Endovascular Repair of Blunt Thoracic Aortic Trauma: Is Postimplant Hypertension an Incidental Finding?

Long-term Outcomes of Endovascular Repair for Blunt Thoracic Aortic Injury: A 10 Year Multi-center Experience

OBJECTIVE

This study aimed to assess the long-term outcomes in patients treated by thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI).

MATERIALS AND METHODS

From January 2010 to December 2019, this retrospective observational study was conducted at 3 centers, involving 62 consecutive BTAI patients who underwent TEVAR. Computed tomography angiography scans were planned to be conducted at 6 months post-procedure, and annually thereafter.

RESULTS

Technical success was achieved in all 62 procedures (100%), which included cases of dissection (n=35, 56.45%), pseudoaneurysm (n=20, 32.26%), and rupture (n=7, 11.29%). Mean injury severity score was 31.66±8.30. A total of 21 supra-arch branches were revascularized by chimney technique, with 12 cases involving the left subclavian artery (LSA) and 9 cases involving the left common carotid artery. In addition, 11 LSAs were covered during the procedure. The in-hospital mortality rate was 1.61% (n=1). The mean follow-up time was 86.82±30.58 months. The all-cause follow-up mortality rate was 3.28% (n=2). Stenosis or occlusion of 3 supra-arch branches (4.92%) was identified at follow-up, with 2 cases (3.28%) requiring re-intervention. No spinal cord ischemia, endoleak, or migration was observed.

CONCLUSIONS

Despite only including patients with long-term follow-up, this study confirms the long-term safety and effectiveness of TEVAR for BTAI. For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta.

CLINICAL IMPACT

This study confirms the long-term safety and effectiveness of endovascular treatment for blunt thoracic aortic injury (BTAI). For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. Through a remarkably extended follow-up period (86.82±30.58 months) conducted at multiple centers in China, this study confirms the long-term safety and effectiveness of endovascular treatment for BTAI.

Calcium in the (Big) Pipes: Intra-TEVAR Calcifications!

Introduction

Calcification of a vascular endograft and adjacent tissues (adventitia, media, and neointima) can result in graft failure. This report shows a rare case of intraluminal calcifications in the distal end of a thoracic endovascular aortic repair (TEVAR) endograft implanted 11 years previously for grade IV blunt traumatic aortic injury (BTAI) in a young patient.

Report

A 24 year old man required TEVAR for a BTAI caused by a motorcycle accident. The procedure consisted of TEVAR and an emergency left carotid subclavian venous bypass. Eleven years after the procedure, he had severe hypertension. Intra-TEVAR calcifications appeared, gradually increasing on computed tomography angiography (CTA). Calcifications in the distal luminal end of the TEVAR were responsible for a 60% stenosis on CTA. An open approach was indicated after multidisciplinary discussion, based on the gradient value. The patient underwent explantation, with total replacement of the aortic arch and descending thoracic aorta with re-implantation of the supra-aortic vessels, under extracorporeal circulation. Macroscopic analysis showed no device degeneration but revealed a solid mass at the distal end of the TEVAR. Both microcomputed tomography and histopathology confirmed the calcific nature of the lesions.

Conclusion

This case highlights a rare long term graft failure due to calcified neo-atherosclerosis in a TEVAR.

Impact of thoracic endovascular aortic repair following blunt traumatic thoracic aortic injury on blood pressure

BACKGROUND

Blunt traumatic thoracic aortic injuries (BTAIs) are associated with a high mortality rate. Thoracic endovascular aortic repair (TEVAR) is the most frequently used surgical strategy in patients with BTAI, as it offers good short- and middle-term results. Previous studies have reported an abnormally high prevalence of hypertension (HT) in these patients. This work aimed to describe the long-term prevalence of HT and provide a comprehensive evaluation of the biomechanical, clinical, and functional factors involved in HT development.

METHODS

Twenty-six patients treated with TEVAR following BTAI with no history of HT at the time of trauma were enrolled. They were matched with 37 healthy volunteers based on age, sex, and body surface area and underwent a comprehensive follow-up study, including cardiovascular magnetic resonance, 24-hour ambulatory blood pressure monitoring, and assessment of carotid-femoral pulse wave velocity (cfPWV, a measure of aortic stiffness) and flow-mediated vasodilation.

