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

Blunt Thoracic Aortic Injury

Blunt thoracic aortic injury (BTAI) is a potentially fatal condition that needs prompt recognition and expedited management. Clinical manifestations of BTAI are not straight forwarding and may be misdiagnosed. The grade of aortic injury is an important determinant of perioperative mortality and morbidity, as well as the indication of treatment, along with the presence of concomitant lesions of other involved organs. The mainstay of treatment nowadays for hemodynamically stable patients who survive the trauma scene is represented by delayed endovascular repair whenever anatomically and clinically feasible. Endovascular repair, in fact, is burdened by lower perioperative mortality and morbidity rates if compared to open surgical repair, but concerns remain about the need for long-term surveillance and radiation exposure in patients who are at a younger age than patients treated for the aneurysmal disease. The aim of the paper is to provide an update on the diagnostic modalities and strategies of treatment for patients affected by BTAI.

Undersized Stentgraft Placement for Traumatic Descending Aorta Rupture, and What Is Next?

BACKGROUND Traumatic injury of the thoracic aorta is proving to be not only the most lethal of traumatic injuries, but also the most urgent reason for vascular intervention among all trauma patients. Endovascular aortic repair is used increasingly often to treat traumatic injuries. We report a case of endovascular treatment and its use as a delayed correction (two-stage treatment) for a traumatic aortic isthmus rupture. CASE REPORT A 20-year-old Asian male was admitted to our department after a car accident presenting symptoms of ischemic shock. Among multiple injuries, a traumatic descending aorta rupture was diagnosed. The patient was referred directly to the operating room for a thoracic endovascular aortic repair (TEVAR). The patient's other trauma-related injuries required additional interventions in the following days. Thirty days after the emergent TEVAR operation, the patient required reintervention due to a major type-I endoleak. Computed tomography angiography revealed a failed stentgraft deployment. We removed the mismatched endovascular equipment and deployed an appropriately sized stentgraft during a hybrid procedure, excluding the ruptured aortic wall altogether. CONCLUSIONS Endovascular treatment of both children and small-framed adults remains a challenge for operating teams. First, no dedicated equipment can be found on the market. Second, measuring and fitting endovascular equipment constitutes a sore point in treatment, so in emergency situations, only off-the-shelf tools are accessible. We assert that, in such cases, the primary procedure should be understood as a lifesaving intervention, awaiting a final and long-lasting solution.

Delayed Aortic Stent Collapse in Blunt Traumatic Aortic Injury Repair

Background  Endovascular stent grafting has emerged as an option to treat traumatic aorta injuries with reported significantly low mortality and morbidity. Stent collapse is one of the complications that can occur in this type of treatment. The aim of this article is to analyze the expected cause of stent collapse and to draw attention to the importance of the surveillance follow-up, as this phenomenon may occur late postdeployment.

Methods  A retrospectively collected dataset from the two highest volume trauma centers in Saudi Arabia was analyzed between April 2007 and October 2012. A total of 66 patients received stent grafts for traumatic aortic injury and were included in the study. We apply Ishimaru's anatomical aortic arch zones and Benjamin's aortic injury grading systems. There were 35 patients with aortic injury at zone 2, 26 patients in zone 3, and 5 patients in zone 4. About 96% (63) of the injuries were grades 2 and 3, including large intimal flap or aortic wall pseudoaneurysm with change in wall contour. The technical success rate, as defined by complete exclusion of lesions without leaks, stroke, arm ischemia or stent-related complications, was 90%.

Results  Proximal stent collapse occurred in 4.5% of patients (3 of 66 inserted stents) during follow-up of 4 to 8 years (mean, 6 years). Patients with stent collapse tended to have an acute aortic arch angle with long-intraluminal stent lip, when compared with patients with noncollapsed stents. Intraluminal lip protrusion more than 10-mm increased collapse ( p  < 0.001). Stent-grafts sizes larger than 28 mm also demonstrated a higher collapse rate ( p  < 0.001).

Conclusions  The risk of stent collapse appears related to poor apposition of the stent due to severe aortic arch angulation in young patients and to large stent sizes (>28 mm). Such age groups may have more anatomical and aortic size changes during the growth. Clinical and radiological surveillance is essential in follow-up after stent-graft treatment for traumatic aortic injury.

Thoracoabdominal aortic aneurysm repair: current endovascular perspectives

Thoracoabdominal aneurysms account for roughly 3% of identified aneurysms annually in the United States. Advancements in endovascular techniques and devices have broadened their application to these complex surgical problems. This paper will focus on the current state of endovascular thoracoabdominal aneurysm repair, including specific considerations in patient selection, operative planning, and perioperative complications. Both total endovascular and hybrid options will be considered.