Journal of Vascular Surgery
Volume 46, Issue 5 , Pages 934-940, November 2007

Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury

Presented at the Thirty-first Annual Meeting of the Southern Association for Vascular Surgery, Rio Grande, Puerto Rico, January 17-20, 2006.

  • Paul J. Riesenman, MD, MS

      Affiliations

    • Department of Surgery, Division of Vascular Surgery, University of North Carolina Hospitals, Chapel Hill, NC
    • ,
  • Mark A. Farber, MD

      Affiliations

    • Department of Surgery, Division of Vascular Surgery, University of North Carolina Hospitals, Chapel Hill, NC
    • Corresponding Author InformationReprint requests: Mark A. Farber, MD, Associate Professor, Division of Vascular Surgery, University of North Carolina, CB#7212, 3024 Burnett-Womack Building, Chapel Hill, NC, 27599-7212.
    • ,
  • Preston B. Rich, MD

      Affiliations

    • Division of Trauma, Critical Care, Burns, University of North Carolina Hospitals, Chapel Hill, NC
    • ,
  • Brett C. Sheridan, MD

      Affiliations

    • Division of Cardiothoracic Surgery, University of North Carolina Hospitals, Chapel Hill, NC.
    • ,
  • Robert R. Mendes, MD

      Affiliations

    • Department of Surgery, Division of Vascular Surgery, University of North Carolina Hospitals, Chapel Hill, NC
    • ,
  • William A. Marston, MD

      Affiliations

    • Department of Surgery, Division of Vascular Surgery, University of North Carolina Hospitals, Chapel Hill, NC
    • ,
  • Blair A. Keagy, MD

      Affiliations

    • Department of Surgery, Division of Vascular Surgery, University of North Carolina Hospitals, Chapel Hill, NC

Received 6 March 2007; accepted 17 July 2007.

Article Outline

Background

Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented for open surgical or endovascular repair.

Methods

Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n = 48, 77%), or endovascular repair (n = 14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open surgical and endovascular groups.

Results

Age, gender, race, and mechanism of injury did not differ between open surgical and endovascular groups. Additionally, RTS, ISS, and NISS values were not significantly different. The proportion of patients with sternal fractures (14% vs 0%), or unstable spinal fractures (36% vs 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n = 13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic endografts (n = 6; 43%) and abdominal aortic endograft components (n = 8; 57%). Forty-one interposition grafts were placed in the open surgical group. Renal complications (32% vs 7%), and urinary tract infections (35% vs 7%) approached significance between surgical and endovascular groups (P = .082 and P = .077, respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0%, respectively (P = .056). Endovascular repair was associated with significant reductions in operative time (118 vs 209 minutes), estimated blood loss (77 vs 3180 ml), and intraoperative blood transfusions (0.9 vs 6.1 units). No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group.

Conclusion

Endovascular repair of blunt descending thoracic aortic injuries utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short term and associated with a lower intraoperative mortality (P = .056). Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions.

 

Blunt thoracic aortic injury (TAI) is a highly lethal injury with a mortality rate at the scene of injury of approximately 85%.1, 2 Patients who survive the initial trauma and present to the hospital remain at risk for mortality secondary to the aortic injury.3, 4 Despite developments in operative techniques, there still remains considerable operative mortality and morbidity associated with a surgical approach.5, 6

Elective endovascular (EV) repair of thoracic aortic lesions is a less invasive intervention that may be superior to open surgical repair for the treatment of a variety of descending thoracic aortic lesions.7 A less invasive approach would be preferable for stabilization of the aortic injury in patients with multiple traumatic injuries. Although single center experience is limited by the rarity of these traumatic lesions and the relative infancy of applying endograft technology to the thoracic aorta, recent reports of endovascular repair of blunt TAIs have been encouraging.8, 9, 10, 11

We reviewed our single-institution experience of patients treated acutely for blunt injuries to the descending thoracic aorta over a 13-year period. Patient characteristics and outcomes were compared between patients who received endografts, and those who underwent open surgical reconstruction. Anatomic and physiologic measures of traumatic injury severity were compared between groups, and short-term outcomes are reported.

