve endograft apposition to the vessel wall.

Endovascular Repair of a Thoracic Aortic Injury in a Burn Patient

Mortality in burn patients who sustain concomitant mechanical traumatic injuries at the time of thermal injury is greater than in patients who sustain isolated injuries. Invasive interventions to treat these mechanical traumatic injuries may be a source of added mortality and contribute to an injury-induced state of immunosuppression. Less-invasive interventions may minimize morbidity and mortality and allow for improved recovery from thermal injury. A case is presented of a patient who sustained 20% TBSA electrical burns and an acute thoracic aortic injury near the diaphragmatic hiatus. Abdominal aortic stent-graft components were used to successfully exclude the patient's thoracic aortic injury. The patient made a successful recovery from his burns and sustained no infectious complications. This case report highlights the potential advantages of endovascular therapy for the treatment of aortic trauma in patients who sustain concomitant burn injuries.