Thoracic endovascular aortic repair for traumatic aortic transection

IMPACT OF THORACIC ENDOVASCULAR AORTIC REPAIR TIMING ON AORTIC REMODELING IN ACUTE TYPE B AORTIC INTRAMURAL HEMATOMA

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) is increasingly utilized in the management of acute type B aortic intramural hematoma (TBIMH). Optimal timing for intervention has not been described. The aim of this study was to evaluate TEVAR timing on post-operative aortic remodeling.

METHODS

A retrospective chart review was performed on patients who underwent TEVAR for TBIMH from January 2008 to September 2018. Imaging was reviewed pre- and postoperatively. Primary data points included true lumen diameter (TLD) and total aortic diameter (TAD) at the site of maximal pathology. Primary endpoint was aortic remodeling evidenced by a TAD/TLD ratio closest to 1.0. Secondary outcome was occurrence of aortic-related adverse events and mortality (AREM): aortic rupture, aortic-related death, progression to dissection or need for aortic re-intervention within 12 months. Patients undergoing emergent TEVAR (within 24 hours, 'eTEVAR') were compared to the remainder - delayed TEVAR ('dTEVAR').

RESULTS

We analyzed 71 patients that underwent TEVAR FOR TBIMH; 25 underwent emergent TEVAR and 46 patients underwent dTEVAR (median: 5.5 days, range: 2-120 days). There were no differences in demographics and comorbidities and patients did not differ in presenting IMH thickness (12.6±3.1 mm vs. 11.3±4.1 mm, p=0.186) nor presenting TAD/TLD ratio (1.535±0.471 vs. 1.525±0.397, p=0.928) for eTEVAR and dTEVAR groups, respectively. eTEVAR patients had larger average presenting maximal descending aortic (DTA) diameter (45.8±14.3 mm vs. 38.2±7.5 mm, p=0.018) and higher incidence of penetrating aortic ulcer (PAU) on presenting CT angiography (52.0% vs 21.7%, p=0.033). Thirty day mortality was 2/25 (8.0%) for eTEVAR and 2/45 (4.4%) for dTEVAR (p=0.602). Postoperative aortic remodeling was more complete in the dTEVAR group (1.23±0.12 vs. 1.33±0.15, p=0.004). Case-control matching (controlling for presenting DTA diameter and PAU) on 30 patients still showed better aortic remodeling in the dTEVAR group (1.125±0.100 vs 1.348±0.42, p<0.001). The incidence of AREM was higher in the eTEVAR - 6/25 (24.0%) - group compared to the dTEVAR group - 2/46 (4.3%). At 12 months, freedom from AREM was higher in the dTEVAR group (95.7% vs. 76.0%, p=0.011). Postoperative TAD/TLD ratio was the best predictor for late aortic-related adverse events (AUROC=0.825, p=0.003).

CONCLUSION

TEVAR for acute type B IMH within 24 hours of admission is associated with lower aortic remodeling and higher occurrence of late aortic related adverse events and mortality. Delaying TEVAR when clinically possible could improve aortic remodeling and aortic-related outcomes.

Epidemiology and injury patterns of aerial sports in Switzerland

BACKGROUND

Airborne sports have become more popular in recent years. The number of accidents has increased linearly as athletes take increasingly greater risks to experience the adventurous spirit of this kind of sports.

AIM

To investigate the variety of injuries in airborne sport accidents, as well as which acute treatment these patients receive, both before and after admission to a level-one-trauma center.

METHODS

We performed a retrospective chart analysis at a major level-one-trauma center in Switzerland for 235-patients who were admitted following airborne sports injuries between 2010 and 2017. Patients’ demographic data, injury patterns, emergency primary care procedures and intra-hospital care were recorded.

RESULTS

Overall, 718-injuries in 235-patients were identified; the spine was the most commonly affected region with 46.5% of injuries (n = 334/718) in 143-patients. In 69-patients (15.5%), the (non-spine) thorax was affected, followed by the lower and upper extremity, pelvis, head/face and abdominal injuries. Eleven-patients had to be intubated at the trauma site. Three patients were resuscitated after onset of pulseless-electrical-activity. Two-patients died in the resuscitation room. In 116-cases, surgery was indicated including 55-emergency surgeries. Another 19 patients (8.1%) were transferred to the intensive care unit.

