Potential Long-Term Complications of Endovascular Stent Grafting for Blunt Thoracic Aortic Injury

Thoracic Aortic Injury ◽

Rapid Deceleration

Blunt thoracic aortic injury (BTAI) is a rare, but lethal, consequence of rapid deceleration events. Most victims of BTAI die at the scene of the accident. Of those who arrive to the hospital alive, expedient aortic intervention significantly improves survival. Thoracic endovascular aortic repair (TEVAR) has been accepted as the standard of care for BTAI at many centers, primarily due to the convincing evidence of lower mortality and morbidity in comparison to open surgery. However, less attention has been given to potential long-term complications of TEVAR for BTAI. This paper focuses on these complications, which include progressive aortic expansion with aging, inadequate stent graft characteristics, device durability concerns, long-term radiation exposure concerns from follow-up computed tomography scans, and the potential for (Victims of Modern Imaging Technology) VOMIT.

Blunt Traumatic Aortic Injury: 10-Year Single-Center Experience

Aorta ◽

10.1055/s-0040-1715608 ◽

2021 ◽

Author(s):

Ahmet Can Topcu ◽

Kamile Ozeren-Topcu ◽

Ahmet Bolukcu ◽

Sinan Sahin ◽

Avni U. Seyhan ◽

...

Keyword(s):

Thoracic Aorta ◽

Subclavian Artery ◽

Open Repair ◽

Left Subclavian Artery ◽

Aortic Injury ◽

Phone Calls ◽

Primary Treatment Modality ◽

Abstract Objective In blunt trauma patients, injury of the thoracic aorta is the second most common cause of death after head injury. In recent years, thoracic endovascular aortic repair (TEVAR) has largely replaced open repair as the primary treatment modality, and delayed repair of stable aortic injuries has been shown to improve mortality. In light of these major advancements, we present a 10-year institutional experience from a tertiary cardiovascular surgery center. Methods Records of patients who underwent endovascular or open repair of the ascending, arch or descending thoracic aorta between January 2009 and December 2018 were retrospectively analyzed. Patients without blunt traumatic etiology were excluded. Perioperative data were retrospectively collected from patient charts. Long-term follow-up was performed via data from follow-up visits and phone calls. Results A total of 1,667 patients underwent 1,740 thoracic aortic procedures (172 TEVAR and 1,568 open repair). There were 13 patients (12 males) with a diagnosis of blunt thoracic aortic injury. Mean patient age was 43.6 years (range, 16–80 years). Ten (77%) patients underwent TEVAR, two (15.4%) underwent open repair, and one (7.7%) was treated nonoperatively. Procedure-related stroke was observed in one (7.7%) case. Procedure-related paraplegia did not occur in any patients. Left subclavian artery origin was covered in seven patients. None developed arm ischemia. Hospital survivors were followed-up for an average of 60.2 months (range, 4–115 months) without any late mortality, endoleak, stent migration, arm ischemia, or reintervention. Conclusion Blunt thoracic aortic injury is a rare but highly fatal condition. TEVAR offers good early and midterm results. Left subclavian artery coverage can be performed without major complications.

Delayed Aortic Stent Collapse in Blunt Traumatic Aortic Injury Repair

Aorta ◽

10.1055/s-0039-3401022 ◽

2019 ◽

Vol 07 (05) ◽

pp. 129-136

Author(s):

Abdullah Alhaizaey ◽

Badr Aljabri ◽

Musaad Alghamdi ◽

Ali AlAhmari ◽

Ahmed Abulyazied ◽

...

