Endovascular Repair of Traumatic Isthmic Ruptures: Special Concerns

A rare case of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery: A case report and literature review

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Blunt thoracic aortic injuries are life threatening and require urgent intervention.

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Rare presentation of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery off the aortic arch distal to the takeoff of the left subclavian artery.

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An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR.

Introduction

Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy.

Presentation of case

A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent.

Discussion

BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks.

Conclusion

Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.

TEVAR for traumatic thoracic injury with the first-generation stent graft

Thoracic endovascular aortic repair (TEVAR) is a life-saving treatment for blunt thoracic aortic injury. We report long-term outcomes of two young patients who underwent TEVAR for blunt thoracic aortic injury with first-generation thoracic stent grafts. The off-label use of the endograft affected the outcomes: one case of open surgery conversion due to an aortoesophageal fistula and one case of endovascular relining for a voluminous pseudoaneurysm associated with a type III endoleak. Long-term follow-up is crucial in TEVAR, especially in case of a first-generation device used in an urgent setting.

Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy

PURPOSE

Blunt aortic injuries (BAI) have historically been considered an indication for emergent surgical intervention. Nevertheless, the observation that the outcome of the concomitant traumatic injuries has a major impact on prognosis and the rise of thoracic endovascular aortic repair (TEVAR) as an effective therapy for BAI have significantly changed in recent years the treatment algorithm of this condition. Our objective was to identify findings associated with the aortic injury which would be the best predictor of prognosis, with the objective of guiding the decision-making process for selecting the optimal timing of aortic repair.

METHODS

We reviewed blunt aortic injuries from 3 Level I Trauma Centers from July 2008 to December 2016. We analyzed overall and BAI-related 30-day mortality in relation to: hemodynamics, timing of treatment, TEVAR vs open repair, and aortic injury grade as defined by the Society for Vascular Surgery. Based on computed tomographic angiography (CT scan) imaging, we selected the radiologic aortic findings most indicative of high mortality risk, which we defined as "Radiographic Severe Injury" (RSI): (1) total/partial aortic transection, (2) active contrast extravasation, or (3) the association of 2 of more of the following: contained contrast extravasation > 10 mm, periaortic hematoma, and/or mediastinal hematoma with thickness > 10 mm, or significant left pleural effusion.

RESULTS

Of a total of 76 consecutive patients, 50 (66%) underwent immediate repair, 24 (31%) delayed aortic repair, and 2 (3%) died prior to repair. 58 patients (76%) had TEVAR, while 16 (24%) had open repair. Overall mortality was 18% and BAI-related mortality was 13%. In BAI-related mortalities, 70% of patients had RSI. Patients with high risk of overall mortality had hypotension and tachycardia (SBP < 100, HR ≥ 100), high ISS, and required vasopressors. Factors only associated with BAI-related mortality included RSI.

CONCLUSION

CT scan findings suggestive of RSI are predictive of mortality associated with BAI. Radiologic assessment of the severity of the aortic injury with characterization for the presence of RSI may represent the key factors to determine the optimal timing of treatment of the aortic injury and guide the overall treatment strategy.

LEVEL OF EVIDENCE

IV.

Multi-organ trauma with rupture and Stanford type B dissection of thoracic aorta. Management sequence. Current possibilities of medical treatment

A case of a 46-year-old car driver struck with great force by a tram through the driver's door is presented. The main trauma consisted in chest injury with multi-rib fracture along with rupture and dissection of the thoracic aorta. Immediate medical rescue actions consisted only in procedures necessary to support vital functions; the patient survived owing to being promptly transported to the Emergency Department to undergo thoracotomy and laparotomy with massive blood transfusion. Polytrauma angio-CT scan revealed a posttraumatic thoracic aorta lesion which in turn was treated by deployment of an endovascular thoracic stent graft. This way, the immediate risk of death was averted, and the remaining traumatic lesions and conditions could be treated. Patient was discharged to a Rehabilitation Center on the 49th day of treatment. The authors stress that trauma resulting from accidents with this particular mechanism, i.e. lateral car crash on the driver's side with the driver's door being staved in by the tram, should be managed by immediate transport of the patient to the Emergency Center. In such cases early drainage of the pleural cavity can deteriorate patient's status by increasing the bleeding from the ruptured aorta.

Successful phased approach to a patient with synchronous traumatic descending aortic pseudoaneurysm and bronchial rupture

A 34-year-old woman was referred to our center because of collapsed left lung and left main bronchial stenosis 1 week after a vehicular accident. Bronchoscopic observation revealed stenosis in the left main and lobar bronchus. Computed tomography (CT) angiography found traumatic descending aortic pseudoaneurysm after admission. Phased intervention strategy was adopted. The aortic rupture was repaired with endovascular stent firstly, followed by sleeve reconstruction of the left main bronchus through posterolateral thoracotomy 11 days later. She recovered uneventfully and resulted in an excellent long-term outcome. The diagnosis and treatment of this case is discussed.