Endovascular Repair Blunt Thoracic Aortic Injury in Adolescent: A Case Series.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is a rare occurrence in adolescents, yet it is associated with a high mortality rate necessitating immediate treatment. Although endovascular repair has become the preferred treatment for such injuries in adults, its effectiveness in adolescents remains uncertain. CASE SUMMARY: Blunt traumatic aortic injury typically presents with concomitant injuries to other organs and carries a high perioperative mortality rate with operative repair (OR). In this report, we describe the treatment of 3 clinical cases of BTAI in adolescents using thoracic endovascular aortic repair (TEVAR). These cases contribute pertinent evidence supporting the efficacy of intravascular repair for BTAI. CONCLUSION: Operative repair (OR) remains the gold standard for treating BTAI in adolescents. Nevertheless, TEVAR therapy presents a viable alternative for patients with multiple injuries in whom anticoagulation is contraindicated. Further long-term observation is necessary to assess the lasting effects of TEVAR therapy. CLINICAL IMPACT: This study has provided insights into endovascular repair for adolescent BTAT, offering clinicians significant reference material for choosing treatment strategies for adolescent BTAT. The study aims to demonstrate the safety and effectiveness of endovascular repair treatments in a series of clinical cases involving adolescent BTAI.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Double Fenestrated Physician-Modified Stent Graft for Endovascular Treatment of Traumatic Aortic Isthmus Rupture With an Aberrant Right Subclavian Artery.

PURPOSE: The purpose of the study was to demonstrate the feasibility of urgent endovascular treatment of a traumatic aortic isthmus rupture in a patient with an aberrant right subclavian artery. CASE REPORT: A 23-year-old man was admitted to a regional trauma center after a motor vehicle collision and found to have cerebral trauma and a large pseudoaneurysm of the aortic arch. Trauma computed tomography (CT) identified a blunt traumatic thoracic aortic injury with an aortic false aneurysm in the context of an aberrant right subclavian artery. A hybrid repair was performed with bilateral subclavian carotid bypasses and a double fenestrated physician-modified stent graft. The patient had an uneventful postoperative course. Postoperative CT scan showed sealing of the aortic arch rupture and patency of all the supra-aortic trunks. CONCLUSION: Endovascular repair of blunt traumatic thoracic aortic injury is considered first-line therapy. Aortic arch anomalies add complexity to treatment. This report demonstrates that a hybrid strategy with bilateral carotid-axillary bypasses and homemade double fenestrated endograft of the aortic arch is a valuable approach for this challenging emergency in the context of an aberrant right subclavian artery.

Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is an effective treatment of blunt thoracic aortic injury (BTAI). However, the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications. METHODS: The Vascular Quality Initiative registry was queried from 2013 to 2019 to identify patients who had undergone TEVAR for BTAI with or without the administration of intraoperative heparin. Univariate analyses were performed with the Student t test, Fisher exact test, or χ2 test, as appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality. RESULTS: A total of 655 patients were included, of whom most had presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) of ≥15 (70.2% vs 90.5%; P < .0001) or major head or neck injury (39.6% vs 62.9%; P < .0001). Patients receiving heparin also had a lower incidence of inpatient death (5.1% vs 12.9%; P < .01). Across all injury grades, heparin use was not associated with the need for intraoperative transfusion or postoperative transfusion or the development of hematoma. In patients with grade III BTAI, the nonuse of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%; P < .05). On multivariable logistic regression analysis for inpatient mortality, intraoperative heparin use (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11-0.86; P < .05) and female gender (OR, 0.11; 95% CI, 0.11-0.86; P < .05) were associated with better survival, even after controlling for head and neck trauma and injury grade. In contrast, increased age (OR, 1.06; 95% CI, 1.03-1.1; P < .001), postoperative transfusion (OR, 1.06; 95% CI, 1.02-1.11; P < .01), higher ISS (OR, 1.04; 95% CI, 1.01-1.07; P < .05), postoperative dysrhythmia (OR, 4.48; 95% CI, 1.10-18.18; P < .05), and postoperative stroke or transient ischemic attack (OR, 5.54; 95% CI, 1.11-27.67; P < .05) were associated with increased odds of inpatient mortality. CONCLUSIONS: Intraoperative heparin use was associated with reduced inpatient mortality for patients undergoing TEVAR for BTAI, including those with major head or neck trauma and high ISSs. Heparin use did not increase the risk of hemorrhagic complications across all injury grades. Also, in patients with grade III BTAI, heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI and should be administered when no specific contraindication exists.