Keyword(s):

Aortic Arch ◽

Age Groups ◽

Young Patients ◽

Aortic Injury ◽

Stent Grafts ◽

Mortality And Morbidity ◽

Technical Success Rate ◽

Stent Grafting ◽

Blunt Traumatic Aortic Injury

Abstract Background Endovascular stent grafting has emerged as an option to treat traumatic aorta injuries with reported significantly low mortality and morbidity. Stent collapse is one of the complications that can occur in this type of treatment. The aim of this article is to analyze the expected cause of stent collapse and to draw attention to the importance of the surveillance follow-up, as this phenomenon may occur late postdeployment. Methods A retrospectively collected dataset from the two highest volume trauma centers in Saudi Arabia was analyzed between April 2007 and October 2012. A total of 66 patients received stent grafts for traumatic aortic injury and were included in the study. We apply Ishimaru's anatomical aortic arch zones and Benjamin's aortic injury grading systems. There were 35 patients with aortic injury at zone 2, 26 patients in zone 3, and 5 patients in zone 4. About 96% (63) of the injuries were grades 2 and 3, including large intimal flap or aortic wall pseudoaneurysm with change in wall contour. The technical success rate, as defined by complete exclusion of lesions without leaks, stroke, arm ischemia or stent-related complications, was 90%. Results Proximal stent collapse occurred in 4.5% of patients (3 of 66 inserted stents) during follow-up of 4 to 8 years (mean, 6 years). Patients with stent collapse tended to have an acute aortic arch angle with long-intraluminal stent lip, when compared with patients with noncollapsed stents. Intraluminal lip protrusion more than 10-mm increased collapse (p < 0.001). Stent-grafts sizes larger than 28 mm also demonstrated a higher collapse rate (p < 0.001). Conclusions The risk of stent collapse appears related to poor apposition of the stent due to severe aortic arch angulation in young patients and to large stent sizes (>28 mm). Such age groups may have more anatomical and aortic size changes during the growth. Clinical and radiological surveillance is essential in follow-up after stent-graft treatment for traumatic aortic injury.

Long-Term Outcomes of Operative and Nonoperative Management of Blunt Thoracic Aortic Injury

Journal of Vascular Surgery ◽

10.1016/j.jvs.2021.06.154 ◽

2021 ◽

Vol 74 (3) ◽

pp. e93

Author(s):

Anthony J. Lewis ◽

Michael Madigan ◽

Mohamed Zaghoul ◽

Sina Asaadi ◽

Nathan L. Liang ◽

...

Keyword(s):

Nonoperative Management ◽

Aortic Injury ◽

Long Term Outcomes ◽

Catastrophic Outcome of De Novo Aortic Thrombus After Stent Grafting for Blunt Thoracic Aortic Injury

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2014.07.093 ◽

2014 ◽

Vol 98 (6) ◽

pp. e139-e141 ◽

Cited By ~ 5

Author(s):

Heidi J. Reich ◽

Daniel R. Margulies ◽

Ali Khoynezhad

Keyword(s):

De Novo ◽

Aortic Injury ◽

Stent Grafting ◽

Thoracic Aortic Injury ◽

Aortic Thrombus

Improving Surveillance of Traumatic Thoracic Aortic Injuries Repaired with Thoracic Endovascular Graft Placement

The American Surgeon ◽

10.1177/000313481808400725 ◽

2018 ◽

Vol 84 (7) ◽

pp. 1129-1132

Author(s):

Nathan A. Ludwig ◽

Neal Bhutiani ◽

Paul L. Linsky ◽

Amit J. Dwivedi ◽

Matthew C. Bozeman

Keyword(s):

Injury Severity ◽

Vascular Complications ◽

Aortic Injury ◽

Late Complications ◽

Thoracic Aortic Injury ◽

University Of Louisville ◽

Long Term Follow Up ◽

Aortic Injuries

The optimal follow-up protocol for patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury remains unclear. The objective of this study was to assess follow-up patterns in such patients and present an approach to improve long-term follow-up in this cohort. The University of Louisville Trauma Registry was queried for patients who underwent TEVAR for traumatic thoracic aortic injuries between 2006 and 2016. Demographic, injury-specific, perioperative, and outcome measures were recorded for each patient. Follow-up evaluation and duration of follow-up were captured. Follow-up imaging was reviewed for any evidence of vascular complications. A total of 56 patients underwent TEVAR for traumatic thoracic aortic injury. Median age was 48 (range 18–86). Injury mechanism was largely blunt trauma (55 (98%)). Median injury severity score was 34 (range 17–43). Median length of stay was 12.5 days (range 1–40 days), and 51 patients (91%) survived to discharge. Of these, 30 (54%) made at least one follow-up appointment, and 21 of those 30 (70%) received a follow-up CT scan. Median time to last follow-up was one month (range 0–48 months), with 12 patients (21%) having follow-up beyond two months. No patients demonstrated any evidence of vascular complications on imaging at last follow-up. Despite the increased use of TEVAR to treat traumatic aortic injuries, limited follow-up data exist to predict the long-term outcomes of such interventions. Development of statewide or regional databases may help better track outcomes and identify late complications.

