Conformable GORE® TAG® Device Exclusion of Severe Descending Thoracic Aortic Traumatic Injury

Traumatic aortic injury carries significant morbidity and mortality. Complete aortic transection is often fatal in the field, with few patients surviving the immediate injury or transport period. Partial transection and aortic disruption also carry a significant mortality rate and pose a management dilemma, as these are almost uniformly compounded by concomitant traumatic injuries associated with rapid deceleration and impact. Anticoagulation during the time of aortic repair may carry an increased risk of hemorrhage in the multitrauma victim, especially when there is associated closed head or spinal injury. In the following case, we present a young multitrauma patient who was successfully managed using the Conformable GORE® TAG® Device (Gore & Associates) thoracic endoluminal prosthesis without the use of systemic heparinization.

CASE REPORT

A 47-year-old woman was injured as a pedestrian who sustained the head-on impact of an automobile, which was estimated to be traveling at approximately 60 miles per hour. She had severe traumatic injuries, including a cervical spine fracture, multiple pelvic bone fractures, bilateral femoral fractures, left femoral neck fracture, left patella fracture, left fibular head fracture, pulmonary contusion, and no pulse in the left lower extremity below the groin. In addition, a computed tomography (CT) scan of her chest showed severe descending thoracic aortic traumatic injury (Figure 1).

After rapid assessment and prioritization of surgical interventions, the patient and her family were consulted regarding the severity of her multiple injuries and the urgency to intervene to prevent life-threatening hemorrhage from the descending thoracic aortic injury. After discussing the options of open descending thoracic repair compared to placement of the recently approved Conformable GORE® TAG® Device for this indication, the patient and her family opted for endovascular repair.

TREATMENT

The left femoral artery was exposed through an oblique incision. After achieving access and passing a starter wire, the thoracic aorta was interrogated with intravascular ultrasound, and the length of injury and landing zones were identified. The CT, angiographic, and intravascular ultrasound findings were consistent with the aortic disruption being approximately 3 cm distal to the takeoff of the left subclavian artery. The diameter of the aorta distal to the left subclavian measured 25 mm. There was evidence of extensive disruption of the tapered aorta over approximately 100 mm in length from the initial entry site. To expediently place the device without heparin due to the risk of hemorrhage from other traumatic injuries, the device and an angiographic catheter were introduced through a GORE® DrySeal Sheath (Gore & Associates), and the landing zones were confirmed with angiography (Figure 2). A Conformable GORE® TAG® Device (28 mm X 28 mm X 15 cm) was deployed distal to the left subclavian artery without difficulty. After deployment of the device (Figure 3), it was apparent that the length of the aortic disruption had been covered by the device, with the left subclavian artery remaining patent.

Before completing the procedure, catheter embolectomy of the left lower extremity was performed; completion angiography showed patency of the femoral and lower extremity arteries without injury. Throughout the procedure, the infusion sheaths in the femoral artery were flushed with heparin to help prevent local thrombosis. Thrombectomy was performed using 2,000 units of heparin to achieve patency while minimizing potential hemorrhagic complications.

A CT scan 4 days post-deployment showed complete coverage of the lesion, with a large hematoma surrounding the device (Figure 4). The patient was subsequently transferred to a rehabilitation facility where a follow-up CT was achieved at 6 weeks, which showed near-complete resolution of the injury, with conformity of the device to the aortic anatomy (Figure 5).

CONCLUSION

This case demonstrates the potential for endoluminal graft exclusion of descending thoracic aortic traumatic disruptions using the newly approved Conformable GORE® TAG® Device. The extent of aortic disruption in this patient clearly exemplifies the advance that endoluminal exclusion of traumatic injuries has provided for severely injured patients while avoiding the concomitant morbidity, mortality, and potential delays associated with open thoracoabdominal repair. The series of images from this patient also show the aortic remodeling that occurred during the post-deployment period with near-complete resolution by 6 weeks.

Rapid deployment of the device without systemic heparin can be accomplished in severely injured patients if the procedure can be completed expeditiously. In this case, the total time from skin incision to completion of device deployment was 20 minutes.

Rodney A. White, MD, is Vascular Surgery Division Chief, Vascular Surgery Fellowship Program Director, and Vice Chairman of Research, Harbor-UCLA Medical Center, and Professor of Surgery, David Geffen School of Medicine at UCLA in Torrance, California. He has disclosed that he is a paid consultant to and receives research support from Gore & Associates, Covidien, Endologix, Inc., Medtronic, Inc., and Volcano Corporation. Dr. White may be reached at (310) 222-2704; rawhite@ucla.edu.

Carlos E. Donayre, MD, is a vascular surgeon with the Department of Surgery, Harbor-UCLA Medical Center in Torrance, California. He has disclosed that he is a paid consultant to and receives research support from Medtronic, Inc. and Volcano Corporation. Dr. Donayre may be reached at cdonayre@cox.net.