Midterm results following endovascular repair of blunt thoracic aortic injuries

A Systematic Review on Thoracic Endovascular Repair Outcomes in Blunt Thoracic Aortic Injuries

PURPOSE

Blunt thoracic aortic injury (BTAI) represents a potentially life-threatening condition and thoracic endovascular aortic repair (TEVAR) is recommended as the first-line treatment (Class I level of evidence C) by the current guidelines. The aim of this systematic review was to determine the perioperative and mid-term follow-up outcomes of patients with BTAI treated with TEVAR.

MATERIALS AND METHODS

We reviewed the English literature published between 2000 and 2022, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until July 30, 2022. Observational studies and case series, with ≥5 patients, reporting on the perioperative and follow-up outcomes of patients who underwent TEVAR for BTAI were included. The Newcastle-Ottawa Scale was used to assess the risk of bias. Primary outcomes were technical success and 30-day mortality, cerebrovascular morbidity. Secondary outcomes were mortality and re-interventions during the mid-term follow-up.

RESULTS

From 5201 articles identified by the literature search, 35 eligible studies were included in this review. All studies had a retrospective study design. In total, 991 patients were included. The mean age was 34.5±16.5 years (range=16-89 years). Technical success was 98.0% (odds ratio [OR], 95% confidence interval [CI]=0.98, 0.99, p<0.001, I2=0%). Mortality at 30 days was 5.0% (OR, 95% CI=0.03, 0.06, p<0.001, I2=5.56%). Spinal cord ischemia occurred in 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and stroke rate was 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%). The available follow-up was estimated at 29 months (range=3-119 months) with mortality rate at 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and re-intervention rate at 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=10.5%).

CONCLUSION

Thoracic endovascular aortic repair showed high technical success and low early cerebrovascular morbidity and mortality rates. In the mid-term follow-up, the estimated mortality and re-intervention rates were also low. Furthermore, higher quality prospective studies are needed.

CLINICAL IMPACT

Thoracic endovascular aortic repair (TEVAR) is recommended as the first line treatement in patients with blunt thoracic aortic injuries (BTAI). This systematic review of 35 retrospective studies and 991 patients showed high technical success (98.0%) with an associated 30-day mortality at 5.0% and low spinal cord ischemia (1%) and stroke rates (2.0%). Mid-term mortality and re-intervention rates reassure the effectiveness of TEVAR in BTAI cases.

Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results

OBJECTIVE

This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up.

METHODS

During the study interval (November 2000-October 2020), a total of 38 patients (63% male; average age 37.5 years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter.

RESULTS

Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft's diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up.

CONCLUSIONS

Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.

[Diagnostics and treatment of traumatic aortic injuries]

Hintergrund

Traumatische Aortenverletzungen (TAV) sind seltene Folgen von stumpfen Traumata, die eine hohe Mortalität und Morbidität aufweisen. Die schnelle und akkurate Diagnostik sowie die Wahl der korrekten Therapie sind für das Patientenüberleben elementar.

Fragestellung

Bestimmung des aktuellen Standards der Abklärung von TAV im akuten Trauma-Setting und Evaluation der aktuellen Leitlinien zur Therapie.

Material und Methode

Eine Literaturrecherche wurde durchgeführt, mit der Suche nach Publikationen, die die Abklärung und Diagnostik der TAV beschreiben. Außerdem wurden Leitlinien für die Behandlung und Nachsorge von TAV zusammengefasst.

Ergebnisse

In der Literatur wird trotz geringer Spezifität eine konventionelle Thoraxröntgenaufnahme als Initialdiagnostik genannt. Es sollte primär, als Modalität der Wahl, zur Diagnostik und zur Therapiestratifizierung eine Computertomographie (CT) aufgrund der hohen Sensitivität und Spezifität nachfolgen. In allen Leitlinien ist die thorakale endovaskuläre Aortenrekonstruktion („thoracic endovascular aortic repair“, TEVAR) die Therapie der Wahl bei höhergradigen TAV (Grade II–IV) und hat die offene Chirurgie in dem meisten Fällen abgelöst.

Schlussfolgerung

Nach einer kurzfristig erfolgten CT-Diagnostik und Einteilung wird die TEVAR der offenen Chirurgie bei therapiebedürftigen TAV vorgezogen.

Spectrum of multi-detector computed tomography imaging findings of thoracic vascular injuries secondary to blunt chest trauma: Correlation with vascular intervention and patient outcomes

Background

Thoracic vascular injuries following blunt chest trauma are the second leading cause of trauma-related deaths. Multi-detector computed tomography (MDCT) is the imaging modality of choice in detecting these injuries.

Objectives

To determine the spectrum of vascular injuries detected on MDCT imaging in patients who sustained blunt chest trauma, and to assess the various types of management options and patient outcomes.

Method

We retrospectively reviewed archived medical records of polytrauma patients who presented with blunt chest trauma and confirmed vascular injury on MDCT and vascular intervention images between May 2015 and August 2018 at Inkosi Albert Luthuli Central Hospital.

