Endovascular Repair of Traumatic Aortic Injury Using a Modified, Commercially Available Endograft to Preserve Aortic Arch Branches Hidetake Kawajiri, Katsuhiko Oka, Osamu Sakai, Taiji Watanabe, Keiichi Kanda, and Hitoshi Yaku, Kyoto, Japan
A 25-year-old woman was admitted to our hospital after being involved in a high-speed motorcycle accident. Computed tomography angiography revealed a blunt traumatic aortic injury of the lesser curvature of the distal aortic arch accompanied by splintered fractures of the seventh thoracic vertebra and left clavicle. If the pseudoaneurysm had been treated with open surgical repair, then arch replacement under cardiopulmonary bypass, which was considered to be too invasive, would have been necessary. Therefore, thoracic endovascular aortic repair (TEVAR) was preferred as a first-line treatment to prevent pulmonary complications and hemorrhaging. Because the proximal landing zone for TEVAR was insufficient, we used a modified (fenestrated) commercially available endograft to preserve the branches of the aortic arch. Postoperative computed tomography scans confirmed that the pseudoaneurysm had been excluded without the endoleaks, and the aortic arch branches were patent. The patient’s postoperative course was uneventful, and she was discharged from the hospital to have surgery for a vertebral fracture on postoperative day 6.
Blunt traumatic aortic injury (BTAI) is commonly associated with multiple organ injuries, and only a few patients who suffer such injuries are able to undergo aortic surgery in stable condition. Thoracic endovascular aortic repair (TEVAR) has been used as an alternative treatment for BTAI since the mid2000s and has shown improved postoperative outcomes compared to open surgical repair.1e3 However, because most BTAIs occur in the isthmus
of the thoracic aorta, the management of aortic arch branches is the most important issue when performing TEVAR in this patient population. We report the successful endovascular treatment of a BTAI in a young patient. In this case, we used a fenestrated commercially available endograft to preserve the blood flow of the aortic arch branches.
CASE REPORT
Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan. Correspondence to: Hidetake Kawajiri, MD, Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 KajiiCho, Kawaramachi-Hirokoji, Kyoto 602-8566, Japan; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1032.e11–1032.e15 http://dx.doi.org/10.1016/j.avsg.2013.07.024 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 28, 2013; manuscript accepted: July 1, 2013; published online: November 4, 2013.
A 25-year-old woman was admitted to our hospital after being involved in a high-speed motorcycle accident. A computed tomography (CT) scan revealed a blunt aortic injury (pseudoaneurysm; type III aortic injury, according to the classification developed by the Society for Vascular Surgery) in the lesser curvature of the thoracic aortic arch (Fig. 1A, B). In addition, the patient had a left pulmonary contusion, hemothorax, and a fracture of the left clavicle. The patient was hemodynamically stable on arrival, and her preoperative mean blood pressure was strictly controlled at 80 mm Hg via the intravenous infusion of calcium channel blockers to reduce the risk of the 1032.e11
1032.e12 Case reports
Annals of Vascular Surgery
Fig. 1. (A) Computed tomography angiography revealing a pseudoaneurysm in the distal aortic arch (arrow). (B) Axial view of the aortic arch indicating a type III aortic injury (pseudoaneurysm; surrounded by arrows). (C, D) A jagged piece of the fractured seventh thoracic
vertebra (arrow) was located on the dorsal side of the descending aorta. The vertebral arch and bodies had been severely damaged, and the spinal cord had almost been severed. Asc. Ao, Ascending aorta; desc. ao, descending aorta; LA, left atrium.
