Blunt traumatic aortic injury: initial experience with endovascular repair

Ali Azizzadeh, Kourosh Keyhani, Charles C Miller, Sheila M Coogan, Hazim J Safi, Anthony L Estrera
Journal of Vascular Surgery 2009, 49 (6): 1403-8

OBJECTIVES: Endovascular treatment of traumatic aortic injury (TAI) is an alternative to open repair (OR) in patients with blunt trauma. We report our initial experience after integration of endovascular repair using thoracic devices.

METHODS: A retrospective review of a prospectively collected institutional trauma registry was performed. Between September 2005 and November 2008, 71 patients with TAI presented to our institution. Based on imaging, TAIs were classified into grade 1-4 in severity. These included: grade 1, intimal tear; grade 2, intramural hematoma; grade 3, aortic pseudoaneurysm; and grade 4, free rupture. Initial management included resuscitation, blood pressure control, and treatment of associated injuries. After stabilization, all patients were considered for thoracic endovascular aortic repair (TEVAR) using a thoracic device. If contraindicated, candidates underwent OR. Outcome measures were mortality, stroke, paraplegia, intensive care unit (ICU), and hospital stay.

RESULTS: The mean age was 39.8 years, with 50 males. The mean injury severity score (ISS) was 42.6. Nineteen (27%) patients with a mean ISS of 60 died shortly after arrival prior to any vascular intervention. Ten (14%) patients with grade 1 injuries were managed medically. The remaining 42 (59%) patients with grade 2 and 3 injuries underwent repair. Median interval between admission and repair was 4.3 days (range, 0-109 days). Fifteen (21%) patients with a mean ISS of 34.4 underwent OR with no mortality, stroke, or paraplegia. Twenty-seven (38%) patients with a mean ISS of 36.7 underwent TEVAR with no mortality or paraplegia. One TEVAR patient suffered a perioperative stroke. Twenty-two patients had a TAG (W.L. Gore & Associates, Flagstaff, Ariz) device. Four patients had a Talent Thoracic (Medtronic Vascular, Santa Rosa, Calif), and 1 patient had an Excluder (W.L. Gore) device. The left subclavian artery was covered in 13 (48%) patients. Patients who underwent TEVAR were older than those who had OR (47.8 vs 31.1 years, P < .006). The aortic diameter proximal to the injury was larger in the TEVAR group (24.4 vs 19.6 mm, P < .0001). There was no difference in the mean ICU or hospital length of stay between the two groups. Mortality correlated with the ISS score (P < .0001). Median follow-up time was 19.4 months (range, 0-27). Only 56% of the TEVAR patients were fully compliant with their surveillance imaging protocol.

CONCLUSION: In this initial experience, the results of TEVAR did not differ from OR. Long-term follow-up is required to determine the effectiveness of this treatment strategy. Adherence to follow-up imaging protocols is challenging in this patient population. Next generation devices will make TEVAR applicable to a wider range of patients.

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