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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.
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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.
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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.
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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
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3
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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.
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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.
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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
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5
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Kuo MC, Meena RA, Ramos CR, Benarroch-Gampel J, Leshnower BG, Duwayri Y, Jordan WD, Rajani RR. Female gender is associated with increased late luminal narrowing within the stent graft after thoracic endovascular aortic repair. J Vasc Surg 2021; 75:67-73. [PMID: 34450242 DOI: 10.1016/j.jvs.2021.07.226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Luminal narrowing, suspected secondary to thrombus, occurs within stent grafts at an unclear incidence after thoracic endovascular aortic repair (TEVAR). The significance of this phenomenon has not been determined, nor have the risk factors for development of intragraft luminal narrowing. Small graft diameter is hypothesized to be a risk factor for the development of ingraft stenosis. METHODS A retrospective analysis was performed of a multicenter healthcare system including all patients who underwent TEVAR between July 2011 and July 2019 with at least 1 year of subsequently available surveillance contrast-enhanced computed tomography imaging. Standard demographic, preoperative, intraoperative, and postoperative variables were collected. Measurements were obtained via direct off-line images from computed tomography scans. Patent intragraft diameters were compared with baseline and interval change values were normalized to time to follow-up. The primary outcome measure was annual rate of intragraft luminal narrowing. RESULTS There were 208 patients who met the inclusion criteria (94 women, 114 men) with a median follow-up of 822 days. The mean annual rate of percent intragraft diameter reduction was 10.5 ± 7.7% for women and 7.6 ± 5.6% for men (P = .0026). Multivariate analysis demonstrated female gender (P = .0283), preoperative diagnosis of hypertension (P = .0449), and need for coverage of the left subclavian artery (P = .0328) were all significant predictors of intragraft luminal narrowing. Small aortic diameters were not found to be associated independently with ingraft luminal narrowing nor was the concomitant use of antiplatelet or anticoagulation medications. Significant amounts of ingraft luminal narrowing, defined as a greater than 20% intragraft diameter decrease, were associated with an increased need for any reintervention, including for malperfusion, endoleak, and symptomatic aneurysm (P = .0249). Kaplan-Meier estimates demonstrated a significant gender-associated difference in high rates of intragraft luminal narrowing (P = .00189). CONCLUSIONS In this analysis, female gender is shown to be a significant nonmodifiable risk factor for intragraft luminal narrowing after TEVAR. The development of this phenomenon is not benign; as such, these findings were associated with an increased need for reintervention. This finding may be attributable to differences in aortic compliance or gender-associated differences in coagulation pathways and merits further investigation. Surveillance after thoracic stent grafting must account for patient-specific variations in complication risk.
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Affiliation(s)
| | - R Anthony Meena
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Christopher R Ramos
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Jaime Benarroch-Gampel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Yazan Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - William D Jordan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Ravi R Rajani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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Updated outcomes from the TRANSFIX study to evaluate endovascular repair of blunt thoracic aortic injuries with the Zenith Alpha thoracic device. J Vasc Surg 2020; 71:1851-1857. [DOI: 10.1016/j.jvs.2019.05.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 05/03/2019] [Indexed: 11/23/2022]
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Abdoli S, Ham SW, Wilcox AG, Fleischman F, Lam L. Symptomatic Intragraft Thrombus following Endovascular Repair of Blunt Thoracic Aortic Injury. Ann Vasc Surg 2017; 42:305.e7-305.e12. [PMID: 28389290 DOI: 10.1016/j.avsg.2016.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/23/2016] [Accepted: 12/11/2016] [Indexed: 11/25/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) can be complicated by graft collapse, endoleaks, and stent migration. The incidence of these complications and other outcomes is poorly understood in young trauma victims who receive endovascular aortic repair of blunt thoracic aortic injury (BTAI). A 29-year-old pedestrian was struck by a vehicle resulting in polytrauma including BTAI with transection distal to the left subclavian artery origin. The patient underwent successful TEVAR. Nine months later, the patient developed transient paresthesia below the waist that progressed to bilateral lower extremity paralysis and malperfusion syndrome below the diaphragm including nonpalpable pulses in the lower extremities, acute renal failure, and ischemic colitis. Imaging demonstrated near occlusive thrombosis of the distal end of the thoracic endograft. An emergent axillobifemoral bypass resolved the organ malperfusion and acute limb ischemia. Patients who have undergone TEVAR for BTAI may develop asymptomatic or symptomatic intragraft thrombosis. In patients presenting with malperfusion syndrome below the diaphragm, extra-anatomic bypass can expeditiously resolve symptoms until definitive treatment can be performed. Oversizing of thoracic stents in trauma patient may lead to intragraft thrombosis.
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Affiliation(s)
- Sherwin Abdoli
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Sung Wan Ham
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Alison G Wilcox
- Department of Radiology, University of Southern California, Los Angeles, CA
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Lydia Lam
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA.