Combined fenestrated/chimney thoracic endovascular repair for the treatment of blunt traumatic aortic injury: A case report.

Blunt traumatic thoracic aortic injury (BTAI) is an extremely serious medical condition with a high rate of associated mortality. Recent advances in techniques such as thoracic endovascular repair offer new opportunities to manage the critical BTAI patients in an efficacious yet less invasive manner. A 65 year-old-male suffered from multiple injuries after a fall, including BTAI in the aortic arch, which resulted in dissection of the descending thoracic-abdominal aorta and iliac artery, development of an intimal flap in the left common carotid artery, and dissection of the left subclavian artery. Based on the imaging information of this patient and our clinical experience, the combined treatment of fenestrated thoracic endovascular repair and a chimney technique was immediately planned to fully repair these dissections and moreover prevent further dissection of the branching vessels, additionally to ensure sufficient blood flow in the left subclavian artery and left common carotid artery. The intervention yielded satisfactory early outcomes. Follow-up assessment at six months reported no symptoms or complications associated with the stent-graft. Computed tomography angiography further confirmed adequate stent-graft coverage of the aortic injury.

Urgent retrograde two-stage hybrid repair of a complicated blunt traumatic aortic injury.

Blunt traumatic aortic injury (BTAI) is a rare but life-threatening emergency that is usually caused by sudden acceleration/deceleration injuries in vehicular accidents. We describe our initial experience of a retrograde two-stage hybrid treatment approach for the emergent management of a 63-year-old motorcyclist who presented with a complicated BTAI with malperfusion syndrome. To our best knowledge, this uncommon BTAI case with fatal distal malperfusion saved by an urgent retrograde two-stage hybrid procedure has been reported rarely. This early reperfusion strategy with two-stage retrograde endovascular technique could be an effective and life-saving treatment option for polytrauma patients with suitable aortic anatomy.

Blunt aortic injury: risk factors and impact of surgical approaches.

PURPOSE: This study reviews our 17-year experience of managing blunt traumatic aortic injury (BTAI). METHODS: We analyzed information collected retrospectively from a tertiary trauma center. RESULTS: Between October 1995 and June 2012, 88 patients (74 male and 14 female) with a mean age of 39.9 ± 17.9 years (range 15-79 years) with proven BTAI were enrolled in this study. Their GCS, ISS, and RTS scores were 12.9 ± 3.7, 29.2 ± 9.8, and 6.9 ± 1.4, respectively. Twenty-one (23.8 %) patients were managed non-operatively, 49 (55.7 %) with open surgical repair, and 18 (20.5 %) with endovascular repair. The in-hospital mortality rate was 17.1 % (15/81) and there were no deaths in the endovascular repair group. The mean follow-up period was 39.9 ± 44.2 months. The survivors of blunt aortic injury had lower ISS, RTS, TRISS, and serum creatinine level and lower rate of massive blood transfusion, shock, and intubation than the patients who died, despite higher rates of endovascular repair, hemoglobin, and GCS on presentation. The degree of aortic injury, different therapeutic options, GCS, shock presentation, and intubation on arrival all had significant impacts on outcome. CONCLUSIONS: Shock, aortic injury severity, coexisting trauma severity, and different surgical approaches impact survival. Endovascular repair achieves a superior mid-term result and is a reasonable option for treating BTAI.

Predictive factors for size change of aorta in patients with acute blunt traumatic aortic injury.