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Materials and methods 

Institutional Review Board approval was obtained for the review of all patient records relevant to this study. For the time period between August 1993 and August 2006, the University of North Carolina (UNC) Hospital’s discharge database was searched for International Classification of Diseases Version 9 (ICD-9) codes 901.0 injury aorta (thoracic), 902.0 injury aorta (abdominal), 441.01 thoracic dissection, 441.01 thoracoabdominal dissection, and 441.1 thoracic aneurysm ruptured. Review of nonthoracic injury ICD-9 codes was necessary due to misclassification of six patients. A total of 73 patients underwent full review of electronic and paper records to identify those whom sustained acute blunt descending TAI. Patients with abdominal aortic injuries (n = 3), thoracic aortic injuries secondary to penetrating trauma (n = 4), and injuries proximal to the origin left subclavian artery (SCA) (n = 1) were excluded from this analysis. Additionally, this analysis only includes patients who presented to the operating room within 14 days of their injury. Patients who died prior to undergoing an intervention for their TAI were excluded (n = 2), as were nonoperatively managed patients (n = 1).

The location of injury was classified as involving the isthmus (from just distal to the left SCA to the third intercostals artery), or the lower descending aorta based upon intraoperative description and/or radiographic evaluation. Injury severity score (ISS)12 and new injury severity score (NISS)13 were obtained from the UNC Hospital’s Trauma Registry Database. Revised trauma score (RTS)14 was calculated based upon the initial Glasgow Coma Scale (GCS), systolic blood pressure (SBP), and respiratory rate (RR).

For patients undergoing EV repair, aortic measurements were obtained on thin cut CT scans of the chest. In patients who received thoracic endografts, devices were sized according to the manufacturer’s instructions for use (IFU). When appropriately configured thoracic endografts were not available, often due to a lack of smaller thoracic devices, abdominal aortic endograft components were utilized and oversized by the attending physician to approximately 10% of the aortic luminal diameter. All thoracic devices were appropriately oversized and oversizing of abdominal components did not exceed 20%. In general, proximal and distal landing zones ≥20 mm were obtained although landing zones <20 mm were deemed acceptable if an adequate seal and lesion exclusion were achieved at the time of deployment. EV outcomes are defined as previously described.15 Follow-up for both EV and open surgical patients was based on the most recent clinic visit or through correspondence if the patient was followed at another institution. Follow-up evaluation for EV patients consisted of both cross-sectional and plain film imaging performed at approximately 30 days, 6 months, and annually thereafter.

Data analysis was performed with the use of StatView (SAS Institute, Cary, NC). Fisher exact test was used to compare population proportions and two-tailed P values are reported. Student t test was used for continuous variables. Comparisons between groups are referred to as being statistically significant if P ≤.05, otherwise the P value is provided for interpretation.

A total of 62 patients met criteria for this review during the 13-year time period. The majority sustained trauma secondary to a motor vehicle collision (81%). The average patient age was 40.3 years and the 20 to 29 age group was the most prevalent (26%) in our series consistent with previous reports of TAI in the state of North Carolina.16 The majority of patients had injuries located at the isthmus (92%), consistent with previously reported series.4, 17, 18 When a delay to intervention was necessary, medical therapy with antihypertensives was routinely utilized.

