Intentional left subclavian artery coverage during thoracic endovascular aortic repair for traumatic aortic injury

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

METHODS

The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.

RESULTS

A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

CONCLUSION

The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

Two cases of complex traumatic aortic dissection combined with multiple organ injuries

Traumatic aortic injury (TAI) is an acute, critical, and severe disease, and then combined with multiple organ damage, it is even more dangerous. TAI progresses very rapidly, with a pre-hospital mortality rate of 57%-80%, and even when arriving at the hospital, more than one-third of the patients die within 4 h, and it is the 2nd leading cause of death in individuals aged 4-34 years. In addition, the incidence of TAI combined with injury was 81.4%. Therefore, early diagnosis, expeditious surgery, and timely and effective multidisciplinary cooperation are essential for successful rescue. The authors report 2 patients with acute traumatic aortic dissection combined with multiple organ injuries and treated with emergency endovascular surgery to discuss their clinical characteristics and treatment experience, and to provide experience in the diagnosis and treatment of such patients.

A 12-year experience in the management of blunt thoracic aortic injury in Otautahi Christchurch

BACKGROUND

Blunt thoracic aortic injury (BTAI) is associated with a high mortality and is the second most common cause of death from trauma. The approach to major trauma, imaging technology and advancement in endovascular therapy have revolutionised the management of BTAI. Endovascular therapy has now become the gold standard technique replacing surgery with its high mortality and morbidity in unstable patients. We aim to assess the outcomes following management of BTAI.

METHOD

This is a retrospective study of all patients with BTAI between 1 January 2010 and 1 January 2022. Data were obtained from electronic health records. The grading of BTAI severity was done based on the Society of Vascular Surgery (SVS) Criteria.

RESULTS

Fifty patients were included in the study analysis. The most common cause of BTAI was due to high-speed motor vehicle accidents (MVA) (36 patients, 72%). Grade 1 and grade 3 BTAI injuries were mostly encountered in 40% and 30% of the study cohort, respectively. Twenty-three patients (46%) underwent thoracic endovascular aortic repair (TEVAR). There was no secondary aortic re-intervention, conversion to open surgery or aortic-related deaths at 30 days or at most recent follow-up.

CONCLUSION

Management of BTAI in our centre compares well with currently published studies. Long-term studies are warranted to guide clinicians in areas of controversy in BTAI management.

[Intervention for Chest Trauma and Large Vessel Injury]

Trauma is an injury to the body that involves multiple anatomical and pathophysiological changes caused by forces acting from outside the body. The number of patients with trauma is increasing as our society becomes more sophisticated. The importance and demand of traumatology are growing due to the development and spread of treatment and diagnostic technologies. In particular, damage to the large blood vessels of the chest can be life-threatening, and the sequelae are often severe; therefore, diagnostic and therapeutic methods are becoming increasingly important. Trauma to non-aortic vessels of the thorax and aorta results in varying degrees of physical damage depending on the mechanism of the accident and anatomical damage involved. The main damage is hemorrhage from non-aortic vessels of the thorax and aorta, accompanied by hemodynamic instability and coagulation disorders, which can be life-threatening. Immediate diagnosis and rapid therapeutic access can often improve the prognosis. The treatment of trauma can be surgical or interventional, depending on the patient's condition. Among them, interventional procedures are increasingly gaining popularity owing to their convenience, rapidity, and high therapeutic effectiveness, with increasing use in more trauma centers worldwide. Typical interventional procedures for patients with thoracic trauma include embolization for non-aortic injuries and thoracic endovascular aortic repair for aortic injuries. These procedures have many advantages over surgical treatments, such as fewer internal or surgical side effects, and can be performed more quickly than surgical procedures, contributing to improved outcomes for patients with trauma.

Physician-Modified Stent Graft for Blunt Thoracic Aortic Injuries: Do the Benefits Worth the Trouble?

BACKGROUND

Obtaining a suitable proximal landing zone in blunt thoracic aortic injuries (BTAI) often necessitates coverage of the left subclavian artery (LSA). This study aimed to evaluate the outcomes of physician-modified endovascular grafts (PMEGs) in this indication.

