Functional Assessment and Evaluation of Outcome After Endovascular Therapy With Coverage of the Left Subclavian Artery in Case of Blunt Thoracic Aortic Injury

Beyond the Slopes and Highways: Endovascular Repair of Blunt Traumatic Aortic Injuries after Skiing versus Motor Vehicle Accidents

Background: Blunt traumatic aortic injury (BTAI) is a potentially fatal condition, typically resulting from high-velocity trauma. To date, little is known about this type of injury among skiers, who form the largest patient cohort with aortic injuries in the alpine region of Tyrol, Austria. Methods: This retrospective, single-center study at the University Hospital of Innsbruck analyzed patients who underwent endovascular treatment for blunt traumatic aortic injury from 2005 to 2023. Patient data were extracted from electronic and digitalized medical history records. Subsequent analyses compared the baseline characteristics and clinical results of the skiing accident (SA) group to the motor vehicle accident (MVA) group. Results: A total of 48 BTAI patients receiving TEVAR were included, 25 (52%) from SAs versus 23 (48%) from MVAs, who were predominantly male (92% vs. 78.3%). Despite similar preoperative risk profiles and ASA Scores (1.44 vs. 1.74) and no marked differences in BTAI injury grades or the affected aortic zones, significant disparities emerged: the SA group experienced shorter median ICU stays (3 vs. 11 days, p = 0.0007), fewer concomitant injuries (5 vs. 7, p = 0.005), and lower Injury Severity Scores (ISSs) (29 vs. 33, p = 0.003) than their MVA counterparts. The presence of rib fractures alongside other thoracic injuries, such as lung injury, pneumothorax, or hemothorax, was strongly correlated with BTAI in patients following skiing accidents (OR = 128.5). Conclusions: The injury severities and locations of BTAI in SA patients were comparable to those in MVA patients, indicating similar mechanisms of thoracic trauma. However, the SA patients experienced fewer concurrent pelvic and extremity fractures, had less post-procedural morbidity, and required shorter ICU stays. The presence of rib fractures combined with other thoracic injuries strongly suggests BTAI. These indicators should lead to prompt imaging and appropriate therapy.

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone.

STUDY DESIGN

Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days.

RESULTS

A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups.

CONCLUSIONS

NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Covering/Overstenting of the left subclavian artery (LSA) in thoracic endovascular repair (TEVAR) to treat various thoracic/thoracoabdominal aortic lesions: Is revascularization of the left arm a must? (A retrospective cohort study with 12 years of experience to describe the real-world situation of daily clinical practice and the literature review)

Background: Pathologies of the descending thoracic aorta inwardly extended towards the aortic arch actually shorten the proximal landing zone for aortic prosthesis. This, in turn, worsens the feasibility of the aorta for endovascular therapeutic options of those pathologies. Objective: This work considers the blockage of the left subclavian artery (LSA) through endovascular treatment of the pathologies of the descending aorta as a main work question, which is based on the hypothesis that there is no necessity for primary standard revascularization of the LSA in TEVAR with LSA covering. The researchers have 12 years of experience in treatment of different thoracic aortic lesions. Their experience will also be reviewed in this paper. Design: Retrospective unicenter cohort study in consecutive patients order to describe the real-world situation of daily clinical practice Material: All the patients who had undergone endovascular, hybrid, or open operative therapy of variant pathologies of descending aorta were included in this study. Methods: Various parameters were investigated, including therapeutic procedures such as i) pure endovascular vs. hybrid; ii) year of therapy; iii) symptomatic vs. asymptomatic status of the patients; iv) variant epidemiological factors (age, sex, risk factors, mortality, and follow up); v) overstenting/blocking of the LSA; vi) complications of applied therapies; vii) further operations/interventions to treat such complications; viii) radiologic aortic measurements (such as lumen extensions, false lumen measurements, distance to the supra-aortic and visceral vessels); and ix) multiple other pathological features. Different statistical parameters were also examined. Survival was analysed by the Kaplan–Meier assessment in the group of whole patients vs. the group of over-stented patients. Here the analysis of variance is performed for the independent parameters for the revascularized patients—not the revascularized patients—who had undergone LSA coverage. For statistical approval, U-test was used. The p-value < 0.05 was considered significantly different. The literature review was achieved by a search in PubMed, Google scholar, Research Gate, ScienceDirect, and Cochrane library by using the following terms endovascular, TEVAR, revascularization, stroke, and left-subclavian-artery ischemia. The literature is classified accordingly in relation to the main topic. In fact, the literature undergoes further analysis if it goes with or against our hypothesis. Results: Overall, 112 patients were enrolled in the study. There was no significant difference comparing the not-revascularized vs. the revascularized group of patients, considering the consequences on cerebrovascular blood circulation (in particular, n=1 case [4.8 %] vs. no case [0 %]; p=1) or the spinal cord ischemia (n=2 [9.5 %] vs. n=1 [7.1 %]; p=1). As the main result, there was no case of manifest left arm ischemia and deaths (mortality, 0). Survival was in both groups as follows: 22 [95% CI, 14.154–29.904] months vs. 43 [95% CI, 33.655–51.921] months with no significant statistical difference (p>0.05) . The only statistically significant risk factor found was renal insufficiency (p, 0.028), but this too is considered a trend by the urgency of revascularization. Postoperatively, pneumonia showed a trend of higher frequency (p=0.058) in the revascularized cases (n=0 in the not-revascularized vs. n=3 [21.4 %] in the revascularized cases). There was no significant difference in the occurance of postoperative neurovascular complications (such as cerebrovascular accidents, spinal cord ischemia, or left arm ischemia) by comparing the groups of not-revascularized and revascularized patients. Conclusion: The revascularization of the overstented LSA due to TEVAR should be limited to certain indications, including i) the inadequate intracerebral circle of Willis; ii) the predominantly perfused left vertebral artery with inadequate blood perfusion via the right vertebral artery (e.g., by stenosis), iii) anatomic variance such as the left vertebral artery originating directly from the aortic arch (and must be blocked by TEVAR); iv) the need of an adequate left internal thoracic artery for coronary-artery-bypass grafting (CABG); v) the need of patent LSA for the dialysis shunt of the left arm. However, there is no appropriate evidence as yet based on sufficient study results achieved in trials with an advanced design (such as [double-]blind, multicenter randomized study) that appears to be urgently required.