Fourteen (23%) patients underwent EV repair and 48 (77%) underwent open surgical repair owing to the relatively recent application of endografts to this vascular pathology. At out institution, EV repair of thoracic aortic lesions became routinely available in 2002. Of the 14 EV cases, 93% occurred in 2003 or later and since 2002, approximately 50% of all repairs for acute blunt TAI have been performed endovascularly. Comparisons of EV and open surgical patients are listed in Table I. Patient age, gender, and race did not differ significantly between groups. The proportion of patients 55 years or older was also not significant (EV 21% vs open 23%; P = 1.000). Chronic comorbidities did not significantly differ between treatment groups, but these measures may have been under-reported given the acute assessments of many of these patients. Measures of traumatic injury (RTS, ISS, and NISS) were not significantly different between EV and open surgical groups, nor was evidence of preintervention hypotension (SBP <90 mm Hg). Only the presence of sternal fractures and unstable spinal fractures were significantly higher in the EV group. Thirteen of the 14 EV patients (93%) were assessed by cardiothoracic surgeons at the referring institution and/or our facility and deemed to be nonoperative surgical candidates due to associated traumatic injuries. No specific predetermined criteria were utilized to refer patients for either of the two treatment modalities. One patient in the EV group had undergone attempted open surgical repair at a referring institution, but this was aborted due to inability to tolerate single lung ventilation. A board certified cardiothoracic surgeon was one of the surgeons of record in 47 of the 48 cases (98%) of attempted or successful open surgical repair.

Table I. Patient characteristics: endovascular and open surgical repair
ValueEVOpenP
n1448
Age (mean)40.740.2.931
Male9(64%)36(75%).502
White8(57%)32(67%).539
Transferred13(93%)25(52%).006
SBP <90 mm Hg⁎6(50%)†24(50%).764
Etiology
Motor vehicle collision9(64%)41(85%).121
Motorcycle collision2(14%)2(4%)
Pedestrian hit by car0(0%)3(6%)
Fall3(21%)1(2%)
Other0(0%)1(2%)
Location of aortic injury
Isthmus12(86%)45(94%).314
Distal descending thoracic aorta2(14%)3(6%)
Measures of traumatic injury
RTS6.5897.024.291
ISS3841.491
NISS4547.549
Associated traumatic injuries
Head injury‡5(36%)10(21%).296
Lung injury9(64%)37(77%).488
Abdomen§9(64%)25(52%).546
Pelvic fracture7(50%)27(56%).765
Long bone fracture4(29%)22(46%).357
Rib fractures8(57%)31(65%).755
Clavicle fracture3(21%)5(10%).365
Scapula fracture0(0%)3(6%).179
Sternum fracture2(14%)0(0%).048
Neurologic deficits2(14%)4(8%).610
Unstable C/T/L spine fractures5(36%)5(10%).038

EV, endovascular, SBP, systolic blood pressure, RTS, revised trauma score, ISS, injury severity score, NISS, new injury severity score, C/T/L, cervical, thoracic, lumbar.

⁎Systolic blood pressure <90 mm Hg on at least one measurement prior to intervention.

†n = 12, pre-transfer vital sign data incomplete on two EV patients.

‡Radiographic evidence of brain trauma on initial head computer tomography scan.

§Solid organ, bowel, bladder, or diaphragm injury.

Six (43%) EV patients received commercially manufactured thoracic endografts including the Talent Thoracic (n = 2) (Medtronic AVE, Santa Rosa, Calif), and the Gore TAG (n = 4) (W. L. Gore & Associates Inc, Flagstaff, Ariz) endoprosthesis. The Talent devices were placed as part of a Food and Drug Administration approved clinical investigative protocol and the Gore TAG devices were placed as off-label applications. Eight (57%) patients received abdominal aortic endograft components including Gore Excluder Aortic Extender cuffs (n = 5); (W. L. Gore & Associates Inc, Flagstaff, Ariz), Zenith AAA iliac leg extensions (n = 2); (Cook Inc, Bloomington, Ind), and a Vanguard Endovascular Aortic Graft Cuff (n = 1); (Boston Scientific, Nantick, Mass). Multiple endograft components were deployed in one patient who received a thoracic endograft and six patients who received abdominal aortic endograft components. Of the patients who received Gore Extender cuffs, four required three components and one required four components. Of the patients who received Zenith iliac leg extensions, one was successfully excluded with one component for an injury at the isthmus and the other required three components to treat a distal descending thoracic aortic injury. The majority of patients underwent vascular access through a femoral approach (n = 13; 93%), although one patient required iliac artery access in order to treat an aortic isthmus injury with Gore Extender cuffs due to the limiting length of the delivery system. All EV patients received systemic heparin intraoperatively at a dose of 60 to 80 units/Kg. The majority of EV patients were treated with general anesthesia (n = 12; 86%). Primary technical success was 100%. Four (29%) EV patients underwent total coverage of their left SCA, and one (7%) patient had partial coverage.