METHODS

We performed a retrospective analysis of a prospective registry including all patients who had undergone a thoracic endovascular aortic repair (TEVAR) for BTAI from October 2008 to October 2020. Starting in 2015, patients requiring coverage of the LSA were either treated using a physician-modified proximal scalloped or single-fenestrated stent graft. After an early postoperative computed tomography scan, follow-up was performed at 3 months, 6-months, and yearly.

RESULTS

Among 58 patients treated with TEVAR for BTAI, 23 (39.6%) patients required a zone 2 landing zone of which 10 (17.2%) patients were treated with PMEGs. The median age was 48 [31-64.5] years, and 78.2% (n = 18) patients were male. The median Injury Severity Score was 38 [27-55.5]. Coverage of the LSA was performed in 25.8% (n = 15) of the total population in which 5 patients had an LSA transposition. The median modification time was 18 [14-27] minutes. Technical success of PMEGs was 90.0% overall and 100% for fenestrated stent grafts. No stroke, paraplegia, or retrograde dissection was observed. The primary patency of the LSA in the PMEGs group was 90 % at 1 year and 28.8 % in the LSA coverage group (P < 0.01).

CONCLUSIONS

The use of PMEGs is feasible and effective in the management of BTAI with a short proximal landing zone. Further evaluation of long-term outcomes and durability are awaited.

Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma

BACKGROUND

Elective Thoracic Endovascular Aortic Repair (TEVAR) with left subclavian artery coverage (LSA-C) without revascularization is associated with increased rates of ischemic stroke. In patients with blunt thoracic aortic injury (BTAI) requiring TEVAR, LSA-C is frequently required in over one-third of patients. This study aimed to evaluate outcomes of TEVAR in BTAI patients with and without LSA-C.

METHODS

The largest existing international multicenter prospective registry of BTAI, developed and implemented by the Aortic Trauma Foundation, was utilized to evaluate all BTAI patients undergoing TEVAR from March 2016 to January 2021. Patients with uncovered left subclavian artery (LSA-U) were compared with patients who had left subclavian artery coverage with (LSA-R) and without (LSA-NR) revascularization.

RESULTS

Of the 364 patients with BTAI who underwent TEVAR, 97 (26.6%) underwent LSA-C without revascularization, 10 (2.7%) underwent LSA-C with revascularization (LSA-R). Late and all ischemic strokes were more common in LSA-NR patients than LSA-U patients ( p = 0.006, p = 0.0007). There was no difference in rate of early, late, or overall incidence of paralysis/paraplegia between LSA-NR and LSA-U. When compiled as composite central nervous system ischemic sequelae, there was an increased rate in early, late, and overall events in LSA-NR compared with LSA-U ( p = 0.04, p = 0.01, p = 0.001).

CONCLUSION

While prior studies have suggested the relative safety of LSA-C in BTAI, preliminary multicenter prospective data suggests there is a significant increase in ischemic events when the left subclavian artery is covered and not revascularized. Additional prospective study and more highly powered analysis is necessary.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Factors affecting success in endovascular treatment of acute aortic transections

Aim: In this study, it was aimed to present the results of patients treated with endovascular treatment between 2002 and 2018 with the diagnosis of Acute Aortic Transection and the factors that may affect the success. Materials and Methods: A total of 17 patients were included in the study and it was planned as retrospectively. All data of the patients were collected by file searching method and demographic features of the patients were recorded. Written informed consent was obtained from all patients prior to study. Trauma types and gender ratios of the patients were calculated as percentages.. Contrast-enhanced thoraco-abdominal computed tomography was performed for definitive diagnosis, and endovascular treatment was evaluated. All patients deemed suitable for endovascular treatment were intervened within the first 24 hours. Results: The most majority of our patient group was in stage 4 and the most common etiology was recorded as in - vehicle traffic accidents. Of the 17 patients included in the study, 2 died in the early period and 1 died in the follow-up period. Complications such as graft migration, pseudo aneurysm and graft kinking, which are known as complications of endovascular treatment, were not encountered. Although the left subclavian artery was closed in 12 of 17 patients, only two of them required carotid-subclavian bypass. Conclusion: The fact that endovascular treatment can be applied with low mortality compared to conventional surgery reduces mortality in acute aortic transections. The most important factors affecting the success of the treatment are that the intervention is performed in the 24 hours, in experienced centers, and that 10% of the aortic diameter is not exceeded in the graft selection, and balloon dilatation is avoided.