aneurysm rupture. On admission, she was in a state of paraplegia because of a severe spinal cord injury associated with a splintered fracture of the seventh thoracic vertebra. Regarding the options for surgical repair, arch replacement is the standard treatment for such cases; however, because our patient was suffering from hemothorax and a left pulmonary contusion, open surgical repair involving hypothermic circulatory arrest was considered to be too invasive. In addition, the pseudoaneurysm was located in the lesser curvature of the aortic arch, so we considered that we would be able to exclude it sufficiently with a fenestrated TEVAR, even though this would represent off-label use. We carefully followed-up the pseudoaneurysm by obtaining CT scans on days 2 and 9 after the accident and found that it had not regressed; therefore, we decided to perform TEVAR on day 12 after the accident. Because a jagged piece of the fractured seventh vertebra was located on the dorsal side of the descending aorta (Fig. 1C, D), we determined that the distal landing zone of the endograft should be located at the level of the eighth vertebra to avoid moving the vertebral fragment, which might have resulted in an injury to the descending aorta during the subsequent spinal surgery. We planned to treat the patient with 2 TX2 endografts (Cook Medical, Bloomington, IN), including a modified (fenestrated) endograft that would be used to treat the
aortic arch. The diameter of the aortic lumen was 21 mm in the region proximal to the left subclavian artery and 19 mm in the middle of the descending thoracic aorta. The pseudoaneurysm was located 15 mm distal from the takeoff of the left carotid artery along the lesser curvature of the vessel and 24 mm distal from the takeoff of the left carotid artery along its greater curvature. The patient was placed in a supine position because of her vertebral fracture. Under general anesthesia, the femoral artery and vein were exposed on the right side. A 4-French pigtail catheter was inserted into the ascending aorta through the right radial artery to allow angiography to be performed. The fenestrated TX2 endograft (TX-28-147-ZT) was prepared during the operation. The endograft was partially deployed on the table, and the fenestration was created using a battery powered handheld cauterizer. A platinum radiopaque marker (Fig. 2A) was placed on the distal edge of the fenestration. Once the modification had been completed, the endograft was placed into the outer sheath of the delivery system. A Lunderquist guidewire (Cook Medical) was inserted into the ascending aorta through the right femoral artery, and a temporary pacing catheter (Edwards Lifesciences, Irvine, CA) was inserted into the right ventricle via the right femoral vein to induce rapid pacing. Next, we inserted a TX2 endograft (TX26-134-ZT; Cook Medical) to cover the region from the proximal to middle
Vol. 28, No. 4, May 2014
Case reports 1032.e13
Fig. 2. (A) Fenestration (10 mm in width 30 mm in length) was created on the dorsal side of the TX2 endograft (Cook Medical, Bloomington, IN) and a radiopaque marker was placed on the distal rim of the fenestration
(arrow). (B) Intraoperative image of the fenestrated endograft, just before deployment. Black arrow showing the leading edge, and white arrow showing the radiopaque marker located on the origin of the left subclavian artery.
descending aorta. Then, we inserted the fenestrated TX2 endograft (TX28-147-ZT) into the aortic arch (Fig. 2B). To ensure accurate positioning of the endograft and prevent the stiff dilator tip of the sheath introducer injuring the aortic valve, a Lunderquist guidewire was carefully inserted into the left ventricle. A radiopaque marker was placed just distal to the left subclavian artery, and then we began endograft deployment. Rapid right ventricular pacing (180 bp/min) was also performed to reduce the patient’s cardiac output during the endograft deployment. A postdeployment angiogram revealed complete exclusion of the aneurysm without any endoleaks and confirmed the preservation of all 3 aortic arch branches. The patient was extubated in the operating room, and there were no signs of cerebral infarction. A CT scan performed on postoperative day 3 revealed complete coverage of the pseudoaneurysm with no evidence of endoleaks or endograft migration (Fig. 3). The descending thoracic aorta had also been successfully covered to the level of eighth thoracic vertebra. On postoperative day 6, the patient was transferred to another institution to have surgery for her vertebral fracture.
does not require thoracotomy, single-lung ventilation, or cardiopulmonary bypass, has been used as an alternative treatment for BTAI and has shown excellent early and midterm outcomes compared to conventional aortic surgery.1,2,7,8 However, the optimal treatment for injuries to the region from the distal aortic arch to the descending aorta, which is the most common site of BTAI, remains controversial. The best treatment might depend on anatomic features, such as the origins of the arch branches, the curvature of the distal arch, and the location of the injury. In the present case, a pseudoaneurysm was detected in the middle of the lesser curvature of the distal aortic arch, which is on the opposite side of the arch branches; therefore, we considered that we would be able to achieve sufficient exclusion of the aneurysm by fenestrated TEVAR even though the proximal landing zone was 10 mm shorter than recommended. The optimal strategy for managing the left subclavian artery in urgent TEVAR is still disputed. Guidelines published in 20099 suggest that the method used to revascularize the left subclavian artery should be chosen on an individual basis depending on patient anatomy, the urgency of the case, and the availability of surgical expertise (grade 2, level C). In the present case, coverage of the left subclavian artery was considered as a possible treatment strategy to secure the longer proximal landing zone in this region. However, maintaining arm blood flow was also recognized as important for this young patient. Because peripheral bypass (i.e., subclavianesubclavian or carotidesubclavian bypass) was not possible because the patient had a left clavicular fracture and severe dislocation, we
DISCUSSION BTAI is the second most common cause of death after blunt trauma. Although improvements in the primary evaluation and treatment of trauma have decreased the mortality and morbidity rates associated with aortic injuries, their prognosis remains poor. In fact, Parmley et al.4 reported that only 15% of patients with BTAIs reached the emergency room alive. Conventional open repair of a BTAI is associated with mortality rates of up to 35e45% and high rates of morbidity, including stroke, spinal cord ischemia, and fatal hemorrhage.5,6 Accordingly, TEVAR, which
1032.e14 Case reports
Annals of Vascular Surgery
Fig. 3. (A) Postoperative computed tomography scan showing the successful coverage of the pseudoaneurysm and (B) a 3-dimensional computed tomography scan
showing the well preserved aortic arch branches. BCA, Brachiocephalic artery; LCCA, left common carotid artery; LSCA, left subclavian artery.