Forty-one (85%) open surgical patients underwent left heart bypass performed through pulmonary vein to distal descending thoracic aorta utilizing a Bio-Medicus centrifugal pump (Bio-Medicus Inc, Eden Prarie, Minn). Twenty-four (50%) of the open surgical patients received systemic heparinazation during the procedure. The majority (85%) had an interposition Dacron graft (Hemashield; Meadox Medicals, Inc, Oakland, NJ and Boston Scientific, Wayne, NJ) placed during the procedure, two underwent primary repair, and five did not have interposition graft placement or primary repair completed prior to intraoperative death. Mean diameter of the interposition grafts placed was 20.3 mm (range 12 to 26 mm). Of these patients, 27% received interposition grafts >23 mm and 80% received grafts ≥18 mm in diameter.

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Results 

Operative outcomes and in-hospital complications of EV and open surgical patients are presented in Table II. The time of injury could not be determined for two patients in the EV group. The same two patients were transferred back to their referring institution prior to completion of their inpatient hospital course. Outcomes and complications were determined from inpatient notes and discharge summaries but duration of intensive care unit stay could not be accurately evaluated from these records. Patients in the EV group underwent intervention at a significantly greater time from injury mainly related to the time required for transfer to our tertiary care center. There were no intraoperative deaths in the EV group and 11 (23%) deaths in the open surgical group (P = .056). The EV group had significantly less blood loss, shorter operative time, and received less intraoperative units of blood. Five (35%) EV patients received at least one unit of intraoperative allogeneic blood, compared with 44 (92%) of open surgical patients (P < .001). Intraoperative blood salvage was not utilized in any of the EV patients while it was used in the majority (75%) of open surgical patients. Of the 37 operative open surgical survivors, 97% had undergone partial left heart bypass and the average aortic cross-clamp time for this subgroup was 59 minutes. The one open operative survivor who did not undergo left heart bypass underwent primary repair through the clamp-and-sew technique with a cross clamp time of 33 minutes. The greater frequency of renal complications and urinary tract infections in the open surgical group approached significance. There were no cases of paraplegia or paraparesis in either the open surgical or EV groups.

Table II. Operative data and hospital complications: endovascular and open repair
ValueEVOpenP
n1448
In-hospital delay (mean)⁎10 hrs 50 min10 hrs 6 min.940
Range31-2163 min14-14204 min
Injury to intervention (mean)†72 hrs 56 min‡23 hrs 15 min.035
Range282-19952 min121-16054 min
Operative Data
Mean operative time (min)118209<.001
Mean estimated blood loss (ml)773180§.005
Mean blood transfusion (units).96.1<.001
Intraoperative death0(0%)11(23%).056
Complications
n=1437
Mean ICU stay (days)23.6‡18.9.631
Range0-4315 hrs17-1825 hrs
LOS (days)34.728.1.551
Range2-2491-97
Multisystem organ failure1(7%)6(16%).657
Pneumonia7(50%)26(70%).204
Pulmonary embolus0(0%)2(5%)1.000
Tracheostomy5(36%)14(38%)1.000
Renal▫1(7%)12(32%).082
Cerebrovascular accident1(7%)1(3%).478
New neurologic deficits0(0%)0(0%)1.000
Recurrent laryngeal nerve injury0(0%)3(8%).552
Urinary tract infection1(7%)13(35%).077
Bacteremia3(21%)10(27%)1.000
Deep venous thrombosis2(14%)4(11%).661
30-day mortality2(14%)19(40%).111

EV, Endovascular, ICU, intensive care unit, LOS, length of stay.