Aortic stiffness and related complications after endovascular repair of blunt thoracic aortic injury in young patients

VASA ◽

10.1024/0301-1526/a000858 ◽

2020 ◽

Vol 49 (4) ◽

pp. 295-300 ◽

Cited By ~ 1

Author(s):

Akram Youssef ◽

Igli Kalaja ◽

Usama Alkomi ◽

Tobias Abt ◽

Ralf-Thorsten Hoffmann ◽

...

Keyword(s):

Arterial Hypertension ◽

Stent Graft ◽

Aortic Stiffness ◽

Young Patients ◽

Cardiovascular Complications ◽

Aortic Injury ◽

Healthy Controls ◽

Summary: Background: This study aimed to evaluate the changes in aortic stiffness in young patients undergoing thoracic endovascular aortic repair (TEVAR) after blunt thoracic aortic injury (TBAI) and to examine the associated cardiovascular complications during follow-up. Patients and methods: We included survivors of TBAI who underwent stent graft placement between November 2009 and November 2019 and gave their consent to participate. Patients with relevant cardiovascular risk factors, comorbidities with potential impact on arterial stiffness, and prior aortic surgical or endovascular interventions were excluded. Fourteen TEVAR patients prospectively underwent clinical and noninvasive examinations and morphological imaging (mean time of follow-up and duration of implanted stent graft: 5.3 ± 1.8 years; mean age: 35.1 ± 8.7 years) and were compared to 14 healthy controls (matched for sex, age, height, and body mass index) in order to evaluate aortic stiffness. During the follow-up examinations, we assessed the pulse wave velocity (PWV; m/s) and development of arterial hypertension or heart failure, as indicated by N-terminal pro-brain natriuretic peptide (NT-proBNP; pg/mL) levels and performed echocardiography. Results: A significant increase in PWV values was recorded in the TEVAR group (median = 10.1; interquartile range [IQR] = 8.9–11.6) compared to the healthy controls (median = 7.3; IQR = 6.7–8.4), with an increase in the rank mean PWV (+ 3.8; Mann-Whitney U test p < .001). NT-proBNP levels of patients after TEVAR did not vary significantly compared to those of healthy controls (Mann-Whitney U test, p = .154). After TEVAR, five patients developed arterial hypertension during the follow-up, and three of them exhibited diastolic dysfunction. Conclusions: In young patients, TEVAR after TBAI may cause adverse cardiovascular complications due to increased aortic stiffness; therefore, screening for arterial hypertension during follow-up is recommended.

Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-020-01432-y ◽

2020 ◽

Author(s):

Dennis Hundersmarck ◽

Quirine M. J. van der Vliet ◽

Lotte M. Winterink ◽

Luke P. H. Leenen ◽

Joost A. van Herwaarden ◽

...

Keyword(s):

Quality Of Life ◽

Aortic Injury ◽

Health Related Quality ◽

Long Term Outcomes ◽

Thoracic Aortic Injury ◽

Related Quality ◽

Health Related

The effect of TEVAR for blunt traumatic thoracic aortic injury on maximal aortic diameter: Mid- and long-term outcome

Vascular ◽

10.1177/1708538119836333 ◽

2019 ◽

Vol 27 (4) ◽

pp. 411-416

Author(s):

Hozan Mufty ◽

Geert Maleux ◽

Sabrina Houthoofd ◽

Sandra A Cornelissen ◽

Kim Daenens ◽

...