OBJECTIVE: We aimed to investigate the changes in aorta size, the factors affecting size changes in patients with acute blunt traumatic aortic injury and to evaluate the adequacy of the current 120% thoracic endovascular aortic repair graft oversizing policy. DESIGN AND METHODS: This retrospective review study was conducted using the prospectively collected medical records of 45 patients (mean age: 53.5 years, male: 39 patients) with blunt traumatic aortic injury treated at a level 1 trauma center between 2012 and 2021. Aortic diameter was measured by computed tomography angiographic images at four different levels [ascending aorta (A), isthmus (B), descending thoracic aorta (C), and infrarenal aorta (D)] on arrival and follow-up (median time interval, 13 days). Associated factors including patient characteristics and hemodynamic parameters on arrival and follow-up were collected to determine their influence on changes in the aorta. RESULTS: The mean diameter of all four aortic levels increased on follow-up computed tomography compared to initial computed tomography (A: + 11.77%, B: + 10.19%, C: + 7.71%, D: + 12.04%). Patient age and injury severity score influenced changes in the diameter of the ascending aorta (P < 0.05). Patient age and blunt traumatic aortic injury grade were significantly associated with changes in the infrarenal aortic diameter (P < 0.05). Three cases of type 1 endoleak were observed at follow-up but all were spontaneously resolved without further intervention at next computed tomography follow-up. CONCLUSIONS: In patients with acute blunt traumatic aortic injury, aortic diameter is significantly smaller by about 10% under shock and is not considered a basis for oversizing the currently implemented 120% thoracic endovascular aortic repair graft sizing. However, in young patients under the age of 40, the change is significantly large and subsequent computed tomography follow-up is required.

Focal Aortic Dissection With Significant Stenosis: A Rare Long Term Complication After TEVAR for Blunt Traumatic Aortic Injury in an Adolescent Patient.

Background: Thoracic endovascular aortic repair (TEVAR) in children and adolescents after blunt traumatic aortic injury (BTAI) is being performed increasingly despite no endovascular graft being approved for TEVAR in this population. The smaller diameter of the aorta and access vessels and steeper angle of the aortic arch pose specific challenges for TEVAR in this population. Moreover, data are lacking regarding medium to long term complications. This case presents an adolescent patient who underwent TEVAR for BTAI and suffered a focal aortic dissection several months later. Report: The patient initially presented after a motor vehicle accident and underwent an uncomplicated TEVAR procedure with a 28 mm diameter stent graft (the smallest device available at the time) for Grade III traumatic aortic dissection; the native aortic diameter was 15 mm. The diameter mismatch was accepted due to the lifesaving nature of the procedure. More than 7 months later the patient presented to the emergency department after not being able to urinate for several days and experiencing pain, tingling, and weakness in both legs. Blood samples showed a severe acute kidney injury and computed tomography angiography showed significant aortic stenosis in the distal part of the stent graft, probably caused by a focal dissection. The stenosis and dissection were successfully treated using a Palmaz stent, after which his renal function and extremity complaints recovered. Conclusion: The focal dissection was probably caused by stress on the aortic wall due to the aorta-stent graft diameter mismatch. This case demonstrates that complications after TEVAR in adolescents can arise months after the initial procedure and underscores the need for continued vigilance, especially in cases with an aorta-stent graft mismatch. The threshold for additional imaging and consultation by a vascular surgeon should be low.

Gore cTAG sleeve-associated maldeployment for traumatic aortic injury with aberrant right subclavian artery.

A 30-year-old woman presented following a motor vehicle collision with a grade III blunt thoracic aortic injury and an aberrant right subclavian artery. Using intraoperative ultrasound and diagnostic subtraction angiography, we deployed an aortic endograft (cTAG; W.L. Gore & Associates), excluding the injury and aberrant right subclavian artery. The patient immediately lost arterial waveforms in her left arm, confirming incidental coverage of the left subclavian artery, likely due to the polytetrafluoroethylene sheath of the endograft. Her pulses returned after placement of a left subclavian chimney via retrograde brachial artery access.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Uncontrollable Bleeding Managed by Thoracic Gauze Packing in Blunt Traumatic Aortic Injury.