decided to revascularize the left subclavian artery by creating a fenestration in the endograft. There are several issues that must be considered when applying TEVAR to young patients. First, young patients that have traumatic injuries display significantly smaller aortic diameters than patients with degenerative aortic aneurysms, which can lead to excessively large endografts (i.e., endografts with diameters that are >20% larger than the diameter of the native aorta) being employed and stent fracturing. Second, the radius of the curvature of the aortic arch is much smaller in young patients, resulting in the endograft displaying poor conformability to the lesser curvature of the arch after implantation, which is often called the ‘‘bird beak phenomenon.’’ Next-generation devices must confront these issues by increasing graft conformability and softening the inner cannula of the deployment system. The treatment of BTAIs using handmade fenestrated endografts have been reported since the mid-2000s and have largely led to fine early outcomes.10,11 The long-term results of handmade endografts, however, have not been satisfactory in our experience because of stent fracture and deformity. We believe that modified, commercially available endografts exceed handmade endografts in sturdiness and convenience. There are 2 reports about the modification of thoracic endografts in order to treat traumatic aortic injuries. One author used a custom fenestrated endograft to preserve the left subclavian artery,12 which was similar to our procedure, and the other performed laserassisted in situ fenestration of the endograft combined with endovascular reconstruction of the left subclavian artery.13 Both cases led to good postoperative courses with no evidence of endoleak. In the present case, the TX2 endograft was considered to be ideal for modification for 2
reasons. First, the TX2 endograft is made of a woven polyester, and it is easy to create fenestrations using electric graft cutters. In addition, the system used to deploy the TX2 is not complicated, and it appears that it is much easier to partially deploy and restore the endograft than other devices. The ideal timing of aortic repair has also been discussed in previous studies. The Eastern Association for the Surgery of Trauma practice workgroup recommended delayed open surgery for indicated cases in 2000.14 They reported that because of blood pressure and anti-impulse management with betablockers, none of the BTAIs that they encountered ruptured preoperatively. Estrera et al.15 reported that the mean interval from admission to surgery was significantly longer in TEVAR (335.6 ± 488.0 hrs) than for open repair with distal aortic perfusion (47.1 ± 129.8 hrs). They also found that TEVAR produced good postoperative outcomes, which confirms the significance of managing potentially fatal nonaortic complications. In our case, we spent 288 hours observing the patient’s associated organ injuries and carefully followed the patient up with CT scans and maintained strict blood pressure control. Currently, earlier TEVAR intervention is recommended to perform surgery for associated organ injuries; a paradigm shift to early invention might occur in the management of BTAI in the near future. In conclusion, the endovascular repair of BTAI is an alternative first-line approach to open surgery in some cases, but the management of aortic arch branches remains an issue. For patients with suitable anatomies and clinical circumstances, fenestrated TEVAR might be a suitable treatment option. Commercially available branched thoracic endografts will play an important role in the treatment of BTAIs in the next decade. However,
Vol. 28, No. 4, May 2014
long-term follow up is required to determine the effectiveness of this treatment. REFERENCES 1. Tang GL, Tehrani HY, Usman A, et al. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. J Vasc Surg 2008;47: 671e5. 2. Xenos ES, Abedi NN, Davenport DL, et al. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008;48:1343e51. 3. Cook J, Salerno C, Krishnadasan B, et al. The effect of changing presentation and management on the outcome of blunt rupture of the thoracic aorta. J Thorac Cardiovasc Surg 2006;131:594e600. 4. Parmley LF, Mattingly TW, Manion WC, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17: 1086e101. 5. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: multi- center trial of the American Association for the Surgery of Trauma. J Trauma 1997;42:374e83. 6. Cowley RA, Turney SZ, Hankins JR, et al. Rupture of the thoracic aorta caused by blunt trauma: a fifteen-year experience. J Thorac Cardiovasc Surg 1990;100:652e61. 7. Alsac JM, Boura B, Desgranges P, et al. Immediate endovascular repair for acute traumatic injuries of the thoracic aorta:
Case reports 1032.e15
8.