Left subclavian artery coverage during endovascular repair of thoracic aorta injury in trauma and non-trauma patients

PURPOSE

In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients.

METHODS

Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass.

RESULTS

Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common.

CONCLUSION

LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.

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.

Blunt Thoracic Aortic Injury and Contemporary Management Strategy

Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.

Anatomic feasibility of off-the-shelf thoracic single side-branched endograft in patients with blunt traumatic thoracic aortic injury

OBJECTIVE

The advent of thoracic single side-branched endograft (TSSBE) has provided a treatment option to obviate the need for open cervical debranching of the left subclavian artery (LSA), thereby enabling total endovascular incorporation of the LSA during thoracic endovascular aortic repair (TEVAR). In a previous study of patients with type B aortic dissection who had required zone 2 TEVAR, the anatomic feasibility of this device was demonstrated to range from 28% to 35%, suggesting limited applicability of the currently available designs. The objectives of the present study were twofold: (1) to evaluate the anatomic feasibility of TSSBE in blunt traumatic thoracic aortic injury (BTAI) patients who would require LSA revascularization; and (2) to describe the anatomic characteristics of the supra-aortic arch branches that could be used to improve future device design.

METHODS

A retrospective review was performed of BTAI patients who had undergone TEVAR at a single institution from November 2013 to October 2018. Preoperative computed tomography angiograms were analyzed using three-dimensional reconstruction to quantify the aortic diameter, distance and arc length between branch vessels, and the LSA diameter and length. We calculated the proportion of patients who had met all aortic and LSA anatomic requirements for TSSBE proposed by investigational protocols. We also assessed the effect of anatomic requirement modifications on device suitability. Finally, we assessed the local anatomic relationship between the supra-aortic branches.

RESULTS

A total of 41 patients (63% men; median age, 39 years; range, 23-88 years; 68% normal aortic arch pattern, 32% bovine aortic arch pattern) with BTAI who had required TEVAR involving the LSA and were, thus, considered potential candidates for TSSBE were included. Of the 41 patients, 13 (32%; 7 with a bovine aortic arch and 6 with a normal aortic arch) had met all proposed aortic and LSA anatomic requirements for TSSBE. An appropriate aortic diameter, LSA diameter, and LSA length to its first branch were observed in 100%, 95%, and 66% of the patients, respectively. An insufficient distance between the arch branch vessels, observed in 41%, was the most common exclusionary criterion. The median clock-face position of the LSA was 12:00 (interquartile range, 30 minutes) in the normal arch group and 11:45 (interquartile range, 15 minutes) in the bovine arch group.

CONCLUSIONS

Despite the numerous potential advantages of TSSBE, only 32% of patients with BTAI requiring LSA revascularization had met all the aortic and LSA anatomic requirements, justifying the need for additional designs. Better characterization and mapping of the aortic arch branches will improve future device design and application.

Blunt Traumatic Aortic Injury: 10-Year Single-Center Experience

OBJECTIVE

 In blunt trauma patients, injury of the thoracic aorta is the second most common cause of death after head injury. In recent years, thoracic endovascular aortic repair (TEVAR) has largely replaced open repair as the primary treatment modality, and delayed repair of stable aortic injuries has been shown to improve mortality. In light of these major advancements, we present a 10-year institutional experience from a tertiary cardiovascular surgery center.

METHODS

 Records of patients who underwent endovascular or open repair of the ascending, arch or descending thoracic aorta between January 2009 and December 2018 were retrospectively analyzed. Patients without blunt traumatic etiology were excluded. Perioperative data were retrospectively collected from patient charts. Long-term follow-up was performed via data from follow-up visits and phone calls.

RESULTS

 A total of 1,667 patients underwent 1,740 thoracic aortic procedures (172 TEVAR and 1,568 open repair). There were 13 patients (12 males) with a diagnosis of blunt thoracic aortic injury. Mean patient age was 43.6 years (range, 16-80 years). Ten (77%) patients underwent TEVAR, two (15.4%) underwent open repair, and one (7.7%) was treated nonoperatively. Procedure-related stroke was observed in one (7.7%) case. Procedure-related paraplegia did not occur in any patients. Left subclavian artery origin was covered in seven patients. None developed arm ischemia. Hospital survivors were followed-up for an average of 60.2 months (range, 4-115 months) without any late mortality, endoleak, stent migration, arm ischemia, or reintervention.