⁎Time of arrival for patients with known aortic injury or time of diagnosis at our institution, to time of presentation to the operating room.

†Time of injury to time of presentation to the operating room.

‡n = 12, time of injury and duration in ICU data incomplete on two EV patients.

§n = 44, blood loss not reported on four open surgical patients.

▫Acute renal failure or insufficiency (creatinine ≥1.5 mg/dL) in the absence of multisystem organ failure.

No cases of device migration or endoleak were detected during a mean follow-up of 9.4 months. Four secondary procedures were performed in three patients. One patient underwent prophylactic left SCA stent placement following total coverage of the left SCA by the endograft resulting in a monophasic left radial pulse and a cool extremity. Due to inability to assess for left upper extremity ischemic symptoms given the patient’s impaired mental status secondary to head trauma, expectant management was not employed. One patient underwent balloon angioplasty of the most proximal of three Gore Excluder Aortic Extender cuffs on postprocedure day two due to endograft malapposition to the lesser curvature of the distal arch. The final patient was also noted to have malapposition of a Zenith AAA iliac leg extension to the lesser curve, and a hemodynamically significant pressure gradient (61 mm Hg) was measured across the endoprosthesis. Attempted balloon angioplasty was partially successful at improving endograft apposition, but the pressure gradient was unresolved (52 mm Hg). The patient experience further endograft malapposition, and this resulted in the development heart failure and signs of poor distal perfusion. Endograft explantation and repair with an interposition graft was not feasible due to severe pulmonary contusions and inability to tolerate single-lung ventilation. This functional coarctation was resolved with the deployment of a Palmaz P4010 stent (Johnson & Johnson, Warren, NJ) across the proximal portion of the endograft improving apposition to the distal arch and resolving the pressure gradient. The patient’s symptoms of distal malperfusion resolved, and she was discharged from the hospital following recovery from her traumatic injuries.

Two EV patients died within 30 days of intervention due to multisystem organ failure (MSOF) and withdrawal of life supporting measures on one patient of advanced age with multiple associated traumatic injuries. For the open surgical group, in addition to the 11 intraoperative deaths, there were eight in-hospital deaths (≤30 days). Causes of death included MSOF (n = 6), cerebrovascular accident (n = 1), and withdrawal of life supporting measures (n = 1).

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Discussion 

In this study, EV repair was associated with significant reductions in operative time, estimated blood loss, and intraoperative blood transfusions despite the utilization of intraoperative blood salvage in the majority of open surgical patients. These benefits occurred despite similar patient characteristics between the EV and open surgical groups. Neither the initial physiologic injury severity score (RTS), nor anatomic measures of injury severity (ISS and NISS) differed significantly. Additionally, the proportion of individual associated traumatic injuries were essentially equally represented between EV and open surgical groups, as was the proportion of patients who demonstrated hemodynamic instability prior to intervention. These observations would suggest that the EV and open surgical groups were comparable in terms of injury severity. Despite these measures of injury severity, the majority of the EV patients had been assessed by cardiothoracic surgeons to be prohibitive operative candidates. The intraoperative dearth rate was lower for the EV group (0% vs 23%). The failure to reach the traditional statistical cut-off of P ≤ .05 for this comparison appears to be a type II error due to the small sample size in the EV group.

Pulmonary complications are common following open repair18, 19 and may possibly be contributed to by the need to perform a thoracotomy. Despite this, we did not observe a significant reduction in pulmonary complications with EV therapy. Injuries to the lung and chest wall are commonly associated with blunt TAI3 and were the most common associated traumatic injuries in both the EV and open surgical groups. The severity of associated pulmonary injuries may preclude the patient from undergoing an emergent open surgical repair due to the inability to tolerate single-lung ventilation. Variation in the severity of these injuries may account for this lack of observed benefit to EV repair and more quantitative measurements of pulmonary complications may demonstrate advantages in future studies. Although infectious complications might be expected to be higher in the open surgical group given the immunosuppressive effects of thoracotomy20 and multiple blood transfusions,21 the incidence of pneumonia and bacteremia were not significantly different compared to the EV group.