9.
10. 11.
12.
13.
14.
15.
a multicenter analysis of 28 cases. J Vasc Surg 2008;48: 1369e74. Doss M, Balzer J, Martens S, et al. Surgical versus endovascular treatment of acute thoracic aortic rupture: a singlecenter experience. Ann Thorac Surg 2003;76:1465e70. Matsumura JS, Lee WA, Mitchell RS, et al. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg 2009;50:1155e8. Kato M, Yatsu S, Sato H, et al. Endovascular stent-graft treatment for blunt aortic injury. Circ J 2004;68:553e7. Kurimoto Y, Asai Y, Nara S, et al. Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury. J Trauma 2009;66:974e8. Gilani R, Ochoa L, Wall MJ Jr, et al. Endovascular repair of traumatic aortic injury using a custom fenestrated endograft to preserve the left subclavian artery. Vasc Endovasc Surg 2011;45:549e52. Murphy EH, Dimaio MJ, Dean W, et al. Endovascular repair of acute traumatic thoracic aortic transection with laserassisted in-situ fenestration of a stent-graft covering the left subclavian artery. J Endovasc Ther 2009;16:457e63. Nagy K, Fabian T, Rodman G, et al. Guidelines for the diagnosis and management of blunt aortic injury: an EAST Practice Management Guidelines Work Group. J Trauma 2000;48:1128e43. Estrera AL, Gochnour DC, Azzizadeh MD, et al. Progress in the treatment of blunt aortic injury: 12-year single institution experience. Ann Thorac Surg 2010;90:64e71.
A 25-year-old woman was admitted to our hospital after being involved in a high-speed motorcycle accident. Computed tomography angiography revealed a blunt traumatic aortic injury of the lesser curvature of the distal aortic arch accompanied by splintered fractures of the seventh thoracic vertebra and left clavicle. If the pseudoaneurysm had been treated with open surgical repair, then arch replacement under cardiopulmonary bypass, which was considered to be too invasive, would have been necessary. Therefore, thoracic endovascular aortic repair (TEVAR) was preferred as a first-line treatment to prevent pulmonary complications and hemorrhaging. Because the proximal landing zone for TEVAR was insufficient, we used a modified (fenestrated) commercially available endograft to preserve the branches of the aortic arch. Postoperative computed tomography scans confirmed that the pseudoaneurysm had been excluded without the endoleaks, and the aortic arch branches were patent. The patient’s postoperative course was uneventful, and she was discharged from the hospital to have surgery for a vertebral fracture on postoperative day 6.
Blunt traumatic aortic injury (BTAI) is commonly associated with multiple organ injuries, and only a few patients who suffer such injuries are able to undergo aortic surgery in stable condition. Thoracic endovascular aortic repair (TEVAR) has been used as an alternative treatment for BTAI since the mid2000s and has shown improved postoperative outcomes compared to open surgical repair.1e3 However, because most BTAIs occur in the isthmus
of the thoracic aorta, the management of aortic arch branches is the most important issue when performing TEVAR in this patient population. We report the successful endovascular treatment of a BTAI in a young patient. In this case, we used a fenestrated commercially available endograft to preserve the blood flow of the aortic arch branches.
CASE REPORT
Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan. Correspondence to: Hidetake Kawajiri, MD, Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 KajiiCho, Kawaramachi-Hirokoji, Kyoto 602-8566, Japan; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1032.e11–1032.e15 http://dx.doi.org/10.1016/j.avsg.2013.07.024 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 28, 2013; manuscript accepted: July 1, 2013; published online: November 4, 2013.