CONCLUSION

 Blunt thoracic aortic injury is a rare but highly fatal condition. TEVAR offers good early and midterm results. Left subclavian artery coverage can be performed without major complications.

Reevaluating the Need for Routine Coverage of the Left Subclavian Artery in Thoracic Blunt Aortic Injury

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic blunt aortic injury (TBAI). A 20 mm proximal seal zone is recommended based on aneurysmal disease literature which often results in coverage of the left subclavian artery (LSA). The aim of this study was to analyze our experience with TEVAR for TBAI and evaluate whether 20 mm is required to achieve successful remodeling.

METHODS

This is a single-center, retrospective study of all consecutive patients who received a TEVAR for treatment of moderate and severe TBAI between April 2014 and November 2018. Three-dimensional software reconstruction was used for computed tomography (CT) scan centerline measurements. Outcomes included technical success, need for reinterventions, and immediate and long-term aortic-related complications.

RESULTS

Sixty-one patients underwent TEVAR for TBAI during the study period. Twenty-eight (46%) patients underwent LSA coverage with an average distance from the LSA to the injury of 6.4 mm (0-15.1 mm). Of the 33 (54%) patients who did not undergo coverage of the LSA, 22 patients (66%) had less than 20 mm of proximal seal zone. The mean distance from the LSA to injury in this group was 16.6 mm (7.9-29.5 mm). None of the patients with LSA coverage developed ischemic symptoms, and an average decrease in left arm systolic blood pressure of 24.8 mm Hg (0-62 mm Hg) was noted versus the right arm. There was no aortic-related mortality in either group. Follow-up CT scans revealed excellent remodeling.

CONCLUSIONS

Immediate outcomes of TEVAR for TBAI with LSA coverage are well tolerated; however, the long-term sequela of LSA coverage is unknown. Exclusion of the injury and excellent remodeling appear to occur with less than 20 mm of proximal seal, and perhaps more attention should be made to preservation of the LSA.

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management

Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ^©RSNA, 2020.

Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives.

EVIDENCE ACQUISITION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI.

EVIDENCE SYNTHESIS

Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases.

CONCLUSIONS

TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.

Clinical outcomes and quality of life in patients with acute and subacute type B aortic dissection after thoracic endovascular aortic repair

Objective

Thoracic endovascular aortic repair (TEVAR) is considered the mini-invasive treatment of choice for patients with Stanford type B aortic dissection (TBAD). This study aimed to investigate the clinical outcomes and quality of life (QoL) in patients with acute and subacute TBAD after TEVAR.

Methods

From January 2014 until July 2016, 22 acute patients (Group A) and 18 subacute patients received TEVAR (Group B), and 13 patients were managed non-operatively (Group C). The Medical Outcomes Study Short Form-36 was used to assess QoL preoperatively and after TEVAR. Operative techniques and complications were retrospectively analyzed.

Results

The role emotion, vitality, and mental health domains scored well preoperatively. Except for role emotion, vitality, and mental health, the remaining domains significantly improved after TEVAR. There was no significant difference in QoL metrics between Groups A and B. In Group C, bodily pain and social functioning domains were improved, and role emotion was decreased, with no improvement in the remaining domains. The 3-year survival rates were 95.5%, 100%, and 85.7% for Groups A, B, and C, respectively.

Conclusions

TEVAR may be safe and effective in patients with acute and subacute TBAD with similar and favorable clinical and QoL metrics.

New Preoperative Spinal Cord Ischemia Risk Stratification Model for Patients Undergoing Thoracic Endovascular Aortic Repair

PURPOSE

Our objective was to determine significant predictors of spinal cord ischemia (SCI) following Thoracic Endovascular Aortic Repair (TEVAR) and to further develop a simple and clinically orientated risk score model.

METHODS

A retrospective review of data from the Society of Vascular Surgery/Vascular Quality Initiative national data set was performed for all patients undergoing TEVAR from January, 2014 to June 2018. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. A SCI risk score was developed utilizing a multivariable logistic regression model.

