Blunt thoracic injury is a lethal condition that is treated with an endovascular stent graft as firstline management. Stent technology is continuously evolving to provide better minimally invasive treatment. The Conformable GORE® TAG® Device (Gore & Associates) is the latest addition to the armamentarium of stent technology, with a special design to cope with challenging anatomy.

Traumatic aortic transection (TAT) is a serious injury that is associated with high mortality and is considered to be the second most common cause of death in trauma patients.1,2 Open surgical repair of TAT used to be the standard form of management. With the advent of endovascular techniques, growing experience, and continuous development of graft technology, thoracic endovascular aortic repair (TEVAR) has become the first-line management of blunt thoracic injury, with good short- and mid-term results in many centers. We report a case of multiple injuries and aortic transection treated with the new Conformable GORE® TAG® Device.

CASE REPORT

A 47-year-old man was transferred to our level 1 trauma center following a car accident. He sustained multiple injuries to the chest, abdomen, and head. On arrival, he was a 6 on the Glasgow Coma Scale and was hemodynamically unstable. The patient was intubated, and life-support resuscitation was provided. A totalbody computed tomography (CT) scan revealed a brain contusion to the right occipital lobe with no intra-axial or extra-axial hematoma, 60% right-sided pneumothorax with flail chest secondary to fractures of right-side ribs 3 through 6, and grade 3 aortic transection (Figure 1). A right-sided chest drain was inserted.

The multidisciplinary trauma team decided to transfer the patient to the hybrid interventional suite for endovascular repair of his aortic injury. The aortic measurements were a 24-mm proximal landing zone, a 23-mm distal landing zone, and a 6-mm distance between the transected area and the origin of the left subclavian artery. Cut-down was performed in the right groin, and a GORE® DrySeal Sheath (Gore & Associates) was inserted into the right iliac artery.

Percutaneous access for a diagnostic catheter was achieved in the left common femoral artery. Under controlled hypotension, a Conformable GORE® TAG® Device stent graft (26 mm X 26 mm X 10 cm) was deployed across the origin of the left subclavian artery. Completion angiography and CT angiography performed on day 3 showed good conformation to the aortic arch, with complete exclusion of the transected segment of the aorta and no endoleak (Figure 2). The patient was then transferred to the intensive care unit for initial recovery. Five days later, he was transferred to a neurology rehabilitation center and discharged to home 5 weeks later with good functional recovery.

DISCUSSION

Traumatic aortic transection (TAT) is a life-threatening condition, associated with a 90% mortality rate.3 The majority of patients die on the accident scene. Of those who make it to the hospital, there is a 50% risk of mortality in the first 24 hours if the patient receives no intervention.4 Furthermore, delayed aortic rupture has been reported in a significant proportion of patients.5 The aortic injury is classified into four grades: grade 1 (intimal injury), grade 2 (intramural hematoma), grade 3 (pseudoaneurysm) and grade 4 (aortic rupture).6 Intervention is needed for grades 2 to 4, while conservative treatment is reserved for grade 1.

Open surgical repair with high thoracotomy, aortic cross-clamping, single-lung ventilation, and systemic heparinization has been the standard treatment. However, the open approach is associated with a reported mortality rate of 24% and a significant paraplegia rate of 13%.7 In addition, the usual polytrauma nature of those patients frequently precludes the use of systemic anticoagulation and single-lung perfusion.

The advent of TEVAR, with its less-invasive approach, is now the preferred method of treatment for anatomically suitable patients in most level 1 trauma centers. Several single- and multicenter studies demonstrate the safety and effectiveness of TEVAR in TAT patients. Ehrlich et al8 reported on 41 patients treated with TEVAR, achieving 100% technical success. The inhospital mortality and paraplegia rates in this series were 2.4% and 0%, respectively. In another series of 48 patients with 10 years of follow-up, the initial technical success rate was 100%. The 30-day mortality and procedure-related complication rates were 8.3% and 2.1%, respectively.9

In a meta-analysis of 699 patients with blunt aortic transection treated with TEVAR or open surgery, endovascular treatment showed significantly better results in the main outcomes of mortality, paraplegia, and stroke.10

Despite the outcomes favoring TEVAR in polytrauma patients, certain limitations and concerns remain unresolved. Wider usage of this technology is hindered by a lack of suitable device sizes for young patients with small aortic diameters, poor conformability of stiff devices in acutely angulated arches, stent failure, large device profiles, and a lack of long-term durability data. Stent collapse, although rare, can be a serious complication of stent grafts. Excessive oversizing and tight arch angulation in young patients with healthy aortas have been implicated in this type of stent failure.11

The new Conformable GORE® TAG® Device is designed to address some of the issues associated with challenging anatomy. The top end of the new device has nine uncovered apices, an increased diameter of the nitinol wire, and multilayer expanded polytetrafluoroethylene reinforcement. Those changes in design result in improved radial force, point-load distribution, and conformability against the inner curve of the aorta. The Conformable GORE® TAG® Device also allows more generous oversizing (6% to 33%) to treat aortas as small as 16 mm. It is available in a wide range of sizes (21–45 mm) in both straight and tapered designs. However, the device profile remains relatively large (18–24 F), which needs particular attention during access planning. The device has been approved by the US Food and Drug Administration for the treatment of isolated lesions of the descending thoracic aorta, which includes thoracic aneurysm and aortic transection.12,13

CONCLUSION

In this case, the Conformable GORE® TAG® Device stent graft was used to treat traumatic aortic transection in a critically injured patient who had challenging anatomy and provided a good technical and clinical outcome. However, further data are needed to establish its mid- and long-term durability.

Mo Hamady, MD, FRCR, is with the Department of Interventional Radiology, Imperial College Healthcare NHS Trust in London, England. He has disclosed that he is an advisory consultant for Gore & Associates. Dr. Hamady may be reached at m.hamady@imperial.ac.uk.

Elika Kashef, MD, FRCR, is with the Department of Interventional Radiology, Imperial College Healthcare NHS Trust in London, England. Dr. Kashef has disclosed that she has no financial interests related to this article.

Mike Jenkins, MD, FRCS, is with the Regional Vascular Unit, Imperial College Healthcare NHS Trust in London, England. He has disclosed that he has no financial interests related to this article.

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