Keyword(s):

Subclavian Artery ◽

Left Subclavian Artery ◽

Aortic Injury ◽

Aortic Diameter ◽

Preoperative Imaging ◽

Long Term Outcome ◽

Thoracic Aortic Injury ◽

Long Term Follow Up

Objective Thoracic endovascular aortic repair (TEVAR) has become the standard of care for blunt thoracic aortic injury (BTAI). Long-term effects of TEVAR on the aortic diameter are not well studied. This study evaluates the effect of TEVAR for BTAI on the aortic diameter in mid- and long-term follow-up. Methods All patients treated with TEVAR for BTAI between August 2000 and May 2016 were included. Maximum aortic diameter was measured at four predetermined thoracic aortic levels in the preoperative and first postoperative CT angiography (CTa) and in the last control CTa or MR angiography: 1 cm proximal (D1) and 1 cm distal to the left subclavian artery (D2), 3 cm distal to the left subclavian artery (D3) and 3 cm proximal to the celiac trunk (D4). Results A total of 27 patients (20 men, mean age 40 years (±17.55) were included. Mean follow-up time was 90 months (±48.36)). No re-interventions were needed. Mean growth of aortic diameter at level D1, D2, D3 and D4 was 0.22 mm ± 3.66, 1.79 mm ± 3.82, 0.73 mm ± 4.18 and –1.06 mm ± 2.82, respectively, when comparing last follow-up to the preoperative imaging without any statistical significant differences. When comparing the preoperative diameter with the first postoperative CT, only a statistical significant growth of 2.81 mm ± 2.69 was seen at level of D2 ( p < 0.05) Conclusion During mid- to long-term follow-up, a temporary significant increase of the maximum aortic diameter was seen at level D2 in the direct postoperative phase This increase was not associated with clinical events and suggests long-term efficacy of TEVAR after BTAI.

Μεσοπρόθεσμα και μακροπρόθεσμα αποτελέσματα της τοποθέτησης ενδαγγειακών προθέσεων στη θωρακική αορτή

10.12681/eadd/37893 ◽

2014 ◽

Author(s):

Κωνσταντίνος Σπηλιωτόπουλος

Keyword(s):

Risk Factors ◽

Cardiovascular Risk ◽

Injury Severity Score ◽

Injury Severity ◽

Aortic Injury ◽

Technical Success ◽

Stent Grafts ◽

Objective: Surveillance for patients undergoing Thoracic Endovascular AorticRepair (TEVAR) for Blunt Thoracic Aortic Injury (BTAI) varies. Empiricalrecommendation of annual chest CTA is often suggested. Concerns over risks andcosts have emerged. Evaluation of optimal follow-up frequency is attempted,based on 11-years outcomes and surveillance experience.Methods: 76 patients with BTAI received TEVAR from May 2002 to July 2013.Demographics, cardiovascular risk factors and Injury Severity Score (ISS), types,sizes, timing and outcomes of stent-grafts were retrospectively collected.Results: Mean age: 39.7 years (17-85), 8 (11%) females. Mean ISS: 46.2+/-18.5(deceased: 61.0+/-19.2, surviving: 44.2+/-17.6, p=0.023). Technical success: 71(93.4%). Mortality, all-cause: 7 (9.2%), of which, one (1.3%) was procedurerelated.Lost in follow-up: 6 (8%). To examine the effect of surveillance frequencyon outcomes, after excluding the 2 most recent (<1 year) surviving patients, wearbitrarily divided the remaining 61, with stable repairs, on the basis of theirfollow-up timing; 36: timely (+/- 6 months annual due visit) follow-up (clinical,CTA/MRA/echocardiogram). 25: delayed (>6 months annual due visit). Nosignificant differences found on survival, graft-related complications, need for reintervention,except from persistent hypertension, higher in 1st group. Allsurviving patients: excellent outcomes, no CVAs, paraplegia/paraparesis, medianfollow-up, both groups: 3 years (IQR 2.0-3.5, 1.5-5.4 years).Conclusions: Mid-term outcomes of TEVAR for BTAI patients with stable repairare excellent, both with timely (1.0-1.5 years) and delayed (>1.5 years) follow-upintervals at a median surveillance of 3 years. A larger prospective randomizedstudy could lead to a more relaxed, but equally safe surveillance schedule forthese patients, lowering both risks and costs.