Endovascular Repair of Thoracic Aortic Injury: Current Thoughts and Technical Considerations

Abstract

Thoracic aortic traumatic injury is a highly morbid event. Mortality and paraplegia rates after emergent open repair remain high. Now, however, thoracic aortic endografting for trauma (TAET) is commonly used. It is appealing due to reduction of operative stress for the multiply injured trauma victim. This minimizing of stress and risk is secondary to avoidance of thoracotomy, single-lung ventilation, aortic cross-clamping, and the more complex anesthetic techniques required. Early and midterm results from TAET delineate improved outcomes, yet access and aortic constraints continue to challenge TAET. Questions regarding longer-term durability of endografts in younger patients remain unanswered. Broader application of TAET within endovascular programs is challenged by appropriate imaging, operating suite inventories, and the logistics and personnel required for TAET. Currently developed thoracic endograft devices are not ideal for TAET due to platform size and graft diameter. This is changing, however, as new modifications have been developed and trials are ongoing. In light of these collective factors, the management paradigm for traumatic aortic injury is beginning to favor TAET.

Transient Paraplegia in a Patient with Bilateral Posterior Frontal Contusions and Traumatic Thoracic Aortic Dissection

“…13,8,11,9 BAI also carries a significant morbidity, including spinal cord ischemia and stroke reported as high as 20% and 8% respectively. 5 Spinal cord ischemia can be the direct result of aortic injury or can be the complication of open and endovascular repairs of the aortic injury. This is thought to be the result of decreased or insufficient blood flow to a susceptible area of the thoracic spinal cord.…”

“…Further, it can also result from open and endovascular repair of this injury due to decreased perfusion to the cord and ensuing ischemia and infarction. 4,5,14 Few cases of acute lower extremity monoparesis have been reported from traumatic injury to the frontal lobe. 2,10 We present the first case of acute paraplegia resulting from bilateral para-sagittal frontal contusions in a patient with concomitant thoracic aorta injury.…”

Thoracic Aortic Endografting for Trauma

“…Thus, the use of avail-able, larger devices designed for degenerative diseases has unmasked serious troubles with graft infolding, graft collapse, aortic thrombosis, and failure when thoracic endografts are significantly oversized. 12,[31][32][33] Therefore, it has become evident that oversizing thoracic grafts by only 10% is ideal. Specifically owing to the concern of aortic size in trauma, smaller and tapered endografts have been developed.…”

“…When iliofemoral access is not appropriate, graft conduits can be placed along the iliac arterial system, usually the common iliac, or the terminal aorta. 33,34 These placements are accomplished via relatively small retroperitoneal incisions. The graft can be amputated after the procedure, and the stump can be oversewn in a straightforward manner.…”