1
|
Ibrahim M, Chung JCY, Ascaso M, Hage F, Chu MWA, Boodhwani M, Sheikh AA, Leroux E, Ouzounian M, Peterson MD. In-hospital thromboembolic complications after frozen elephant trunk aortic arch repair. J Thorac Cardiovasc Surg 2024; 167:1217-1226. [PMID: 36137836 DOI: 10.1016/j.jtcvs.2022.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study evaluated the frequency and clinical impact of thromboembolic complications after frozen elephant trunk aortic arch repair using the Thoraflex device (Terumo Aortic). METHODS A total of 128 consecutive patients (mean age 67.9 ± 13.7 years, 31.0% female) underwent frozen elephant trunk aortic arch repair using the Thoraflex device between September 2014 and May 2021 in 4 Canadian centers. Patient baseline characteristics, intraoperative details, and frozen elephant trunk thromboembolic complications were collected retrospectively and analyzed. RESULTS Fifteen patients (11.7%) had thrombus visualized within the frozen elephant trunk stent graft on imaging (n = 8; 53.3%) or had a thromboembolic event (n = 9; 60.0%) before hospital discharge. Sites of embolism were mesenteric (n = 8; 88.9%), renal (n = 4; 44.4%), and iliofemoral (n = 1; 11.1%). Patients who experienced thromboembolic complications were more likely to have a history of autoimmune disease (n = 3; 20.0% vs n = 2; 1.8%; P = .01) and implantation of a longer frozen elephant trunk stent graft (150 mm vs 100 mm) (n = 13; 86.7% vs n = 45; 39.8%; P < .001). All patients with thromboembolic complications received therapeutic anticoagulation, and a smaller proportion required an open surgical (n = 5; 33.3%) or an endovascular (n = 2; 13.3%) intervention. Radiographic resolution of thromboembolic complications was observed in 86.7% of patients (n = 13). In-hospital mortality occurred in 1 patient, stroke occurred in 1 patient, and transient spinal cord injury occurred in 1 patient. CONCLUSIONS Thromboembolic complications occur more often than previously recognized after frozen elephant trunk aortic arch repair using the Thoraflex device and are associated with increased rates of surgical and endovascular reintervention. Prevention and management of these complications require further study.
Collapse
Affiliation(s)
- Marina Ibrahim
- Division of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Ascaso
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fadi Hage
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Azmat A Sheikh
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Emilie Leroux
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
2
|
van Rijn K, Schepers A, van der Meer RW, van Rijswijk CS, van Schaik J, van der Vorst JR. Therapeutic management of in-stent thrombosis after thoracic endovascular aortic repair for blunt thoracic aortic injury in a coronavirus disease 2019 patient. J Vasc Surg Cases Innov Tech 2023; 9:101297. [PMID: 37767352 PMCID: PMC10520436 DOI: 10.1016/j.jvscit.2023.101297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/01/2023] [Indexed: 09/29/2023] Open
Abstract
A 27-year-old man underwent thoracic endovascular aortic repair for blunt thoracic aortic injury. Fourteen months later, he presented with intermittent paraplegia, congestive heart failure, and a decline of kidney function as a result of high-grade aortic stenosis caused by in-stent thrombosis. He had a concurrent infection with coronavirus disease 2019. The patient was successfully treated using axillofemoral bypass, followed by stent relining 2 weeks later. The possible risk factors and the optimal therapeutic approach for in-stent thrombosis remain unknown, because only a limited number of cases describing this rare complication have been reported.
Collapse
Affiliation(s)
- Karen van Rijn
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Abbey Schepers
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Jan van Schaik
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Joost R. van der Vorst
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
3
|
Late Stent Thrombosis in a Patient with Endovascular Aortic Repair for Blunt Thoracic Aortic Injury. Case Rep Vasc Med 2022; 2022:5583120. [PMID: 35198259 PMCID: PMC8860563 DOI: 10.1155/2022/5583120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 11/18/2022] Open
Abstract
Blunt thoracic aortic injury (BTAI) is associated with high mortality and morbidity. Thoracic endovascular aortic repair has become the recommended treatment modality given improved short-term results compared to open repair. We present a case of a 19-year-old male who presented with acute paralysis and multiorgan dysfunction from acute TEVAR thrombosis. Systemic thrombolysis, catheter-directed thrombolysis followed by aspiration thrombectomy, and angioplasty were initially successful in restoring perfusion. However, he developed progressive multiorgan failure related to prompt reocclusion within 48 hours. This case is the first to describe thrombolysis and angioplasty as a management strategy for acute TEVAR thrombosis. We also review the literature surrounding this uncommon complication.