RESULTS

For the 7889 patients in the final analysis who underwent TEVAR during the study period, the mean age was 67.6 ± 13.9, range 18 to 90 years, and the majority was male (65%). Postoperative outcomes included stroke (3.0%), myocardial infarction (2.9%), inhospital mortality (5.4%), transient SCI (1.5%), and permanent SCI (2.1%). Nearly half of the overall cases were performed in high volume centers. Predictors of increased risk for SCI included age by decade (odds ratio [OR]: 1.2), celiac coverage (OR: 1.5), current smoker (OR: 1.6), dialysis (OR: 1.9), 3 or more aortic implanted devices (OR: 1.7), emergent or urgent surgery (OR: 1.5), adjunct aorta-related procedure (OR: 2.5), adjunct not related (OR: 2.6), total estimated length of aortic device (19-31 cm, OR: 1.9 and ≥32 cm, OR: 3.0), ASA class 4 or 5 (OR: 1.6), and procedure time ≥154 minutes (OR: 1.8). Two predictors decreased the risk of SCI, cases from high-volume centers (OR: 0.6) and eGFR ≥ 60 (OR: 0.6). To evaluate the risk score model, probabilities of SCI from the original regression, raw score, and raw score categories resulted in area under the curve statistics of 0.792, 0.786, and 0.738, respectively.

CONCLUSIONS

Spinal cord ischemia remains one of the most feared complications of TEVAR. Incidence of SCI in this large series of patients with TEVAR was 3.6% with nearly 60% being permanent. The proposed model provides an assessment tool to guide clinical decisions, patient consent process, risk-assessment, and procedural strategy.

Clinical Outcomes of the Seal® Thoracic Stent Graft for Traumatic Aortic Injury in a Korean Multicenter Retrospective Study

BACKGROUND

Thoracic endovascular aneurysm repair (TEVAR) has been used as a primary treatment for blunt traumatic aortic injury (TAI). However, the outcomes of midterm surveillance of Seal® stent-graft durability for TAI have not been extensively studied. Thus, we aimed to report the midterm outcomes of TEVAR using the Seal® stent graft for blunt TAI.

METHODS

Patients with blunt TAI treated with TEVAR using the Seal® thoracic stent graft between 2007 and 2013 in Korea were included. Midterm outcomes included technical/clinical success, in-hospital death, aorta/procedure/device-related adverse events, secondary procedures, and 30-day and all-cause mortality.

RESULTS

A total of 99 patients (54% men; mean age, 48 years) were included. Grade III or higher injuries were present in 95% of patients, including 15 free ruptures of the thoracic aorta, and 64% of injuries were located in zone III. The median procedure and hospitalization duration were 90 min and 11 days, respectively. The technical success rate was 98%. The number of in-hospital mortalities (n = 8) and stroke (n = 2) were observed at 30 days. Late stroke and paraplegia (>30 days) were not observed during the mean 49 ± 26 months of follow-up (median, 48 months; range, 0-117 months). There were no aorta-related mortalities or conversions to open repair. Secondary procedures were performed in 8 patients, all of which were carotid-subclavian bypasses for delayed left subclavian occlusion. The all-cause mortality rate was 5% at 30 days and 8% at 1 year. The survival rate was 95% at 30 days, 92% at 1 year, 92% at 3 years, and 89% at 5 years. One type Ia endoleak occurred at 18 months after the procedure.

CONCLUSIONS

TEVAR with the Seal® stent graft for TAI showed favorable midterm outcomes. The incidence of major adverse events after the procedure was low.

Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience

OBJECTIVES

Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury.

METHODS

We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods.

RESULTS

Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively.

CONCLUSIONS

Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.

Mid-term outcomes of endovascular repair for traumatic thoracic aortic injury: a single-center experience

PURPOSE

Thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury (TTAI) reports short-term benefits. However, long-term durability and the need of reintervention remain unclear. Here, we determined mid-term outcome of TEVAR for TTAI and investigated the influence of the length of proximal landing zone on aorta.

METHODS

Between October 2009 and February 2018, 69 patients diagnosed TTAI and 42 included patients underwent TEVAR. Patients were divided into two groups by the length of proximal landing zone; ≤ 20 mm and > 20 mm. The primary endpoint was success and survival rate, and the secondary endpoint was the increase of aorta size and the need of reintervention.