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Catastrophic Outcome of De Novo Aortic Thrombus After Stent Grafting for Blunt Thoracic Aortic Injury. Ann Thorac Surg 2014; 98:e139-41. [DOI: 10.1016/j.athoracsur.2014.07.093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 06/19/2014] [Accepted: 07/14/2014] [Indexed: 11/21/2022]
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Kumpati GS, Patel AN, Bull DA. Thrombosis of a descending thoracic aortic endovascular stent graft in a patient with factor V Leiden: case report. J Cardiothorac Surg 2014; 9:47. [PMID: 24618347 PMCID: PMC3984718 DOI: 10.1186/1749-8090-9-47] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 03/04/2014] [Indexed: 11/10/2022] Open
Abstract
We present a case of a 14 year old Caucasian male who underwent initially successful endovascular repair of a traumatic injury to the descending thoracic aorta. The patient had undiagnosed Factor V Leiden at the time of the endovascular repair. He later presented with thrombosis of the endovascular stent graft, necessitating open removal of the stent graft and replacement of the involved aorta with a Dacron graft.
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Affiliation(s)
- Ganesh S Kumpati
- Division of Cardiothoracic Surgery, University of Utah, 30 N, 1900 E,, #3C-127, Salt Lake City, UT 84132, USA.
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Takeda Y, Daimon M, Tsuji M, Katsumata T, Morita H, Ishizaka N. Repetitive complications after prosthetic graft for inflammatory aortic aneurysm. SAGE Open Med Case Rep 2013; 1:2050313X13513230. [PMID: 27489635 PMCID: PMC4857269 DOI: 10.1177/2050313x13513230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 10/10/2013] [Indexed: 11/29/2022] Open
Abstract
The presence of retroperitoneal fibrosis after an aortic graft replacement is a marker of poor prognosis following aortic graft replacement. Herein we report the case of a 39-year-old man with retroperitoneal fibrosis that had been causing ureteral obstruction. The man had undergone repeated aortic graft replacement due to bacteremia and aortic graft–small intestinal fistula that occurred 4 years after initial aortic grafting for an inflammatory aortic aneurysm. The patient was discharged after 4 weeks of intravenous antibiotic therapy following the latest aortic graft replacement.
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Affiliation(s)
| | - Masahiro Daimon
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Motomu Tsuji
- Division of Pathology, Osaka Medical College, Osaka, Japan
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Hideaki Morita
- Department of Cardiology, Osaka Medical College, Osaka, Japan
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Lioupis C, MacKenzie KS, Corriveau MM, Obrand DI, Abraham CZ, Steinmetz OK. Midterm results following endovascular repair of blunt thoracic aortic injuries. Vasc Endovascular Surg 2012; 46:109-16. [PMID: 22308206 DOI: 10.1177/1538574411431648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Previous studies have focused on early outcomes of thoracic endovascular repair (TEVAR) of blunt thoracic aortic injuries (BTAIs). Late results remain ill-defined. The purpose of this study is to review the midterm results of our experience with endovascular repair of BTAIs. METHODS A retrospective analysis was performed reviewing all endovascular repairs of BTAIs from 2002 to present. Preoperative, operative, and postoperative variables were recorded. Clinical end points included aortic-related mortality, stroke and paraplegia, hospital length of stay, procedure-related complications, endoleaks, and reinterventions. Computed tomography data sets were postprocessed for assessing integrity of stent grafts and late complications. RESULTS A total of 24 cases of BTAIs treated with TEVAR were identified. Thoracic endovascular repair was successful in treating BTAIs in all patients and there were no instances of procedure-related death, stroke, or paraplegia. One access complication occurred, requiring an iliofemoral bypass. Actuarial survival estimates and freedom from reintervention at 5 years were 88.7% and 95.8%, respectively. No late endoleaks, stent fractures, or device migration were identified. One patient required a secondary intervention 1 year following the initial repair to treat a pseudocoarctation syndrome caused by a diaphragm at the distal half of the stented aorta. This was treated successfully with repeated endografting. CONCLUSIONS Thoracic endovascular repair for BTAIs can be performed safely with low periprocedural mortality and morbidity. Midterm follow-up data presented in this report further support the therapeutic role of endoluminal approach for treating BTAIs in anatomically suitable patients.
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Affiliation(s)
- Christos Lioupis
- Division of Vascular Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada
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Surgical conversion for intragraft thrombosis following endovascular repair of traumatic aortic injury. J Vasc Surg 2012; 55:538-41. [DOI: 10.1016/j.jvs.2011.07.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 07/14/2011] [Accepted: 07/15/2011] [Indexed: 11/21/2022]
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Fernandez V, Mestres G, Maeso J, Domínguez JM, Aloy MC, Matas M. Endovascular Treatment of Traumatic Thoracic Aortic Injuries: Short- and Medium-term Follow-up. Ann Vasc Surg 2010; 24:160-6. [PMID: 19900782 DOI: 10.1016/j.avsg.2009.05.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 04/08/2009] [Accepted: 05/14/2009] [Indexed: 10/20/2022]
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