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

Introduction

Methods

Results

Conclusion

Meta-analysis of the outcomes of revascularization after intentional coverage of the left subclavian artery for thoracic endovascular aortic repair

OBJECTIVE

Coverage of the left subclavian artery (LSA) is often required to achieve complete proximal sealing during thoracic endovascular aortic repair. However, whether LSA revascularization should be performed remains controversial.

METHODS

MEDLINE, Embase, and Cochrane databases were systematically searched to identify all the relevant studies. A random-effects model was applied to pool the effect measures. Dichotomous data were presented using an odds ratio (OR).

RESULTS

There were 32 studies included for qualitative analysis and 31 studies for quantitative analysis. We found that patients who underwent LSA revascularization had a significantly decreased risk of spinal cord ischemia (OR, 0.62; 95% confidence interval [CI], 0.41-0.92; P = .02; I² = 0%), cerebrovascular accident (OR, 0.63; 95% CI, 0.42-0.95; P = .03; I² = 22%), and left upper extremity ischemia (OR, 0.18; 95% CI, 0.09-0.36; P < .00001; I² = 0%). However, no significant differences were found in the risk of paraplegia (OR, 0.91; 95% CI, 0.55-1.51; P = .71; I² = 0%) and 30-day mortality (OR, 0.89; 95% CI, 0.59-1.36; P = .60; I² = 21%) between the groups of patients with and without LSA revascularization.

CONCLUSIONS

Revascularization of the LSA is associated with decreased risks of cerebrovascular accident, spinal cord ischemia, and left upper limb ischemia in thoracic endovascular aortic repair with LSA coverage at the cost of higher local complications, such as possible vocal cord paresis.

Off-label use of thoracic aortic endovascular stent grafts to simplify difficult resections and procedures in general thoracic surgery

OBJECTIVES

Tumour infiltration, or gross infectious involvement of the thoracic aortic wall, poses a significant intraoperative risk for fatal bleeding and therefore could compromise adequate resection or efficient surgical management of pleural infection in a considerable amount of cases. We present 3 successful cases of off-label thoracic aortic endografting to safeguard thoracic aortic wall integrity.

METHODS

After all patients received thoracic stent grafts through femoral access into the descending aorta, the first patient underwent a resection of a locally advanced squamous cell carcinoma of the left inferior lobe cT4cN0-1cM0 after neoadjuvant chemoradiation, which had infiltrated the descending aortic wall. The second case was video-assisted thoracoscopic bilateral pleural decortication for empyema with aortic ulcers of the distal thoracic aorta in a patient with pancreatic intrathoracic fistula in a necrotizing pancreatitis. The third patient was operated for a locally advanced squamous cell carcinoma of the left inferior lobe initial stage cT4 cN1-2 cM0 after neoadjuvant chemoradiation, which had broad contact to the descending aorta at the level of thoracic vertebrae 7 and 8 on a circumference of circa 180°. Regional ethics committee approval according the Swiss Federal Human Research Act was obtained according to regulations.

RESULTS

Preventive stent graft placement resulted in complication-free resection and significantly minimized the risk of fatal intraoperative bleeding. Patients were thus not exposed to complications associated with aortic cross-clamping, possible prosthetic replacement and extracorporeal circulation techniques.

CONCLUSIONS

In carefully selected patient populations, the resection of locally advanced tumours or infectious processes involving the aortic wall can be facilitated by thoracic endovascular aortic repair prior to resection.