Blunt traumatic aortic injury is a deadly phenomenon in traumatic injuries. Damage control is essential in the management of traumatic patients. We reported a 20-years-old man brought to the trauma center from a car turnover crash scene. Blunt traumatic aortic injury grade III was revealed by contrast-enhanced computed tomography requiring urgent intervention. After an uneventful open repair of the aorta with Dacron graft, diffuse blood oozing occurred from the mediastinum and left pleural cavity. We packed the thoracic bleeding sites and removed the packings after four days. The patient developed no signs of cardiopulmonary compromise until the removal of the packings. Later, the patient was discharged with no complications. Through the follow-ups, he had no complaint regarding the surgery. The patient has a normal chest x-ray one year later. Thoracic gauze packing is limitedly practiced due to concerns for cardiopulmonary compromises. To the best of our knowledge, this is the first time that this technique has been performed in the open repair of blunt traumatic thoracic aortic injury as damage control.

The Role of Surgical and Endovascular Repair of Blunt Traumatic Aortic Injury in the Modern Era: A Single-Center Experience.

Objective: To evaluate the efficacy of chest x-ray (CXR) in blunt traumatic aortic injury (BTAI) as a primary imaging tool in trauma patients. Methods: We retrospectively reviewed our hospital records for blunt thoracic aortic injury patients who had a therapeutic intervention from January 2015 to February 2021. Patients' characteristics, initial chest x-rays, and computed tomography (CT) scan were extracted and re-evaluated. Results: Eighteen patients matched the criteria of our research. The mean age and the injury severity score (ISS) was 29.8±11.2 and 38.4±14.4, respectively. Seven patients (38.9%) underwent thoracic endovascular aortic repair (TEVAR), and 11 (61.1%) had open surgery. The TEVAR group had significantly lower mean intensive care unit stay days (6.6±3.9 vs. 10.8±6.9 in open aortic repair (OAR), p<0.05). The percentile of patients requiring blood transfusion was significantly lower in the TEVAR group (57% vs. 100% in OAR, p<0.05). Mediastinal widening (66.7%) was the most common finding during the evaluation of initial chest x-rays. Interestingly, 22.2% of the initial x-rays were not remarkable for BTAI. Conclusion: TEVAR is an advantageous choice in the management of BTAI. However, open aortic repair is the optimal decision in certain situations. It is suggested that the Interventional management of the BTAI must be performed by experienced vascular surgeons in a medical center capable of both OAR and TEVAR.

Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life.

PURPOSE: Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL). METHODS: Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population. RESULTS: Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01). CONCLUSION: This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Grade four blunt traumatic aortic injury with massive haemothorax: Resuscitation considerations during the primary survey.

Advanced Trauma Life Support principles prioritise the management of 'breathing' over 'circulation' in an acute trauma primary survey. In a tamponaded thoracic aortic rupture, however, this may lead to fatal haemorrhagic shock. In this case, we discuss the resuscitation and management of a patient with a massive left sided haemothorax secondary to a grade four blunt traumatic aortic injury. A 26-year-old male was involved in a high-speed motor vehicle crash and was hypoxic and hypotensive at the scene. His oxygenation and haemodynamics improved with supplemental oxygen and fluid resuscitation. He had a left intercostal catheter inserted after an urgent thoracic endovascular aortic repair was performed to prevent disruption of the contained haemothorax in the presence of a grade four thoracic aortic injury. It is vital to recognise the potential disruption of a tamponaded blunt traumatic aortic injury during consideration of thoracostomy and chest drain decompression.

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.

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients.