Paraplegia is a devastating complication associated with open surgical repair of TAI.4, 22 Although the use of partial bypass has reduced the incidence of paraplegia, this complication still occurs.5, 23 Of the open surgical operative survivors in our series, 97% underwent partial bypass, and there were no postoperative cases of paraplegia. This benefit of distal perfusion occurred despite a mean aortic cross-clamp time >30 minutes, which has been associated with the development of paraplegia even in the setting of distal perfusion.4, 17 Although paraplegia has been observed after elective EV repair of degenerative thoracic aneurysms,7 there has never been a reported case of this complication following EV repair of blunt TAI.24

Two endograft specific complications were observed. Two patients experienced malapposition to the lesser curvature of the distal arch; one had received multiple Gore Excluder Aortic Extender cuffs, and the other received a Zenith AAA iliac leg extender. Complications such as device collapse following thoracic endograft repair of blunt TAI have been previously reported.25, 26 Malapposition of endografts to the inferior curve of the distal aortic arch is a potential consequence of the application of currently available endografts to the relatively young healthy aortas encountered in the trauma patient population. Malapposition may lead to device collapse or a functional coarctation. One of the EV patients required deployment of a Palmaz stent across the proximal portion of the endograft in order to improve apposition. Successful utilization of balloon expandable stents or additional endograft components to improve proximal apposition and resolve endograft collapse has previously been reported,25, 27

Experience with endografts to treat blunt TAI is limited and difficult to study given the low prevalence of patients who survive to presentation. Retrospective case series of acute EV repair of TAI report an intraoperative mortality of 0%, and a hospital mortality of 6.3% to 14.3%10, 11, 28, 29 consistent with the outcomes observed in our series. A current search of the English literature revealed nine single-institution studies that report parallel outcomes for both open surgical and EV treatment of acute TAI (Table III).9, 30, 31, 32, 33, 34, 35, 36, 37 Review of these reported outcomes reveals an absence of intraoperative mortality and postoperative paraplegia/paraparesis events, as well as a tendency for less hospital mortality in patients who underwent EV repair. We considered subjecting these reports to a meta-analysis although the small number of subjects in each study, variability in open surgical techniques, and inclusion of patients treated greater then 14 days from the time of injury made statistical conclusions unreliable. Additionally, these reports are limited by their retrospective case control design, as well as possible reporting biases for outcomes in favor of EV therapy.

Table III. Open surgical vs endovascular repair: summary of the literature
ReferenceYearnIntraoperative mortalityHospital mortalityParaplegia/paraparesis
Kasirajan302003
Open 10NR(5)50%(0)0%
EV 5NR(2)20%(0)0%
Ott312004
Open 12NR(2)17%(2)17%
EV 6NR(0)0%(0)0%
Amabile322004
Open 11(1)9%(1)9%(0)0%
EV 9(0)0%(0)0%(0)0%
Rousseau92005
Open 35(4)11%(6)17%(3)9%
EV 29(0)0%(0)0%(0)0%
Pacini332005
Open 51(3)6%(4)8%(4)8%
EV 15(0)0%(0)0%(0)0%
Stampfl342006
Open⁎ 5(0)0%(0)0%(0)0%
EV 5(0)0%(0)0%(0)0%
Andrassy352006
Open 16(0)0%(3)19%(2)13%
EV 15(0)0%(2)14%(0)0%
Broux362006
Open 17(0)0%(4)23%(3)18%
EV 13(0)0%(2)15%(0)0%
Reed372006
Open 11(1)9%(1)9%(0)0%
EV 13(0)0%(3)23%(0)0%
Present Series2006
Open 48(11)23%(19)40%(0)0%
EV 14(0)0%(2)14%(0)0%

EV, Endovascular, NR, not reported.

