Endovascular repair of traumatic thoracic aortic disruptions with "stacked" abdominal endograft extension cuffs

David Rosenthal, Eric D Wellons, Allison B Burkett, Paul V Kochupura, Susan M Hancock
Journal of Vascular Surgery 2008, 48 (4): 841-4

OBJECTIVE: Endovascular stent graft repair of a traumatic thoracic aortic disruption (TTAD) is rapidly becoming an accepted alternative to open surgical repair. The use of currently approved thoracic stent grafts especially in younger patients with small, "steep," tapered aortas, remains a concern due to the acute thoracic endograft collapse and enfolding. The objective of this study, the largest report to date, was to evaluate the mid-term results of TTAD treated with abdominal aortic "stacked" extension cuffs, with follow-up extending to 41 months.

METHODS: Thirty-one patients with multi-system trauma (age range, 15 to 61; mean 31.4 years) were seen after motor vehicle accidents between January 1, 2003 and July 1, 2007. Chest x-ray findings warranted thoracic CT scans, which revealed disruptions of the thoracic aorta. Intra-operative arteriograms in all patients and intravascular ultrasound (IVUS) (n = 17) delineated the extent of the aortic injuries. The aortic length from the subclavian artery to the injury averaged 2.5 cm (range, 1.5 to 4.0 cm). The repairs were performed with Gore (W.L. Gore & Associates, Flagstaff, Ariz) (n = 15), Aneuryx (Medtronic, Santa Rosa, Calif) (n = 15), and Zenith (Cook, Inc., Bloomington, Ind) (n = 1) Aortic Extension Cuffs. A femoral artery approach was used in 27 patients and a supra-inguinal retroperitoneal iliac approach in four. All patients underwent thoracic CT scans during follow-up.

RESULTS: In all patients, the stent-graft cuffs successfully excluded the TTAD: 21 patients had 2 cuffs, 9 had 3 cuffs, and 1 had 4 cuffs. The aorta adjacent to the injury mean diameter was 18.5 mm (range, 17-24 mm). No subclavian arteries were covered. Two patients required an additional cuff for exclusion of the Type I endoleaks at the distal attachment site within 6 weeks of initial endograft repair. There were no procedure-related deaths; 2 patients died of other injuries. At follow-up, extending to 41 months (range, 3 to 41 months), two pseudo-aneurysms occurred which required open operative repair: 1 due to infection (4 months) and a leaking pseudoaneurysm (14 months). A CT scan in all other survivors demonstrated no device-related complications, endoleaks, or cuff migrations.

CONCLUSION: Stent-graft repair of TTAD is technically feasible. The technique of "stacked" aortic cuffs provides an acceptable option when urgent therapy is needed, when patients are deemed high-risk for open operative repair, or until thoracic endografts are designed which can safely treat focal, smaller aortic diameter injuries.

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