RESULTS

The mean follow-up period was 47.9 ± 29.6 months and 100% success rate. No endoleaks or additional reinterventions during the follow-up period. The cumulative survival of all-cause death was 90.5 ± 2.3%, 85.7 ± 4.1% and 61.7 ± 8.4% at 1, 5 and 7 years, respectively. There was no statistically significant difference in the increase of aorta size due to the length of the proximal landing zone (p = 0.65).

CONCLUSION

In selective TTAI patients for TEVAR, the length of proximal landing zone did not considerably influence the aorta size or needed further reintervention.

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.

Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature

Objective:

To review the current use of endovascular techniques in trauma.

Summary Background Data:

Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma.

Methods:

The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines.

Results:

Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability.

Conclusions:

The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.

Implementation and results of a practical grading system for blunt thoracic aortic injury

OBJECTIVE

We previously proposed a grading system for blunt thoracic aortic injury (BTAI) designed to guide therapy. This study analyzed our outcomes since implementing this system.

METHODS

A single-center, retrospective study was conducted of consecutive patients presenting with BTAI between January 2014 and December 2017. This grading system classified injuries into minimal, moderate, or severe on the basis of computed tomography imaging. Primary end points included timing of operation and mortality. Secondary end points included associated injuries, aortic anatomy, and operative details as well as 30-day follow-up.

RESULTS

During the study period, 87 patients with BTAI were identified. The majority of patients had a moderate injury occurring just distal to the left subclavian artery (LSA); 59 patients underwent thoracic endovascular aortic repair (TEVAR), whereas none of the patients with minimal injury (n = 24) required surgical treatment. The mean time to repair was 53 hours (1-191 hours) for moderate injury and 3.6 hours (0-7 hours) for severe injury. The average diameter and length of the endograft was 26 mm and 112 cm, respectively, and the LSA was covered in 42% of patients. Intravascular ultrasound to confirm sizing was used in 83% of cases. Most patients (92%) received intravenous heparin during TEVAR; the remainder received only heparin sheath flush because of concern for intracranial hemorrhage. None of the patients underwent LSA revascularization or developed stroke or spinal cord ischemia as a result of the procedure. Operative complications were seen in 6% of patients and included 1 femoral pseudoaneurysm, 1 lower extremity compartment syndrome, 1 type II endoleak requiring LSA embolization, and 1 intracranial bleed. The 30-day mortality was 7% (one aorta-related death). On 30-day postoperative follow-up, computed tomography imaging uniformly revealed positive aortic remodeling, and no secondary aortic intervention was required.

CONCLUSIONS

Institutional implementation of our grading system has streamlined treatment of BTAI, and our results confirm the following: patients with minimal injury do not require surgical treatment; patients with moderate injury can safely undergo TEVAR in a semielective manner once they are stable from other injuries; and patients with severe injury require emergent repair. These procedures are expeditious and can be successfully performed percutaneously with a single endograft. Complications are rare, and follow-up reveals excellent remodeling of the aorta, likely resulting in lengthened interval surveillance requirements for these patients.

Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges

Blunt thoracic aortic injuries are rare occurrences but carry an increased risk of mortality. Over the last two decades, however, major advances in diagnostic imaging, staging, and treatment have significantly improved outcomes. Modern imaging paved the way for a new staging system based on the anatomical layers of the aortic wall. This staging system, in turn, allowed for refinement of treatment, which now includes nonoperative management with anti-impulse therapy, endovascular intervention, and, if needed, open surgical repair. As is the case with any other rapidly evolving therapy, however, new challenges and controversies arise. The resolution of these challenges will rely on a broad, international, and multidisciplinary effort. (This is a review article based on the invited lecture of the 46th Annual Meeting of Japanese Society for Vascular Surgery.)

Is endovascular repair the first choice for all blunt aortic injury? A real-world assessment

Blunt thoracic aortic injury (BTAI) represents an infrequently encountered but lethal traumatic injury. Minimal aortic injuries are appropriately treated by medical management, while more severe injuries require endovascular or open repair. Rapidly evolving endovascular technology has largely supplanted open repair as first line operative intervention, however, the complexity of the severely injured blunt trauma patient can complicate management decisions. The development and implementation of an optimal consensus grading system and treatment algorithm for the management of BTAI is necessary and will require multi-institutional study.

Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience

OBJECTIVES

Endovascular repair has been proposed as an alternative to classical surgical repair for the management of blunt traumatic thoracic aortic injury. However, the long-term outcomes of endovascular repair and the risks of left subclavian coverage remain unclear.

METHODS

From April 2001 to August 2018, 33 patients with blunt traumatic thoracic aortic injury underwent endovascular repair in our institution. A follow-up computed tomography and a clinical examination were performed before discharge and at 1 month, and yearly or every 2 years thereafter.

RESULTS

The mean age was 45 ± 19 years. The technical success rate was 100%. Complete coverage of the left subclavian artery (LSCA) was performed in 20 patients (60.6%). Among 20 patients with coverage of the LSCA, revascularization was performed in 1 patient. No in-hospital deaths occurred. The clinical follow-up rate was 97%, with a mean period of 7 years and a maximum of 18 years. The survival rates were 100% at 1 year, 95% at 5 years and 88.7% at 10 years after the event. Among the 5 patients (20%) who developed neurological complications, 1 who had undergone implantation of a 200-mm long stent graft and LSCA coverage without revascularization developed paraplegia during the long-term follow-up.

CONCLUSIONS

This study demonstrates that the endovascular treatment of blunt traumatic thoracic aortic injury is a safe and effective therapeutic method over a long-term follow-up period. LSCA coverage and long stent graft placement might be indications for revascularization to prevent spinal cord injury.

Management of the left subclavian artery during TEVAR - complications and mid-term follow-up

BACKGROUND

Numerous conditions that affect the boundary between the aortic arch and descending aorta are treated with thoracic endovascular aortic repair (TEVAR). In 40 % of cases, coverage of the left subclavian artery (LSA) cannot be prevented. Subsequently, neurological complications such as stroke or ischemia of the left upper extremity may develop. However, the actual risk of these complications is subject to considerable controversy. The optimal treatment approach, specifically the question whether primary revascularization of the LSA should be performed in all cases, is unclear.

PATIENTS AND METHODS

The present retrospective study analyzed the short- and mid-term results of patients treated with TEVAR with complete coverage of the LSA. The postoperative protocol consisted of clinical and noninvasive examinations as well as morphological imaging. Survival, complication, and reintervention rates were recorded.

RESULTS

A total of 40 patients, undergoing TEVAR with complete coverage of the LSA between January 2010 and December 2014 were analyzed retrospectively. The 30-day survival rate was 95 %, the survival one year after performed TEVAR was 67.5 %. The average follow-up was 1.5 years. After TEVAR procedure with complete coverage of the LSA, only one patient (2.5 %) developed critical ischemia of the left arm immediately after aortic stent implantation, requiring revascularization by transposition of the LSA. Anterior spinal artery syndrome occurred in another patient (2.5 %) immediately following TEVAR. During follow-up examinations, all patients showed a compensated arterial arm status. None of the patients developed new neurological deficits during the follow-up period.

CONCLUSIONS

The study shows that performing TEVAR without primary revascularization of the LSA was justifiable in our cohort. An important risk factor of developing cerebral ischemia seems to be insufficient collateralization through the circle of Willis.

A simple patient-tailored aortic arch tangential angle measuring method to achieve better clinical results for thoracic endovascular repair of type B aortic dissection

Background

To report a simple individual tailored aortic arch tangential angle (θ-AATA) measuring method and its clinical application efficacy in the endovascular treatment of type B aortic dissection (AD).

Methods

From January 2013 to December 2014, acute type B AD patients were prospectively enrolled and treated with endovascular therapy in our center. Among these patients, a specific method was applied to measure θ-AATA based on the axial images of the CT scan. The length of proximal landing zone (PLZ) of each patient was measured at the routinely applied left-anterior oblique (LAO) 45-degree and θ-AATA. Respective treatment strategies based on the length of the PLZ were planned accordingly, and the stent-graft was deployed under the fluoroscopy at θ-AATA. The occurrence of immediate type I endoleak was recorded during the completion angiogram, while the alignment of the proximal marks was determined under fluoroscopy at θ-AATA and at LAO-45-degree as well.