CONCLUSION

Paragliders are most commonly affected, although the highest injury severities were identified for Building, Antenna, Span and Earth-jumping athletes. First responders, treating physicians and pilots should be aware of the risk for potentially serious and life-threatening injury with an in-hospital mortality of 0.9%.

An In Vitro Phantom Study on the Role of the Bird-Beak Configuration in Endograft Infolding in the Aortic Arch

Purpose: To assess endograft infolding for excessive bird-beak configurations in the aortic arch in relation to hemodynamic variables by quantifying device displacement and rotation of oversized stent-grafts deployed in a phantom model. Methods: A patient-specific, compliant, phantom pulsatile flow model was reconstructed from a patient who presented with collapse of a Gore TAG thoracic endoprosthesis. Device infolding was measured under different flow and pressure conditions for 3 protrusion extensions (13, 19, and 24 mm) of the bird-beak configuration resulting from 2 TAG endografts with oversizing of 11% and 45%, respectively. Results: The bird-beak configuration with the greatest protrusion extension exhibited the maximum TAG device displacement (1.66 mm), while the lowest protrusion extension configuration led to the minimum amount of both displacement and rotation parameters (0.25 mm and 0.6°, respectively). A positive relationship was found between the infolding parameters and the flow circulating in the aorta and left subclavian artery. Similarly, TAG device displacement was positively and significantly (p<0.05) correlated with the pulse pressure for all bird-beak configurations and device sizes. However, no collapse was observed under chronic perfusion testing maintained for 30 days and pulse pressure of 100 mm Hg. Conclusion: These findings suggest that endograft infolding depends primarily on the amount of aortic pulsatility and flow rate and that physiological flows do not necessarily engender hemodynamic loads on the proximal bird-beak segment sufficient to cause TAG collapse. Hemodynamic variables may allow for identification of patients at high risk of endograft infolding and help guide preventive intervention to avert its occurrence.

[Management of the traumatic aortic blunt injury in 2014]

Diagnosis of blunt thoracic aortic injury (BAI) should be considered in any serious polytrauma. The diagnosis is mainly based on the CT scan at baseline. Life-threatening lesions are often associated with BAI. Hospital mortality is mainly due to associated lesions. Except the complete rupture of the aorta, treatment should be initiated after hemodynamic and respiratory stabilization of the patient and after the treatment of a lesion involving the immediate prognosis. Endovascular treatment of BAI became the treatment of choice, especially for patients with severe associated injuries and bleeding risk. Additional data on the long-term stents are necessary in these young patients. Conventional surgical treatment is always indicated for young subjects with stable hemodynamic, low risk of bleeding and when surgery may be delayed several hours.

Epidemiology of concomitant injuries in traumatic thoracic aortic rupture: a meta-analysis

Traumatic thoracic aortic rupture is a highly lethal injury. For those who arrive alive at the hospital, it is of utmost importance to quickly evaluate concomitant injuries and prioritize therapeutic interventions. We aimed to review the frequency of concomitant injuries in patients with thoracic aortic rupture, according to anatomic location and type of injury. A systematic literature search of six medical databases led to the identification of 90 publications; 27 categories of thoracic aortic rupture concomitant injuries were thereafter created. The respective pooled proportions and 95% confidence intervals were calculated and ranked in order of frequency. Among the 7258 patients studied, orthopedic fractures were the most frequent thoracic aortic rupture concomitant injury, amounting to a high pooled proportion of almost 70%, followed by thoracic injury in ∼50% and abdominal injury in over 40%. Pooled proportion for any type of head injury was also high (37%) pointing to the multiple-injury type of lesions among thoracic aortic rupture victims. Thoracic aortic rupture is a devastating injury, but rarely occurs as a sole traumatic entity. The recognition of concomitant thoracic, abdominal, head injuries and fractures after thoracic aortic rupture is of paramount importance. Future studies should focus on the impact of these injuries upon survival, morbidity and disability of multiple-injured thoracic aortic rupture patients.