A 25-year-old woman was admitted to our hospital after being involved in a high-speed motorcycle accident. A computed tomography (CT) scan revealed a blunt aortic injury (pseudoaneurysm; type III aortic injury, according to the classification developed by the Society for Vascular Surgery) in the lesser curvature of the thoracic aortic arch (Fig. 1A, B). In addition, the patient had a left pulmonary contusion, hemothorax, and a fracture of the left clavicle. The patient was hemodynamically stable on arrival, and her preoperative mean blood pressure was strictly controlled at 80 mm Hg via the intravenous infusion of calcium channel blockers to reduce the risk of the 1032.e11
1032.e12 Case reports
Annals of Vascular Surgery
Fig. 1. (A) Computed tomography angiography revealing a pseudoaneurysm in the distal aortic arch (arrow). (B) Axial view of the aortic arch indicating a type III aortic injury (pseudoaneurysm; surrounded by arrows). (C, D) A jagged piece of the fractured seventh thoracic
vertebra (arrow) was located on the dorsal side of the descending aorta. The vertebral arch and bodies had been severely damaged, and the spinal cord had almost been severed. Asc. Ao, Ascending aorta; desc. ao, descending aorta; LA, left atrium.
aneurysm rupture. On admission, she was in a state of paraplegia because of a severe spinal cord injury associated with a splintered fracture of the seventh thoracic vertebra. Regarding the options for surgical repair, arch replacement is the standard treatment for such cases; however, because our patient was suffering from hemothorax and a left pulmonary contusion, open surgical repair involving hypothermic circulatory arrest was considered to be too invasive. In addition, the pseudoaneurysm was located in the lesser curvature of the aortic arch, so we considered that we would be able to exclude it sufficiently with a fenestrated TEVAR, even though this would represent off-label use. We carefully followed-up the pseudoaneurysm by obtaining CT scans on days 2 and 9 after the accident and found that it had not regressed; therefore, we decided to perform TEVAR on day 12 after the accident. Because a jagged piece of the fractured seventh vertebra was located on the dorsal side of the descending aorta (Fig. 1C, D), we determined that the distal landing zone of the endograft should be located at the level of the eighth vertebra to avoid moving the vertebral fragment, which might have resulted in an injury to the descending aorta during the subsequent spinal surgery. We planned to treat the patient with 2 TX2 endografts (Cook Medical, Bloomington, IN), including a modified (fenestrated) endograft that would be used to treat the
aortic arch. The diameter of the aortic lumen was 21 mm in the region proximal to the left subclavian artery and 19 mm in the middle of the descending thoracic aorta. The pseudoaneurysm was located 15 mm distal from the takeoff of the left carotid artery along the lesser curvature of the vessel and 24 mm distal from the takeoff of the left carotid artery along its greater curvature. The patient was placed in a supine position because of her vertebral fracture. Under general anesthesia, the femoral artery and vein were exposed on the right side. A 4-French pigtail catheter was inserted into the ascending aorta through the right radial artery to allow angiography to be performed. The fenestrated TX2 endograft (TX-28-147-ZT) was prepared during the operation. The endograft was partially deployed on the table, and the fenestration was created using a battery powered handheld cauterizer. A platinum radiopaque marker (Fig. 2A) was placed on the distal edge of the fenestration. Once the modification had been completed, the endograft was placed into the outer sheath of the delivery system. A Lunderquist guidewire (Cook Medical) was inserted into the ascending aorta through the right femoral artery, and a temporary pacing catheter (Edwards Lifesciences, Irvine, CA) was inserted into the right ventricle via the right femoral vein to induce rapid pacing. Next, we inserted a TX2 endograft (TX26-134-ZT; Cook Medical) to cover the region from the proximal to middle
Vol. 28, No. 4, May 2014
Case reports 1032.e13
Fig. 2. (A) Fenestration (10 mm in width 30 mm in length) was created on the dorsal side of the TX2 endograft (Cook Medical, Bloomington, IN) and a radiopaque marker was placed on the distal rim of the fenestration
(arrow). (B) Intraoperative image of the fenestrated endograft, just before deployment. Black arrow showing the leading edge, and white arrow showing the radiopaque marker located on the origin of the left subclavian artery.
