Stent-graft repair of traumatic thoracic aortic disruptions

Eric D Wellons, Ross Milner, Maurice Solis, Adam Levitt, David Rosenthal
Journal of Vascular Surgery 2004, 40 (6): 1095-100

OBJECTIVE: Blunt traumatic thoracic aortic disruption results in pre-hospital death in 80% to 90% of patients. Because of the significant surgical morbidity and mortality associated with open operative repair, endovascular stent-graft repair has been investigated. The objective of this study was to evaluate the efficacy of thoracic aortic disruptions treated with commercially available proximal aortic extension cuffs.

METHODS: Nine patients with multiple system trauma (age range, 16-42 years) were seen after motor vehicle accidents between January 1, 2003, and April 1, 2004. Chest x-ray findings warranted thoracic computed tomography scans, which revealed disruptions of the thoracic aorta. Aortograms delineated the extent of the aortic injuries and identified a "landing zone" (neck length range, 1.5-2.0 cm) distal to the subclavian artery but proximal to the tear. The repairs were performed with AneuRx (n= 8) and Excluder (n = 1) proximal aortic extension cuffs. A left femoral artery approach was used in 6 patients, a suprainguinal retroperitoneal approach with an iliac conduit in 2 patients, and direct tunnel in 1 patient. An Amplatz super-stiff wire was placed in the right axillary artery to enable easy tracking of the endografts, and left brachial artery access was used for arch arteriography.

RESULTS: In each patient the stent-graft cuff was deployed adjacent to the left subclavian artery, with successful exclusion of traumatic disruptions verified at intraoperative arteriography and on computed tomographic scans obtained within 48 hours of initial repair. One patient required a second cuff for exclusion of a type I endoleak at the distal attachment site 1 month after the initial endograft repair. There were no procedure-related deaths; 1 patient, however, died of other injuries.

CONCLUSIONS: Stent-graft repair of traumatic thoracic aortic disruptions is technically feasible. Placement of a stiff wire in the right axillary artery and percutaneous left brachial artery access for arteriography are useful adjuncts during endograft deployment. Endovascular stent grafts may enable definitive repair or serve as a bridge until the patient is stable enough to undergo an operation, if necessary. This technique warrants further investigation.

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