The role of mandatory lifelong annual surveillance after thoracic endovascular repair

Thoracic endovascular aortic repair (TEVAR) has become an attractive and well-accepted option for the management of the various thoracic aortic pathologies that vascular surgeons are confronted with. As in the abdominal aorta, current management trends include the treatment of younger patients with longer life expectancies, raising the issue of postoperative surveillance. There are several relevant differences between these anatomic areas when it comes to surveillance, including the relative inaccessibility of the thoracic aorta to ultrasound interrogation and the increased variability of thoracic aortic pathologies and post-TEVAR complications. In addition, concerns regarding radiation-induced carcinogenesis and contrast-induced nephropathy reduce the enthusiasm of many surgeons for regular computed tomography surveillance. Most agree that surveillance is important after TEVAR, but the method, duration, and frequency of that surveillance is much less clear and is the topic of this debate.

Diagnosis and management issues in thoracic aortic aneurysm

Thoracic aortic enlargement is an increasingly recognized condition that is often diagnosed on imaging studies performed for unrelated indications. The risk of unrecognized and untreated aortic enlargement and aneurysm includes aortic rupture and dissection which carry a high burden of morbidity and mortality. The etiologies underlying thoracic aortic enlargement are diverse and can range from degenerative or hypertension associated aortic enlargement to more rare genetic disorders. Therefore, the evaluation and management of these patients can be complex and requires knowledge of the pathophysiology associated with thoracic aortic dilation and aneurysm. Additionally, there have been important advances in the treatment available to patients with thoracic aortic disease, including an increased role of endovascular therapy. Given the risk of mortality, increased clinical recognition and advances in therapeutics, the American College of Cardiology, American Heart Association and related professional societies have recently published guidelines on the management of thoracic aortic disease. This review focuses on the pathophysiology and various etiologies that lead to thoracic aortic aneurysm along with the diagnostic modalities and management of asymptomatic patients with thoracic aortic disease.

Delayed endovascular treatment of descending aorta stent graft collapse in a patient treated for post- traumatic aortic rupture: a case report

BACKGROUND

We report a case of delayed endovascular correction of graft collapse occurred after emergent Thoracic Endovascular Aortic Repair (TEVAR) for traumatic aortic isthmus rupture.

CASE PRESENTATION

In 7th post-operative day after emergent TEVAR for traumatic aortic isthmus rupture (Gore TAG® 28-150), a partial collapse of the endoprosthesis at the descending tract occurred, with no signs of visceral ischemia. Considering patient's clinical conditions, the graft collapse wasn't treated at that time. When general conditions allowed reintervention, the patient refused any new treatment, so he was discharged.Four months later the patient complained of severe gluteal and sural claudication, erectile disfunction and abdominal angina; endovascular correction was performed. At 18 months the graft was still patent.

DISCUSSION AND CONCLUSION

Graft collapse after TEVAR is a rare event, which should be detected and treated as soon as possible. Delayed correction of this complication can be lethal due to the risk of visceral ischemia and limbs loss.

Endograft collapse after thoracic endovascular aortic repair

PURPOSE

To provide insight into the causes, timing, and optimal management of endograft collapse after thoracic endovascular aortic repair (TEVAR).

METHODS

A comprehensive review was conducted of all published cases of endograft collapse after TEVAR identified using Medline, Cochrane Library Central, and EMBASE. In total, 32 articles describing 60 patients (45 men; mean age 40.6 ± 17.2 years, range 17-78) with endograft collapse were included. All data were extracted from the articles and systematically entered into a database for meta-analysis.

