Chimney parallel grafts and thoracic endovascular aortic repair for blunt traumatic thoracic aortic injuries: A systematic review

Background Whilst the management of blunt traumatic thoracic aortic injury has seen a paradigm shift to an ‘endovascular first’ approach, the limitations of thoracic endovascular aortic repair remain. An inadequate proximal landing zone limits the use of thoracic aortic stent grafts and in an emergent polytrauma setting, aortic arch debranching via open surgery may not be practical or feasible. A wholly endovascular approach to debranching utilising ‘off-the-shelf’ stents and parallel graft techniques may represent a possible solution. Hence, we sought to perform a systematic review investigating the use of chimney graft techniques alongside thoracic aortic stenting in blunt traumatic thoracic aortic injury. Methods We performed the systematic review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on Medline (PubMed), Web of Science and Scopus to identify articles describing the use of chimney grafts in traumatic aortic transection (PROSPERO: CRD42017082549). Results The systematic search revealed 172 papers, of which 88 duplicates were removed resulting in 84 papers to screen. Based on title, abstract and full text review, six articles were included for final analysis. There were nine patients in total with an average age of 41 (three females, five males, one unspecified), all with significant polytrauma, secondary to the mechanism of injury. A variety of stents were used between centres, with techniques showing a predominance to stenting of the left subclavian artery (77%, n = 7). The technical success rate was 82%, with two (18%) cases of type 1 endoleaks, of which one resolved spontaneously. Conclusions Despite the encouraging results, this by no means provides for a firm conclusion given the small sample size. Patients should still be judiciously selected on a case-by-case basis when employing the chimney graft technique. Larger cohort studies are needed to establish these findings.

Download Full-text

The endovascular repair of blunt traumatic thoracic aortic injury in Asia: A systematic review and meta-analysis

Vascular ◽

10.1177/1708538119828887 ◽

2019 ◽

Vol 27 (2) ◽

pp. 213-223 ◽

Cited By ~ 3

Author(s):

Xin Nee Ho ◽

Ian JY Wee ◽

Nicholas Syn ◽

Michael Harrison ◽

Lauren Wilson ◽

...

Keyword(s):

Systematic Review ◽

Endovascular Repair ◽

Meta Analysis ◽

Aortic Injury ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Aortic Repair ◽

Pooled Prevalence ◽

Thoracic Aortic Injury ◽

Related Mortality

Introduction Blunt traumatic thoracic aortic injury, the second leading cause of death from trauma, poses unique challenges in its management. However, there has not yet been a corresponding consolidated series of outcomes reported in Asia, which this systematic review aims to address. Method This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database for studies performed in Asia reporting the endovascular management of blunt traumatic thoracic aortic injury. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of pooled proportions were performed using the metaprop command in STATA. This review has been prospectively registered in PROSPERO (CRD42018083773). Results Sixteen retrospective cohort studies were included, reporting a total of 238 patients. The pooled Injury Severity Score was 32.5 (95%CI 27.8–37.1). The pooled mean time to operation from diagnosis was 39.2 hours (95%CI 24.6–53.8 hours), and operation time was 100 min (95%CI 63.5–136.5 min). The pooled rate of procedural conversion from endovascular repair to open surgery was 0.17% (95%CI 0–3.7%), and the proportion of left subclavian artery coverage was 55% (95%CI 37–72%). The pooled prevalence of intra-operative all-cause and aortic-related mortality was 0.72% (95%CI 0–4.9%) and 0.27% (95%CI 0–3.8%), respectively. The pooled prevalence of 30-day all-cause and aortic-related mortality was 2.2% (95%CI 0.16–5.6%) and 2.1% (95%CI 0–3.7%), respectively. In terms of 30-day complication, the pooled prevalence rates of type 1 endoleak, endograft complications, vascular access injury, strokes, and aortic re-rupture were 1.2%, 0.34%, 0.14%, 0.02%, and 0.01%, respectively. There were no cases of types II and III endoleak, and renal failure. Conclusion Short- to mid-term results for thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury in Asia are encouraging. However, there is a distinct disparity in reporting across Asia. We propose a prospective database for outcome reporting post thoracic endovascular aortic repair in this patient population, and ongoing follow up to assess long-term efficacy of this treatment strategy.

Download Full-text