Improvements in technology continue to expand the indications for endovascular repair of traumatic thoracic aortic pathology. We present the following case, which utilized the newergeneration Conformable GORE® TAG® Device (Gore & Associates) for successful endovascular treatment of a complex traumatic aortic tear.

CASE REPORT

The patient was a 74-year-old man who sustained a 25-foot fall and presented to the emergency department as a critical trauma patient. Upon presentation, he was hemodynamically stable, with a heart rate ranging between 100 to 110 bpm and a blood pressure of 118/78. A computed tomography (CT) scan of his chest demonstrated a traumatic aortic tear involving the arch distal to the left subclavian artery origin (Figure 1). An intramural dissection and mediastinal hematoma were also present. Multiple associated injuries included right-sided rib fractures of ribs 5 through 11, bilateral pulmonary contusions, a right psoas muscle hematoma, multiple serosal bowel injuries, a right adrenal hematoma, a left open tibial fracture, multiple transverse process fractures, and a left sacral fracture.

The patient was immediately taken to the operating room for endovascular thoracic repair. We began with an ultrasound-guided puncture of the right common femoral artery. Due to the patient's multiple concomitant injuries, it was decided not to administer systemic heparin. Percutaneous arterial access was achieved using the preclose technique, and two PROGLIDE Sutures (Abbott Vascular, Santa Clara, CA) were placed. The right common femoral artery was predilated with 9- and 14-F sheaths, respectively, over a BENTSON Guidewire (Cook Medical, Bloomington, IN). A Lunderquist Extra- Stiff wire (Cook Medical) was exchanged and advanced to the descending thoracic aorta, and a 24-F GORE® DrySeal Sheath (Gore & Associates) was advanced to this level. A Bentsen “buddy” wire was placed through the sheath, and a marker pigtail catheter was advanced to the ascending aorta.

Aortography confirmed the presence of the traumatic aortic dissection approximately 3 cm distal to the subclavian artery origin. We loaded a 37-mm X 37-mm X 15-cm Conformable GORE® TAG® Device over the Lunderquist wire and positioned the partially uncovered stent portion of the graft immediately distal to the subclavian artery takeoff. The graft was deployed at this level, and completion angiography showed successful coverage of the aortic tear without evidence of endoleak or extravasation and continued patency of the arch vessels. The total time between pre- and post-deployment angiography was 17 minutes. The volume of iodinated contrast administered for the thoracic repair was 60 mL.

Upon completion of the endovascular repair, exploratory laparotomy was performed for hemoperitoneum and associated serosal bowel injuries. The patient also underwent subsequent angiographic embolization the next day for continued retroperitoneal bleeding from a lumbar artery and open repair of his open tibial fracture. After stabilization of his multiple traumatic injuries, the patient had a prolonged hospital course that was complicated by acute respiratory distress syndrome. He was extubated on postoperative day 14 and discharged to a rehabilitation facility. One month postoperatively, a follow-up CT of the chest demonstrated no evidence of aortic dissection or endoleak, and there was no evidence of stent graft migration (Figure 2).

DISCUSSION

Aortic injury after blunt trauma is associated with extremely high morbidity and mortality; up to 80% of patients with this injury are thought to die prior to arrival at a hospital.1 It most frequently occurs after sudden deceleration and focal disruption at the level of aortic fixation to the chest wall. In a contemporary series by Canaud and colleagues, the mortality rates after open repair in these patients was 11.4% compared with 2.5% after endovascular repair.2 A recent review of 100 consecutive patients treated with stent grafts following blunt traumatic thoracic aortic injury demonstrated an in-hospital mortality rate of 12%.3 Endovascular repair was also associated with lower operative times, estimated blood loss, and intraoperative blood transfusions compared with open repair. In addition, endovascular repair is associated with decreased postoperative pneumonia, shorter length of hospital stay, and a decreased incidence of paraplegia.4

Several key technical points regarding endovascular repair of traumatic aortic injuries should be emphasized. The severe blunt chest trauma associated with aortic tears frequently causes multiple associated injuries, which may be present in multiple body cavities and extremities.5 Thus, rapid evaluation of CT images and measurements should be performed as the patient is being prepped for surgery. Intravascular ultrasound may be used to measure aortic landing zone diameters and locate the precise location of the intimal defect in patients who are unable to be imaged with CT scans. Our 17-minute case duration demonstrates that the Conformable GORE® TAG® Device can be optimally positioned and rapidly deployed following arch angiography. Short operative times are essential to reduce thrombotic complications because systemic anticoagulation is frequently contraindicated in patients following severe blunt trauma.6 Because these patients frequently have multiple concomitant injuries that also require operative or interventional repair after stent graft placement, delays in treatment of the thoracic aortic injury due to long operative times may lead to poor outcomes.

The development of newer, more flexible stent grafts, such as the Conformable GORE® TAG® Device, has allowed for improved circumferential aortic wall apposition in patients with tortuous anatomy over a wider range of aortic diameters. Traditionally, many patients with traumatic aortic injuries are younger and have relatively smaller-diameter aortas compared to the aneurysmal aortas that the stent grafts were originally designed to accommodate. The newer-generation Conformable GORE® TAG® Device can be used to treat aortas of 16 to 42 mm, and modifications, which add to its conformability, include increased wire diameter for higher radial force and optimized expanded polytetrafluoroethylene graft material for increased flexibility. Additionally, use of the GORE® DrySeal Sheath allowed us to perform the operation using unilateral femoral artery access with the use of a “buddy” wire, pigtail catheter, and stent graft through a single sheath.

CONCLUSION

In summary, endovascular repair of blunt traumatic aortic injuries has improved mortality rates and perioperative morbidity for this complex problem. Further refinement of existing commercial devices will likely continue to improve patient outcomes and allow for successful treatment in a wider range of anatomic variants and clinical scenarios.

Juan Carlos Jimenez MD, FACS, is with the Division of Vascular Surgery, Gonda Vascular Center, David Geffen School of Medicine at UCLA in Los Angeles, California. He has disclosed that he has no financial interests related to this article. Dr. Jimenez may be reached at (310) 206-1786; jcjimenez@mednet.ucla.edu.

Sharon C. Kiang, MD, is a vascular surgery fellow in the Division of Vascular Surgery, Gonda Vascular Center, David Geffen School of Medicine at UCLA in Los Angeles, California. She has disclosed that she has no financial interests related to this article.

William J. Quinones-Baldrich, MD, is a professor in the Division of Vascular Surgery, Gonda Vascular Center, David Geffen School of Medicine at UCLA in Los Angeles, California. He has disclosed that he is a proctor and lecturer for Gore & Associates.

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