Results

Thirty-nine patients with vascular injury findings were analysed. The injury spectrum comprised: 15 aortic injuries (AI), 19 non-aortic injuries (NAI), 4 combined (AI and NAI) and 1 aorto-venous injury. A majority of males (69%) with an overall mean age of 39 years constituted the study cohort. The commonest injury mechanisms included motor vehicle collisions (61%) and pedestrian accidents (28%); the remaining 11% were shared amongst motorbike accidents or falling from a moving train or a height. The subclavian artery (36%) was the most common anatomical location in the NAI and the frequent imaging finding was vessel occlusion (55%). The most common imaging findings in AI were the indirect signs (20.5%) followed by a grade III injury (15.4%). Six patients with a grade III AI were successfully managed with endovascular repair.

Conclusion

A thorough knowledge of blunt vascular injury spectrums and imaging manifestations is critical when interpreting MDCT scans. Awareness of the mechanism of injury will trigger a high index of suspicion and probe a search for a vascular injury.

Endovascular management of penetrating and non-penetrating aortic injury

Aortic trauma is a devastating injury often associated with significant polytrauma. Penetrating injury of the aorta is highly lethal and therefore rarely encountered in the hospital setting. The management of blunt trauma of the aorta has changed significantly over the past decade, principally due to improved imaging technology and the development of endovascular therapy. The most common site of injury is the proximal descending thoracic aorta. The degree of aortic wall injury guides the indication for therapy, while a combination of the degree of injury and the extent of co-morbid injuries drives the timing of repair. Lower grade injuries frequently do not require any surgical intervention. Thoracic aortic endograft repair can be performed in a safe, expeditious fashion. Short-term and mid-term outcomes appear excellent, with patient survival based mainly on concomitant traumatic injuries. Long-term outcomes are less well known. Future endeavors will be guided toward gaining a better understanding of the indications for repair and the long-term outcomes for endograft devices designed for this purpose.

The Evaluation of Aortic Diameter Changes During Long-Term Follow-Up After Endovascular Treatment of Acute Blunt Traumatic Thoracic Aortic Injuries

Purpose:

To evaluate the variations in aortic diameters and long-term results in patients who underwent thoracic endovascular aortic repair (TEVAR) for acute blunt traumatic thoracic aortic injuries (BTTAIs).

Materials and Methods:

We retrospectively evaluated 23 patients with a mean age of 39 years (range: 17-74 years) who underwent TEVAR for BTTAI between October 2000 and November 2014. All of the patients underwent computed tomography angiography (CTA) before hospital discharge as a baseline imaging for the subsequent follow-up examinations. The technical success, overall survival, and complications were evaluated. Furthermore, the aortic diameters outside of the stent-graft (1 cm proximal and 1 cm distal to the stent-graft) and the aortic diameters within the stent-graft (2 cm distal to the proximal end and 2 cm proximal to the distal end) were assessed. The diameters at baseline on CTA were compared with those of the latest available follow-up examination.

Results:

Technical success was 100% with a mean follow-up of 65.4 months (range: 12-171 months). No death was registered, and 2 (8.7%) of 23 endograft-related complications (1 stent-graft distal infolding and 1 endoleak 2 and 4 months after the procedure, respectively) were observed. An increase in aortic diameter either proximal or distal to the stent-graft (mean value 0.7 and 0.5 mm, respectively) or within the stent-graft (mean value of 0.5 mm for both proximal and distal diameters) was registered (mean follow-up at 65.4 months, range: 12-171 months).

Conclusion:

Aortic dilatation following TEVAR for BTTAI is minimal during long-term follow-up. Endovascular treatment represents a durable and safe option in acute BTTAIs.

Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis

INTRODUCTION

To provide an overview of the experience of endovascular treatment for traumatic thoracic aortic lesions (TTAL). Thoracic aortic injury secondary to high-energy chest trauma constitutes an emergency situation with potentially devastating outcome. In the present time, the majority of patients are treated with thoracic endovascular aortic repair. The aim of this study was to provide a systematic overview of endovascular aortic repair in patients with TTAL with special attention to perioperative mortality, paraplegia, stroke, influence of left subclavian artery (LSA) coverage herein, and long-term stent-related complications.

EVIDENCE ACQUISITION

PubMed and Embase were searched for studies describing endovascular treatment of TTAL in the period between January 1st, 2000 and January 30th, 2016. The methodological quality of articles was assessed using the MINORS score and PRISMA guidelines. Data on early mortality, perioperative complications, and long-term stent-related complications were extracted.

EVIDENCE SYNTHESIS

A total of 2005 reports were screened, and 74 publications were finally included in the analysis describing treatment of 1882 patients. Early mortality rate, paraplegia rate, and stroke rate were 7.5%, 0.4%, and 1.5%, respectively. LSA coverage did not increase the risk of stroke. The severity of injuries had a positive association on early mortality. Late stent related mortality and morbidity were uncommon.

CONCLUSIONS

TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications but is associated with a moderate risk of left arm ischemia. Long-term stent-related complications are rare, but the available data is limited.

[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.