Collapse
|
4
|
Beijer E, Scholtes VPW, Truijers M, Nederhoed JH, Yeung KK, Blankensteijn JD. Intragraft Obstructive Thrombus Two Years After Endovascular Repair of Traumatic Aortic Injury: A Case Report and Review of the Literature. EJVES Vasc Forum 2021; 53:36-41. [PMID: 34927115 PMCID: PMC8652008 DOI: 10.1016/j.ejvsvf.2021.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 08/07/2021] [Accepted: 10/20/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for blunt thoracic aortic injury (BTAI) and has proven to be a good alternative to open surgery. TEVAR requires less operation time, has fewer complications, can be used for relatively unstable patients, and is associated with a significantly lower mortality rate. Moreover, long term follow up data demonstrate low re-intervention rates and stentgraft failure. Report The case of a 21 year old man who sustained severe trauma, including a traumatic pseudoaneurysm of the descending thoracic aorta distal to the left subclavian artery in 2016, is presented. The patient was treated by TEVAR. Two years later, he presented with progressive paraplegia due to stentgraft occlusion occurring four days after a new high velocity motor vehicle accident. An axillofemoral bypass was performed to assure blood flow to the lower body. Two days later the stentgraft was removed via left thoracotomy and replaced by a Dacron graft. Gross examination showed severe thrombus formation at the proximal edge, and a thrombotic occlusion in the middle and distal third of the stent. After three months of hospitalisation the patient was discharged to a rehabilitation clinic with partial recovery of his paraplegia. As of June 2020, the patient was able to walk without assistance and his paraplegia improved with only loss of sensation of his lower legs. Conclusion A serious thrombotic complication two years after TEVAR is described. Although TEVAR is the currently preferred treatment for BTAI, more research is needed to examine the mechanisms behind this thrombotic complication and to elucidate whether TEVAR is definitive treatment or a “bridge to further surgery”. Smaller diameter stentgrafts, anticoagulation, regular (lifelong) follow up imaging, and prophylactic surgical conversion in (selected) patients might help to prevent this serious complication. Although thoracic endovascular aortic repair is the first choice treatment for blunt thoracic aortic injury, the cause of intragraft thrombus is unknown. Nine cases have been reported with thrombotic (near) occlusions of thoracic stentgrafts. This is the first reported total occlusion following a second trauma. Oversizing and trauma can potentially play a role in the formation and progression of obstructive thrombus in thoracic stentgrafts. Follow up is important to detect intragraft thrombus deposition and to prevent major complications by adjusting anticoagulation or performing prophylactic removal of thrombotic stentgrafts.
Collapse
Affiliation(s)
- E Beijer
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - V P W Scholtes
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - M Truijers
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - J H Nederhoed
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - K K Yeung
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - J D Blankensteijn
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| |
Collapse
|
5
|
Hundersmarck D, van der Vliet QMJ, Winterink LM, Leenen LPH, van Herwaarden JA, Hazenberg CEVB, Hietbrink F. Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. Eur J Trauma Emerg Surg 2020; 48:1961-1973. [PMID: 32632630 PMCID: PMC9192473 DOI: 10.1007/s00068-020-01432-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/28/2020] [Indexed: 11/30/2022]
Abstract
Purpose
Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL). Methods Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population. Results Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01). Conclusion This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries. Electronic supplementary material The online version of this article (10.1007/s00068-020-01432-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Dennis Hundersmarck
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Quirine M. J. van der Vliet
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Lotte M. Winterink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Luke P. H. Leenen
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | | | | | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| |
Collapse
|