Management of Traumatic Aortic Isthmus Rupture in Case of Aberrant Right Subclavian Artery (Arteria Lusoria)

Double Fenestrated Physician-Modified Stent Graft for Endovascular Treatment of Traumatic Aortic Isthmus Rupture With an Aberrant Right Subclavian Artery

PURPOSE

The purpose of the study was to demonstrate the feasibility of urgent endovascular treatment of a traumatic aortic isthmus rupture in a patient with an aberrant right subclavian artery.

CASE REPORT

A 23-year-old man was admitted to a regional trauma center after a motor vehicle collision and found to have cerebral trauma and a large pseudoaneurysm of the aortic arch. Trauma computed tomography (CT) identified a blunt traumatic thoracic aortic injury with an aortic false aneurysm in the context of an aberrant right subclavian artery. A hybrid repair was performed with bilateral subclavian carotid bypasses and a double fenestrated physician-modified stent graft. The patient had an uneventful postoperative course. Postoperative CT scan showed sealing of the aortic arch rupture and patency of all the supra-aortic trunks.

CONCLUSION

Endovascular repair of blunt traumatic thoracic aortic injury is considered first-line therapy. Aortic arch anomalies add complexity to treatment. This report demonstrates that a hybrid strategy with bilateral carotid-axillary bypasses and homemade double fenestrated endograft of the aortic arch is a valuable approach for this challenging emergency in the context of an aberrant right subclavian artery.

Endovascular repair of traumatic aortic isthmic rupture: Early and mid-term results

INTRODUCTION

Conventional open repair of a traumatic aortic isthmic rupture is associated with a significantly high mortality and morbidity rates. Thoracic endovascular aortic repair (TEVAR) is currently often performed because it is a less invasive treatment than surgery. The aim of this study was to evaluate short and mid-term results of TEVAR in traumatic aortic isthmic rupture.

METHODS

This is a retrospective study conducted between 2010 and 2018 including patients who underwent TEVAR for traumatic aortic isthmic rupture.

RESULTS

Thirty-six consecutive patients were included. All patients had sustained a violent blunt chest trauma after a sudden deceleration with associated injuries. The injury severity score (ISS) was 40 (14-66). All patients were hemodynamically stable at admission. We deployed thoracic aorta stent grafts with a mean diameter of 26mm (18-36). The procedural success rate was 100%. We reported one intra-operative complication which was a distal migration of the graft, managed by an implantation of an aortic extension graft. On the first postoperative day, one patient presented an acute lower limb ischemia, probably due to the surgical femoral access, treated with an embolectomy with a Fogarty catheter with satisfactory results. The mean follow-up was 40.41 months (6.5-96). The mortality and paraplegia rates were 0% at one month and during the follow-up period. We reported a case of kinking of the graft that occurred at 6 months. No cases of endoleak neither re-intervention were reported.

CONCLUSION

TEVAR is a safe and a reliable method for the treatment of sub-acute traumatic thoracic aortic injuries.

Endovascular Repair of Traumatic Isthmic Ruptures: Special Concerns

Injury of the aortic isthmus is the second most frequent cause of death in cases of blunt traumatic injury. Conventional open repair is related to significant morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) has increasing role in traumatic isthmic rupture, as it avoids the thoracotomy-related morbidity, aortic cross clamping, and cardiopulmonary bypass. Additionally to the technical difficulties of open repair, multi-trauma patients may not tolerate the manipulations necessary to undergo open surgery, due to concomitant injuries. TEVAR is a procedure easier to perform compared to open surgery, despite that a considerable degree of expertise is necessary. Direct comparison of the two methods is difficult, but TEVAR appears to offer better results than open repair in terms of mortality, incidence of spinal cord ischemia, renal insufficiency, and graft infection. TEVAR is related to a-statistically not significant-trend for higher re-intervention rates during the follow-up period. Current guidelines support TEVAR as a first-line repair method for traumatic isthmic rupture. Certain specific considerations related to TEVAR, such as the timing of the procedure, the type and oversizing of the endograft, heparinization during the procedure, the necessity of cerebrospinal fluid drainage, type of anesthesia, and the necessary follow-up strategy remain to be clarified. TEVAR should be considered advantageous compared to open surgery, but future developments in endovascular materials, along with accumulating long-term clinical data, will eventually improve TEVAR results in traumatic aortic isthmic rupture (TAIR) cases. This publication reviews the role, outcomes, and relevant issues linked to TEVAR in the repair of TAIR.

Delayed-onset tension hemothorax following blunt trauma and the rupture of a previously undiagnosed aberrant right subclavian artery

An arteria lusoria is a well-known anatomic variant of the right subclavian artery. We describe a patient in whom an arteria lusoria injury was revealed by delayed-onset tension hemothorax following blunt trauma to the thorax.

A Rare Entity: Traumatic Thoracic Aortic Injury in a Patient with Aberrant Right Subclavian Artery

BACKGROUND

Aberrant right subclavian artery is an uncommon entity incidence ranging from 0.5 to 2.5%. Management of thoracic aortic injury in the presence of such anomalies can be a challenge. We present here a case of traumatic aortic injury, which was incidentally found to have an asymptomatic aberrant right subclavian artery. The patient was managed by an endovascular repair of thoracic aortic injury with an endograft and a right carotid to subclavian artery bypass as a hybrid procedure.

METHODS

A 40-year male patient was brought to the emergency in shock with an alleged history of road traffic accident an hour back. After initial resuscitation as per advance trauma life support protocol, imaging revealed thoracic aortic injury with aberrant right subclavian artery with multiple rib and bilateral humerus fracture. After primary stabilization of arm fractures, the patient was shifted to a hybrid operation room. As the aortic injury was within 10 mm of the origin of both subclavian arteries, it was decided to cover the origin of both subclavian arteries and land the endograft distal to the left carotid artery origin. Since there was a right dominant vertebral artery on imaging, right carotid to right subclavian artery bypass was done with expanded polytetrafluoroethylene graft to prevent posterior circulatory stroke along with thoracic endovascular aortic repair to seal the thoracic aortic injury.

RESULTS

After endovascular repair of thoracic aortic injury, left subclavian artery perfusion was maintained through left vertebral artery; and hence, revascularization of left subclavian artery was deferred. After management of all fractures, the patient was discharged 3 weeks after the date of admission without any complications. At 6 months follow-up, patient was stable and images showed patent bypass graft and sealed aortic injury.

CONCLUSIONS

In a trauma setting with multiple injuries, hybrid procedure with a thoracic endograft is associated with low mortality and morbidity; hence, it is the treatment of choice for thoracic aortic injury over open surgical repair. A hybrid suite can be life and time saving in situations which mandate simultaneous endovascular repair along with surgical revascularization when indicated, especially in cases with aberrant aortic arch anatomy.