INTRODUCTION: Blunt thoracic aortic injury (BTAI) is rare in elderly patients. As the population ages and life expectancy increases, the frequency of this injury will increase, while the treatment and outcomes remain unclear. METHODS: We retrospectively analyzed the collected data of patients >60 years old with BTAI to investigate the mechanism of trauma; time interval from injury to diagnosis; type and timing of surgical intervention; aortic arch pattern; choice of left subclavian artery reconstruction; endograft to treat BTAI; length of the endovascular procedure; endoleaks; complications including stroke, paraplegia, and renal failure; length of hospital stay (LOS) and intensive care unit stay (L.ICUS); and 30-day mortality. RESULTS: Five elderly trauma patients were found to have BTAI. Four (80%) were males, the cohort mean age was 68 years, the major mechanism of trauma was fall injury, and the associated injury was thoracic trauma. All patients were transferred to our hospital, and emergency computed tomography angiography showed BTAI in each patient. The average time interval from injury to diagnosis was 2.7 days. Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair, while 3 patients underwent delayed endovascular repair. The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery; the aortic arch pattern was II (80.0%) in 4 cases and III in 1 case (20.0%). The choice of left subclavian artery reconstruction included chimney, double chimney, prefenestration, and chimney combined with in situ fenestration. Endografts to treat BTAI included the Ankura (Lifetech Scientific, Shenzhen, China) and the C-TAG (W.L. Gore & Associates, Flagstaff, AZ USA).The length of the endovascular procedure was 75.4 min; there were no endoleaks and no complications including stroke, paraplegia, or renal failure. The average LOS was 25 days, and the average L.ICUS of 2 patients was 15 days, with no 30-day mortality. CONCLUSION: Elderly patients with fall injury should promptly exclude BTAI. Thoracic endovascular aortic repair (TEVAR) with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications. Because of the low incidence of this type of injury, we are unable to provide any evidence to guide the treatment option for this life-threatening condition.

Efficacy and safety of TEVAR with debranching technique for blunt traumatic aortic injury in patients with severe multiple trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) patients are severely ill, with high mortality and morbidity. As 60% of BTAIs occur in the distal arch, left subclavian artery (LSCA) management is determined without knowing posterior cerebral or left arm circulation in emergent cases. Because we perform thoracic endovascular aortic repair (TEVAR) + debranching technique for thoracic BTAI, we assessed efficacy and safety of debranching TEVAR in BTAI patients. METHODS: We retrospectively reviewed vital signs on arrival, injury mechanism, characteristics, clinical time-series, concomitant injuries, injury description, operative procedures, and results from patient records. We excluded patients in cardiopulmonary arrest on arrival. RESULTS: From April 2014 to December 2018, nine of 25 patients admitted with BTAI underwent TEVAR. Median Injury Severity Score was 34 (29-34) and probability of survival was 0.82 (0.16-0.94). Society for Vascular Surgery BTAI injury grade was III or IV in all patients. Three patients underwent simple TEVAR and six underwent debranching TEVAR (LSCA occlusion + left common carotid artery to LSCA bypass). Median operation time was 108 (75-157) min for simple TEVAR and 177 (112-218) min for debranching TEVAR. Concomitant injuries included intracranial hemorrhage (N = 1), intra-abdominal injuries (N = 3), pneumo- or hemothoraxes (N = 4) and pelvic/extremities fractures (N = 7). Only one complication of left-hand claudication occurred postoperatively in a patient with simple TEVAR with LSCA occlusion. CONCLUSION: Despite debranching TEVAR taking approximately 60 min longer than simple TEVAR, short-term results indicated it to be acceptable for BTAI in multiple trauma patients to avoid LSCA complications unless we fail to stop bleeding first.

Fenestrated Endovascular Repair with Debranching Technique for Blunt Traumatic Isthmus Injury.

Thoracic endovascular repair (TEVAR) is a safe treatment alternative to open repair for blunt traumatic aortic injury (BTAI). A 29 year-old-female had multiple traffic injuries, including BTAI located in lesser curve of the isthmus close to the left common carotid artery with an isolated left vertebral artery. TEVAR with simple covering of the left subclavian artery was not adequate to prevent the endoleak. We considered fenestrated TEVAR with RELAY® PLUS to ensure blood flow to the left common carotid artery and reconstruction of the left isolated vertebral and left subclavian artery. The fenestrated TEVAR with a debranching technique provided good results without device-related complications.