RESULTS

In the 60 cases of endograft collapse, TEVAR had most commonly been applied to repair traumatic thoracic aortic injuries (39, 65%), followed by acute and chronic type B aortic dissections (9, 15%). The median time interval between TEVAR and diagnosis of endograft collapse was 15 days (range 1 day to 79 months). On average, the collapsed endografts were oversized by 26.7% ± 12.0% (range 8.3%-60.0%). Excessive oversizing was reported as the primary cause of endograft collapse in 20%, and a small radius of curvature of the aortic arch was responsible for 48% of the cases. The 30-day mortality was 8.3%, and the freedom from procedure-related death at 3 years after diagnosis of stent-graft collapse was 83.1% for asymptomatic patients compared with 72.7% for patients who had symptoms at diagnosis (p=0.029).

CONCLUSION

Endograft collapse typically occurs shortly after TEVAR, most frequently after endovascular repair of traumatic aortic injury. A high level of suspicion for endograft collapse in the first month after TEVAR, as well as further improvement of current endovascular devices, may be required to improve the long-term outcomes of patients after TEVAR.

A multicenter experience of the management of collapsed thoracic endografts

OBJECTIVES

Thoracic endograft collapse after thoracic endovascular aortic repair (TEVAR) is a potentially devastating complication. This study evaluates the management of thoracic stent graft collapse.

METHODS

A multicenter review of thoracic stent graft collapse was performed from 2005 to 2009. Diagnosis and preoperative planning was performed by computed tomography angiography (CTA). Outcome measures included success of endovascular salvage, postoperative complications, and conversion to open repair.

RESULTS

Eleven patients (10 men) with thoracic endograft collapse were identified. Mean age was 41.2 years old (range, 21-66 years). Indications for the index TEVAR were traumatic aortic transections in 8 patients and acute type B dissections in 3 patients. All were initially treated with the TAG endoprosthesis (Gore and Associates, Flagstaff, Ariz). The median duration from initial repair to diagnosis of collapse was 9 days (range, 1 day-38 months). All collapses were initially treated by endovascular means using another TAG device in 7 patients, a Talent (Medtronic, Santa Rosa, Calif) thoracic stent graft in 3 patients, and a Palmaz (Cordis Endovascular, Warren, NJ) stent in 1 patient. In 1 patient, the secondary TAG did not resolve the collapse and required a Palmaz stent placement. Technical success rate was 91%, while re-expansion of the collapsed endograft was achieved in all patients. Early and late complications were observed in 3 patients. Delayed (>30 days) open conversion with device explantation was performed for an aortoesophageal fistula, physiological aortic coarctation, and prevention of a recurrent collapse in 1 patient each. There were no perioperative deaths or recurrent collapses.

CONCLUSION

Endograft collapse can be successfully managed by endovascular techniques in most cases. Redo-TEVAR using high radial force devices should be considered the initial treatment of choice. Late endograft-related complications after treatment of collapsed endografts are not uncommon and can be safely managed by open conversion.

Unsuccessful treatment of a collapsed thoracic stent graft by Palmaz stent

A Gore TAG Excluder stent graft was deployed in a 35-year-old woman for an isthmic saccular aneurysm. At 12-hour follow-up, we diagnosed a proximal collapse. A Palmaz stent was used to reopen the proximal segment. Two months later, she presented with a transient ischemic attack (embolic process) related to a suboptimal apposition of the Palmaz stent in the distal aortic arch. This led to open surgical replacement of the ascending aorta and aortic arch with reimplantation of the supraaortic branches. Reopening of a stent graft collapse with a Palmaz stent might be a short-term solution; however, its presence can lead to embolic complications.

Endovascular Management of Traumatic Thoracic Aortic Transection

The conventional treatment of traumatic thoracic aortic transection is open surgical repair but it is associated with high rates of morbidity and mortality, particularly in patients with multiple injuries. We reviewed our experience of endovascular repair of traumatic thoracic aortic transection. Between March 2002 and December 2007, 7 patients (male 6, female 1; mean age 40 years) with multiple injuries secondary to blunt trauma underwent endovascular stenting. One patient required adjunctive surgery to facilitate endovascular stenting. Mean intensive care unit stay was 8.6 days (range, 3–16 days). Arterial access in all patients was obtained by femoral cut-down. The mean operating time was 122 min. Technical success was achieved in all cases. There was no mortality. One patient suffered a right parietal stroke, but none developed procedure-related paralysis. The mean follow-up period was 18.6 months (range, 6–48 months). There was no evidence of endoleak, stent migration, or late pseudoaneurysm formation on follow-up computed tomography. Endovascular stents can be used to treat traumatic thoracic aortic transection, with low rates of morbidity and mortality. Although early and midterm results are promising, the long-term durability of endovascular stenting for traumatic thoracic aortic transection remains unknown.

Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels

BACKGROUND

Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times.

METHODS

A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma.

RESULTS

In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%.

CONCLUSION

The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

Late failure after endovascular repair of descending thoracic aneurysms

Although endovascular repair of descending thoracic aneurysm has been increasingly utilized as a minimally invasive alternative to open repair, the availability of late results remains quite limited, and what exists does not yet completely reflect the rapid evolution of devices, refinement in delivery systems and maturation of both institutional and general learning curves. Durability of endografts in the thoracic aorta continues to be defined as more long-term data emerge from the major device regulatory trials. This review describes the currently available published long-term results and describes some of the anecdotally reported modes of late failure associated with the technique.

Infolding and collapse of thoracic endoprostheses: manifestations and treatment options

OBJECTIVES

We sought to review the clinical sequelae and imaging manifestations of thoracic aortic endograft collapses and infoldings and to evaluate minimally invasive methods of repairing such collapses.

METHODS

Two hundred twenty-one Gore endografts (Excluder, TAG; W. L. Gore & Associates, Inc, Flagstaff, Ariz) were deployed in 145 patients for treatment of pathologies including aneurysms and pseudoaneurysms, dissections, penetrating ulcers, transections, fistulae, mycotic aneurysms, and neoplastic invasions in 6 different prospective trials at a single institution from 1997 to 2007. Device collapses and infoldings were analyzed retrospectively, including review of anatomic parameters, pathologies treated, device sizing and selection, clinical sequelae, methods of repair, and outcome.

RESULTS

Six device collapses and infoldings were identified. Oversized devices placed into small-diameter aortas and imperfect proximal apposition to the lesser curvature were seen in all proximal collapses, affecting patients with transections and pseudoaneurysms. Infoldings in patients undergoing dissection represented incomplete initial expansion rather than delayed collapse. Delayed collapse occurred as many as 6 years after initial successful deployment, apparently as a result of changes in the aortic configuration from aneurysmal shrinkage. Clinical manifestations ranged from life-threatening ischemia to complete lack of symptoms. Collapses requiring therapy were remedied percutaneously by bare stenting or in one case by branch vessel embolization.

CONCLUSIONS

Use of oversized devices in small aortas carries a risk of device failure by collapse, which can occur immediately or after years of delay. When clinically indicated, percutaneous repair can be effectively performed.

Erosion of elephant trunk Dacron graft limb by thoracic endograft causing acute aneurysm expansion

We recently treated a patient in whom a Gore TAG thoracic endograft (W.L. Gore and Assoc, Flagstaff, Arix) had been used to repair a descending thoracic aneurysm as the second stage of a hybrid procedure. This patient had previously undergone repair of ascending and aortic arch aneurysms, with an elephant trunk graft limb placed in the descending thoracic aorta for subsequent repair of the descending thoracic aneurysm. Eight months after placement of the thoracic endograft, the patient presented with an acutely expanding and symptomatic thoracic aneurysm. The patient was operated on urgently. The proximal portion of the endograft had eroded into the previously placed Dacron elephant trunk limb. The proximal portion of the endograft was removed and was replaced with a Dacron graft. The management of this patient forms the basis of this report.

Endovascular intervention in thoracic arterial trauma

The management of thoracic vascular injury has improved dramatically over the past two decades. The availability of multi-row detector CT has facilitated early diagnosis and incorporation of minimally invasive endograft repair for traumatic aortic injury has improved mortality and paraplegia rates. This review evaluates the available data on stent-graft repair of acute blunt traumatic aortic injury and traumatic great vessel injury with regard to safety and efficacy in comparison with conventional open surgical repair.