RESULTS

The mean patient age was 43.5 ± 12.9 years, and the majority were male (23 of 26; 88.5%). At a mean of 120.2 ± 69.7 months after intervention, 17 patients (65%) presented with HT, 14 (54%) had abnormal nighttime blood pressure dipping, and 6 (23%) high cfPWV. New-onset HT was related to a more proximal TEVAR landing zone and greater distal oversizing. Abnormal nighttime blood pressure was related to high cfPWV, which in turn was associated with TEVAR length and premature arterial aging.

CONCLUSIONS

HT frequently occurs otherwise healthy subjects undergoing TEVAR implantation after BTAI. TEVAR stiffness and length, the proximal landing zone, and distal oversizing are potentially modifiable surgical characteristics related to abnormal blood pressure.

In-silico investigations of haemodynamic parameters for a blunt thoracic aortic injury case

Accounting for 1.5% of thoracic trauma, blunt thoracic aortic injury (BTAI) is a rare disease with a high mortality rate that nowadays is treated mostly via thoracic endovascular aortic repair (TEVAR). Personalised computational models based on fluid-solid interaction (FSI) principals not only support clinical researchers in studying virtual therapy response, but also are capable of predicting eventual outcomes. The present work studies the variation of key haemodynamic parameters in a clinical case of BTAI after successful TEVAR, using a two-way FSI model. The three-dimensional (3D) patient-specific geometries of the patient were coupled with three-element Windkessel model for both prior and post intervention cases, forcing a correct prediction of blood flow over each section. Results showed significant improvement in velocity and pressure distribution after stenting. High oscillatory, low magnitude shear (HOLMES) regions require careful examination in future follow-ups, since thrombus formation was confirmed in some previously clinically reported cases of BTAI treated with TEVAR. The strength of swirling flows along aorta was also damped after stent deployment. Highlighting the importance of haemodynamic parameters in case-specific therapies. In future studies, compromising motion of aortic wall due to excessive cost of FSI simulations can be considered and should be based on the objectives of studies to achieve a more clinical-friendly patient-specific CFD model.

Late Stent Thrombosis in a Patient with Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

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.

Influence of TEVAR on blood pressure in subacute type B aortic dissection (TBAD) patients with refractory and non-refractory arterial hypertension

BACKGROUND

Aim of this study was to compare the modifications of systemic blood pressure in patients with subacute type b aortic dissection (TBAD) and refractory (rHTN) and non-refractory arterial hypertension (N-rHTN) treated by thoracic endovascular aortic repair (TEVAR).

METHODS

Patients were divided into two groups, rHTN defined as blood pressure >140/90 mmHg with ≥5 antihypertensive drugs and patients with N-rHTN. Primary endpoint was the variation of mean systolic, diastolic and overall pressure (MSP, MDP and MAP) before and after antihypertensive treatment or TEVAR. Secondary endpoints were the 30-days mortality. Fifty-seven patients were included in this study.

RESULTS

Of the 44 Patients of the TEVAR group 21 were included in the N-rHTN group. The MSP before and after surgery for the N-rHTN group was 130 (±10 SD) and 111 (±22 SD) mmHg, P=0.01. In the rHTN group 164 (±17 SD) and 118 (±17 SD) mmHg (P=0.01). The reduction of MSP was greater in the rHTN group (P=0.01). The MAP before and after the TEVAR for the N-rHTN group was 90 (±10 SD) and 74 (±12 SD) mmHg (P=0.01), in the rHTN group 111 (±14 SD) and 70 (±9 SD) mmHg (P=0.01). The overall mortality rate group was 2.2% (1/44).

CONCLUSIONS

TEVAR for TBAD appears to positively affect blood pressure in patients with rHTN and N-rHTN.