descending aorta. Then, we inserted the fenestrated TX2 endograft (TX28-147-ZT) into the aortic arch (Fig. 2B). To ensure accurate positioning of the endograft and prevent the stiff dilator tip of the sheath introducer injuring the aortic valve, a Lunderquist guidewire was carefully inserted into the left ventricle. A radiopaque marker was placed just distal to the left subclavian artery, and then we began endograft deployment. Rapid right ventricular pacing (180 bp/min) was also performed to reduce the patient’s cardiac output during the endograft deployment. A postdeployment angiogram revealed complete exclusion of the aneurysm without any endoleaks and confirmed the preservation of all 3 aortic arch branches. The patient was extubated in the operating room, and there were no signs of cerebral infarction. A CT scan performed on postoperative day 3 revealed complete coverage of the pseudoaneurysm with no evidence of endoleaks or endograft migration (Fig. 3). The descending thoracic aorta had also been successfully covered to the level of eighth thoracic vertebra. On postoperative day 6, the patient was transferred to another institution to have surgery for her vertebral fracture.
does not require thoracotomy, single-lung ventilation, or cardiopulmonary bypass, has been used as an alternative treatment for BTAI and has shown excellent early and midterm outcomes compared to conventional aortic surgery.1,2,7,8 However, the optimal treatment for injuries to the region from the distal aortic arch to the descending aorta, which is the most common site of BTAI, remains controversial. The best treatment might depend on anatomic features, such as the origins of the arch branches, the curvature of the distal arch, and the location of the injury. In the present case, a pseudoaneurysm was detected in the middle of the lesser curvature of the distal aortic arch, which is on the opposite side of the arch branches; therefore, we considered that we would be able to achieve sufficient exclusion of the aneurysm by fenestrated TEVAR even though the proximal landing zone was 10 mm shorter than recommended. The optimal strategy for managing the left subclavian artery in urgent TEVAR is still disputed. Guidelines published in 20099 suggest that the method used to revascularize the left subclavian artery should be chosen on an individual basis depending on patient anatomy, the urgency of the case, and the availability of surgical expertise (grade 2, level C). In the present case, coverage of the left subclavian artery was considered as a possible treatment strategy to secure the longer proximal landing zone in this region. However, maintaining arm blood flow was also recognized as important for this young patient. Because peripheral bypass (i.e., subclavianesubclavian or carotidesubclavian bypass) was not possible because the patient had a left clavicular fracture and severe dislocation, we
DISCUSSION BTAI is the second most common cause of death after blunt trauma. Although improvements in the primary evaluation and treatment of trauma have decreased the mortality and morbidity rates associated with aortic injuries, their prognosis remains poor. In fact, Parmley et al.4 reported that only 15% of patients with BTAIs reached the emergency room alive. Conventional open repair of a BTAI is associated with mortality rates of up to 35e45% and high rates of morbidity, including stroke, spinal cord ischemia, and fatal hemorrhage.5,6 Accordingly, TEVAR, which
1032.e14 Case reports
Annals of Vascular Surgery
Fig. 3. (A) Postoperative computed tomography scan showing the successful coverage of the pseudoaneurysm and (B) a 3-dimensional computed tomography scan
showing the well preserved aortic arch branches. BCA, Brachiocephalic artery; LCCA, left common carotid artery; LSCA, left subclavian artery.