⁎Patients who underwent an emergency thoracotomy in the shock unit were censored from open subgroup.

Candidacy and endograft availability are important considerations when considering EV repair of a TAI. Approximately 90% to 93% of patients who survive to presentation sustain injuries to the aortic isthmus or distal thoracic aorta,4, 17, 18 and therefore may be EV candidates without the need for extra-anatomic bypass. Obtaining an adequate proximal landing zone may require coverage of the left SCA,38 although this appears to be well tolerated without revascularization given no contraindications.39 The diameter of the vessel lumen currently dictates device selection. The smallest Gore TAG endoprosthesis available (26 mm) allows for the treatment of patients with landing zone diameters as small as 23 mm based in the manufacturer’s IFU. Current device lengths allow for adequate coverage of these lesions without the need for multiple components. Based upon indirect measures of aortic vessel diameter, 27% of patients in our series who underwent open repair would have been candidates for currently available thoracic endografts, while the remaining 73% would require abdominal aortic endograft components. Off-label utilization of abdominal aortic endografts in the thoracic territory has been previously reported8, 40 and allows for the treatment of these smaller aortas.

We have found that main body extension cuffs and flexible iliac leg extensions are the abdominal aortic endograft components best suited for application to traumatic aortic injuries in the thoracic territory when the aortic diameter is less than 23 mm or the radius of curvature is small. In general, three abdominal aortic cuff components are required to successfully exclude most injuries. Based upon device sizing, distal to proximal cuff deployment is ideal although not always practical. The utilization of multiple short extension cuffs may allow for improved accommodation to the curvature of the distal arch, although this may put the patient at risk for component separation and type III endoleak. Iliac leg extenders may allow for repair with a single endoprosthesis. Stiff iliac components should be avoided as these devices can resist accommodation to the curvature of the distal arch resulting in significant malapposition, as was observed in our one patient who received a single Zenith AAA iliac leg extension. Additionally, the diameters of the femoral and iliac vessels, as well as the maximal length of the delivery system to be utilized, can dictate the need for a more proximal level of vascular access necessitating a more invasive procedure.24

Long-term radiographic surveillance is necessary to monitor the integrity of the endoprosthesis. This may present a problem for patients who undergo EV repair for TAIs as the reliability of this patient population to follow-up after discharge may be difficult to assess. Issues surrounding patient attrition should be considered in one’s decision to perform EV repair.

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Conclusion 

The utilization of thoracic and abdominal aortic endograft components to treat blunt TAI results in reductions in operative time, blood loss, and intraoperative blood transfusions compared with open surgical reconstruction. Furthermore, a review of comparative studies to date suggests that EV repair may be associated with reductions in intraoperative mortality, hospital mortality, and paraplegia/paraparesis. Additional experience with EV repair of blunt TAIs may clarify these observations. Endograft repairs of blunt TAIs may be prone to device-related complications and the long-term durability of endografts in this patient population remains to be defined.

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Author contributions 


Conception and design: PJR, MF, PBR, RM, WM, BK

Analysis and interpretation: PJR, MF, PBR, BS, RM, WM, BK

Data collection: PJR

Writing the article: PJR

Critical revision of the article: MF, PBR, BS, RM, WM, BK

Final approval of the article: PJR, MF, PBR, BS, RM, WM, BK

Statistical analysis: PJR, MF

Obtained funding: Not applicable

Overall responsibility: MF

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The authors thank Cat Colvin for assistance with obtaining data from the UNC Hospitals Trauma Registry Database.

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 Competition of interest: Mark A. Farber is a consultant for Cook Inc, W. L. Gore & Associates, Inc, and Medtronic, Inc.

PII: S0741-5214(07)01191-3

doi:10.1016/j.jvs.2007.07.029

Journal of Vascular Surgery
Volume 46, Issue 5 , Pages 934-940, November 2007

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