Aortic stiffness and related complications after endovascular repair of blunt thoracic aortic injury in young patients

Summary: Background: This study aimed to evaluate the changes in aortic stiffness in young patients undergoing thoracic endovascular aortic repair (TEVAR) after blunt thoracic aortic injury (TBAI) and to examine the associated cardiovascular complications during follow-up. Patients and methods: We included survivors of TBAI who underwent stent graft placement between November 2009 and November 2019 and gave their consent to participate. Patients with relevant cardiovascular risk factors, comorbidities with potential impact on arterial stiffness, and prior aortic surgical or endovascular interventions were excluded. Fourteen TEVAR patients prospectively underwent clinical and noninvasive examinations and morphological imaging (mean time of follow-up and duration of implanted stent graft: 5.3 ± 1.8 years; mean age: 35.1 ± 8.7 years) and were compared to 14 healthy controls (matched for sex, age, height, and body mass index) in order to evaluate aortic stiffness. During the follow-up examinations, we assessed the pulse wave velocity (PWV; m/s) and development of arterial hypertension or heart failure, as indicated by N-terminal pro-brain natriuretic peptide (NT-proBNP; pg/mL) levels and performed echocardiography. Results: A significant increase in PWV values was recorded in the TEVAR group (median = 10.1; interquartile range [IQR] = 8.9–11.6) compared to the healthy controls (median = 7.3; IQR = 6.7–8.4), with an increase in the rank mean PWV (+ 3.8; Mann-Whitney U test p < .001). NT-proBNP levels of patients after TEVAR did not vary significantly compared to those of healthy controls (Mann-Whitney U test, p = .154). After TEVAR, five patients developed arterial hypertension during the follow-up, and three of them exhibited diastolic dysfunction. Conclusions: In young patients, TEVAR after TBAI may cause adverse cardiovascular complications due to increased aortic stiffness; therefore, screening for arterial hypertension during follow-up is recommended.

Open Conversion for Recurrent Endograft Occlusion after Endovascular Treatment of Blunt Traumatic Aortic Injury: A Peculiar Case Report

BACKGROUND

We report a rare case of delayed, symptomatic thoracic endograft thrombosis after the initial thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury which was successfully retreated with a redo TEVAR, followed by open conversion due to recurrent partial occlusion of the distal edge of the endografts.

METHODS

Two years ago, a 22-year-old man had undergone an emergency TEVAR for blunt thoracic aortic injury. A Zenith Cook 22 × 100 mm (Cook Incorporated, Bloomington, IN) endograft was used. Six months later, he underwent an emergency endovascular relining of the endograft using the same type of device. The multiorgan perfusion was completely restored except for the spinal cord injury. After 8 months, a recurrent partial occlusion of the distal edge of the second graft was documented. The thoracic aorta was replaced with a 22-mm silver-coated graft (Maquet Spain, SLU).

RESULTS

Histology examination showed a neointimal formation and thickening and fibrosis of the inner 1/3 of the media with loss of smooth muscle cells and increase of the elastic fibers.

CONCLUSIONS

The need for secondary interventions or open conversion because of potential complications after TEVAR for traumatic aortic injury is an additional consideration when weighing the risks and benefits of endovascular repair and subsequent surveillance strategies.

Cardiovascular Remodeling after Endovascular Treatment for Thoracic Aortic Injury

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) currently represents the gold standard of treatment for thoracic aortic injury (TAI). Nevertheless, there is an ongoing debate surrounding its safety and subsequent cardiovascular effects. Our aim is to assess heart and vascular structure and function remodeling after TEVAR in TAI young patients.

METHODS

We evaluated 20 patients (18 men, age 41 ± 14 years, 11 treated with Gore CTAG, 9 with Medtronic Valiant) with office and 24-hr blood pressure (BP) with specific vascular stiffness analysis (Mobil-O-Graph), aortic diameters (computed tomography scan) and left ventricular mass index (LVMI echocardiogram). Evaluation was done after a median time of 5.0 ± 3.5 years from the trauma.

RESULTS

After TAI 12 patients (55%) developed hypertension. When patients were divided according to treating time, those treated for more than 3 years show higher LVMI, PWV, and ascending aorta dilatation.

CONCLUSIONS

Our study shows that TEVAR for TAI is associated with heart and vascular remodeling. The presence of TEVAR modifies aortic functional properties and could induce an increase in BP that can promote aortic and cardiac damage, even in young patients.