Results

Totally 76 patients with type B AD were prospectively enrolled. The average value of θ-AATA was 58.3±5.2 degrees, which was significantly larger than the routine 45 degrees (P<0.01). The mean landing zone length measured under θ-AATA (18.4±3.9 mm) was longer than that (15.9±3.1 mm) obtained at the routine LAO-45 degrees (P<0.05). Stent-grafts' deployment strategies were substantially changed accordingly. Alignment of the proximal marks was achieved in 72 patients (93.4%) under θ-AATA and only in two patients (2.7%) at LAO-45 degrees (P<0.01). All stent-grafts' implantation was successfully completed. No major type I endoleak was found in the immediate post-deployment angiography.

Conclusions

It is easy to apply this patient-tailored θ-AATA measuring method in clinical practice. This more precise measurement is benefit for more reasonable treatment strategy planning, more precise deployment, and therefore a better outcome.

Surgical Management of Vascular Trauma

Vascular injuries remain among the most challenging entities encountered in trauma care. Improvements in diagnostic capabilities, resuscitation approaches, vascular techniques, and prosthetic device options have afforded considerable advancement in the care of these patients. This evolution in care capabilities continues. Despite advances, uncontrolled hemorrhage due to major vascular injury remains one of the most common causes of death after trauma. Successful management of vascular injury requires the timely diagnosis and control of bleeding sources; to facilitate this task, trauma providers must appreciate the capabilities and limitations of diagnostic imaging modalities. Trauma providers must understand when and how to effectively apply these strategies.

Blunt Trauma of the Aorta, Current Guidelines

Blunt thoracic aortic injury remains a major cause of prehospital deaths. For patients who reach the hospital alive, diagnosis and management have undergone dramatic changes over the last 50 years. Computed tomography scanning is the imaging modality of choice for injury diagnosis and repair planning. Medical management with antihypertensives dramatically decreases the risk of rupture, allowing for delayed repair, while abnormal physiology and more immediately life-threatening injuries can be addressed. Endovascular techniques and endograft technology have reduced significantly the risks associated with repair. However, the incidence of late complications associated with the devices currently available is not known.

Revascularisation of the left subclavian artery for thoracic endovascular aortic repair

BACKGROUND

Controversy exists as to whether revascularisation of the left subclavian artery (LSA) confers improved outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR). Even though preemptive revascularisation of the LSA has theoretical advantages, including a reduced risk of ischaemic damage to vital organs, such as the brain and the spinal cord, it is not without risks. Current practice guidelines recommend routine revascularisation of the LSA in patients undergoing elective TEVAR where achievement of a proximal seal necessitates coverage of the LSA, and in patients who have an anatomy that compromises perfusion to critical organs. However, this recommendation was based on very low-quality evidence.

OBJECTIVES

To assess the comparative efficacy of routine LSA revascularisation versus either selective or no revascularisation in patients with descending thoracic aortic disease undergoing TEVAR with coverage of the LSA origin.

SEARCH METHODS

The Cochrane Vascular Trials Search Co-ordinator (TSC) searched the Specialised Register (June 2015). In addition, the TSC searched the Cochrane Register of Studies (CENTRAL (2015, Issue 5)).Trials databases were also searched (June 2015).

SELECTION CRITERIA

We had planned to consider all randomised controlled trials (RCTs) that compared routine revascularisation of the LSA with selective or no revascularisation, in patients undergoing TEVAR.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the title and abstract of articles identified through literature searches. An independent third review author was consulted in the event of disagreement. We had planned for two review authors to independently extract data and assess the risk of bias of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We did not identify any RCTs relevant to our review topic. Therefore, no quantitative analysis was conducted.

AUTHORS' CONCLUSIONS

High quality RCT evidence for or against routine or selective revascularisation of the LSA in TEVAR is not currently available. It is not possible to draw conclusions with regard to the optimal management of LSA coverage in TEVAR, and whether routine revascularisation, which was defined as the intervention of interest in our review, confers beneficial effects, as indicated by reduced mortality, cerebrovascular events, and spinal cord ischaemia. This review highlights the need for continued research to provide RCT evidence and define the role of LSA revascularisation in the context of TEVAR with coverage of the LSA.