decided to revascularize the left subclavian artery by creating a fenestration in the endograft. There are several issues that must be considered when applying TEVAR to young patients. First, young patients that have traumatic injuries display significantly smaller aortic diameters than patients with degenerative aortic aneurysms, which can lead to excessively large endografts (i.e., endografts with diameters that are >20% larger than the diameter of the native aorta) being employed and stent fracturing. Second, the radius of the curvature of the aortic arch is much smaller in young patients, resulting in the endograft displaying poor conformability to the lesser curvature of the arch after implantation, which is often called the ‘‘bird beak phenomenon.’’ Next-generation devices must confront these issues by increasing graft conformability and softening the inner cannula of the deployment system. The treatment of BTAIs using handmade fenestrated endografts have been reported since the mid-2000s and have largely led to fine early outcomes.10,11 The long-term results of handmade endografts, however, have not been satisfactory in our experience because of stent fracture and deformity. We believe that modified, commercially available endografts exceed handmade endografts in sturdiness and convenience. There are 2 reports about the modification of thoracic endografts in order to treat traumatic aortic injuries. One author used a custom fenestrated endograft to preserve the left subclavian artery,12 which was similar to our procedure, and the other performed laserassisted in situ fenestration of the endograft combined with endovascular reconstruction of the left subclavian artery.13 Both cases led to good postoperative courses with no evidence of endoleak. In the present case, the TX2 endograft was considered to be ideal for modification for 2
reasons. First, the TX2 endograft is made of a woven polyester, and it is easy to create fenestrations using electric graft cutters. In addition, the system used to deploy the TX2 is not complicated, and it appears that it is much easier to partially deploy and restore the endograft than other devices. The ideal timing of aortic repair has also been discussed in previous studies. The Eastern Association for the Surgery of Trauma practice workgroup recommended delayed open surgery for indicated cases in 2000.14 They reported that because of blood pressure and anti-impulse management with betablockers, none of the BTAIs that they encountered ruptured preoperatively. Estrera et al.15 reported that the mean interval from admission to surgery was significantly longer in TEVAR (335.6 ± 488.0 hrs) than for open repair with distal aortic perfusion (47.1 ± 129.8 hrs). They also found that TEVAR produced good postoperative outcomes, which confirms the significance of managing potentially fatal nonaortic complications. In our case, we spent 288 hours observing the patient’s associated organ injuries and carefully followed the patient up with CT scans and maintained strict blood pressure control. Currently, earlier TEVAR intervention is recommended to perform surgery for associated organ injuries; a paradigm shift to early invention might occur in the management of BTAI in the near future. In conclusion, the endovascular repair of BTAI is an alternative first-line approach to open surgery in some cases, but the management of aortic arch branches remains an issue. For patients with suitable anatomies and clinical circumstances, fenestrated TEVAR might be a suitable treatment option. Commercially available branched thoracic endografts will play an important role in the treatment of BTAIs in the next decade. However,
Vol. 28, No. 4, May 2014
long-term follow up is required to determine the effectiveness of this treatment. REFERENCES 1. Tang GL, Tehrani HY, Usman A, et al. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. J Vasc Surg 2008;47: 671e5. 2. Xenos ES, Abedi NN, Davenport DL, et al. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008;48:1343e51. 3. Cook J, Salerno C, Krishnadasan B, et al. The effect of changing presentation and management on the outcome of blunt rupture of the thoracic aorta. J Thorac Cardiovasc Surg 2006;131:594e600. 4. Parmley LF, Mattingly TW, Manion WC, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17: 1086e101. 5. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: multi- center trial of the American Association for the Surgery of Trauma. J Trauma 1997;42:374e83. 6. Cowley RA, Turney SZ, Hankins JR, et al. Rupture of the thoracic aorta caused by blunt trauma: a fifteen-year experience. J Thorac Cardiovasc Surg 1990;100:652e61. 7. Alsac JM, Boura B, Desgranges P, et al. Immediate endovascular repair for acute traumatic injuries of the thoracic aorta:
Case reports 1032.e15
8.
9.
10. 11.
12.
13.
14.
15.
a multicenter analysis of 28 cases. J Vasc Surg 2008;48: 1369e74. Doss M, Balzer J, Martens S, et al. Surgical versus endovascular treatment of acute thoracic aortic rupture: a singlecenter experience. Ann Thorac Surg 2003;76:1465e70. Matsumura JS, Lee WA, Mitchell RS, et al. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg 2009;50:1155e8. Kato M, Yatsu S, Sato H, et al. Endovascular stent-graft treatment for blunt aortic injury. Circ J 2004;68:553e7. Kurimoto Y, Asai Y, Nara S, et al. Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury. J Trauma 2009;66:974e8. Gilani R, Ochoa L, Wall MJ Jr, et al. Endovascular repair of traumatic aortic injury using a custom fenestrated endograft to preserve the left subclavian artery. Vasc Endovasc Surg 2011;45:549e52. Murphy EH, Dimaio MJ, Dean W, et al. Endovascular repair of acute traumatic thoracic aortic transection with laserassisted in-situ fenestration of a stent-graft covering the left subclavian artery. J Endovasc Ther 2009;16:457e63. Nagy K, Fabian T, Rodman G, et al. Guidelines for the diagnosis and management of blunt aortic injury: an EAST Practice Management Guidelines Work Group. J Trauma 2000;48:1128e43. Estrera AL, Gochnour DC, Azzizadeh MD, et al. Progress in the treatment of blunt aortic injury: 12-year single institution experience. Ann Thorac Surg 2010;90:64e71.
