Dr. Kenton Rommens serves as a consultant for Gore Medical and Terumo Aortic. The remaining authors have no other disclosures or conflicts of interest.
The authors received no financial support for the research, authorship, and/or publication of this article.
Blunt thoracic aortic injury (BTAI) presents a significant challenge in trauma management in patients presenting with multi-system injury. It remains the second most common cause of death in the setting of blunt chest trauma [
GRADE classification of blunt thoracic aortic injury (BTAI).
|
Intimal tear Intramural hematoma Aortic pseudoaneurysm Aortic rupture |
Most patients with BTAI die before arriving at the hospital and in-hospital mortality has been reported to be as high as 46% [
Surgical management depends on both the degree of injury and the required triaging of concomitant injuries. Aortic rupture is a surgical emergency requiring immediate intervention. Intimal tears are managed with anti-impulse therapy alone. Intramural hematomas are usually treated using anti-impulse therapy, with surgical intervention individualized to the patient considered in a delayed fashion [
High risk features of aortic pseudoaneurysm in blunt thoracic aortic injury (BTAI).
| Aortic arch hematoma |
Thoracic endovascular aortic repair (TEVAR) is the mainstay of surgical intervention due to its superior survival rate compared to open repair, especially in unstable patients [
Novel innovations such as the Gore Thoracic Branched Endoprosthesis (TBE) add to the toolbox of the vascular surgeon in the setting of BTAI. In Canada, the TBE device has recently received Health Canada approval with limited authorized special access across the country. The use of a TBE device allows for Zone 2 stent graft deployment with simultaneous endovascular revascularization of the LSA. The following is the presentation of the first two Canadian cases of BTAI treated with the Gore TBE.
A 27-year-old male was involved in a motor vehicle collision at highway speeds. On arrival at a peripheral hospital, he was hemodynamically stable with a Glasgow Coma Scale score of 8. Endotracheal intubation was attempted for airway protection but failed, following which a cricothyrotomy was performed. The computed tomography (CT) scan showed a large traumatic hematoma centered in the left submandibular space, bilateral pulmonary hemorrhage, pneumomediastinum, subarachnoid hemorrhage, and a traumatic aortic injury with intimal tearing in Zones 2 and 3 of the aorta. This scan was initially interpreted as a Grade 1 injury.
The patient was transported to our tertiary level 1 trauma center. The BTAI was managed with anti-impulse therapy with agreement from the neurosurgery team. A repeat CT scan seven days later demonstrated progression to a Grade 3 BTAI, with a 1 cm pseudoaneurysm extending into Zone 2 on the inner curve of the aortic arch, as well as a codominant left vertebral artery (Supplementary Video 1; Supplementary Digital Content is available online at https://doi.org/10.26676/jevtm.33826). Due to the presence of the codominant vertebral artery and in the setting of TBI, it was felt that a Zone 2 TEVAR without subclavian revascularization was not appropriate. It was also felt that the presence of a surgical airway significantly increased the risk of a bypass graft infection with a left carotid-subclavian bypass. A Gore TBE device was immediatetly acquired.
The patient was brought urgently to the operating room. Using ultrasound guidance, percutaneous arterial and venous access was obtained. Systemic heparin was administered. A 12 F Gore dryseal sheath was advanced from the right femoral vein to the cavoatrial junction. A pigtail catheter was positioned in the ascending aorta from the left common femoral artery. A Lunderquist wire was positioned at the aortic root of the right common femoral artery and a 22 F Gore Dryseal sheath was advanced to the descending thoracic aorta. A snare sheath was advanced in a coaxial fashion from the right common femoral artery within the 22 F sheath and positioned in the descending thoracic aorta. From the left radial access, a 6F Terumo R2P sheath was advanced retrograde into the LSA. The descending thoracic aorta was cannulated from the LSA with a hydrophilic glide wire, which was subsequently snared. A 26 mm by 15 cm Gore TBE Aortic Component was advanced into the aortic arch, the C-arm was positioned with an extreme cross-table angulation, and an angiogram was performed. A cava balloon was advanced into the right atrium and inflated to induce systolic hypotension, allowing for precise deployment of the device. Final positioning of the graft was confirmed to be in Zone 2, just distal to the left common carotid artery as desired. The cava balloon was deflated, and a 12 mm by 6 cm long subclavian branch was then advanced, deployed, and post-dilated. Completion aortography demonstrated wide patency of the carotid and subclavian arteries. All devices and wires were subsequently removed, and all access sites were closed. A CT Angiogram obtained on post- operative day 4 demonstrated widely patent stent grafts with no endoleaks (Supplementary Video 2). The patient was discharged home on post-operative day 10. A 3-month follow-up CT demonstrated exclusion of the traumatic pseudoaneurysm and patent aortic and LSA stents.
The second case is that of a 65-year-old male who fell 10 m off scaffolding. The patient had loss of consciousness at the time of the event. His concomitant injuries included bilateral wrist fractures, rib fractures, and a right-sided pneumothorax. A CT scan was performed that demonstrated an aberrant right subclavian artery (RSA) and a Grade 3 BTAI, with a focal pseudoaneurysm at the origin of the aberrant RSA that projected superomedially and was surrounded by a mediastinal hematoma (Supplementary Video 3). The patient was transferred to our level 1 trauma center and anti-impulse therapy was initiated.
Upon arrival, the patient was taken to the operating room for a combined cervical debranching procedure and placement of the Gore TBE. It was determined that bilateral carotid subclavian bypasses would not be appropriate given the increased risk of airway compromise due to neck edema post-operatively, and a plan to revascularize his RSA with an open bypass and concomitant endovascular repair of his LSA was undertaken.
Appropriate exposure of the second portion of the aberrant RSA was obtained. The dissection was then extended medially allowing for exposure of the carotid sheath; the common carotid artery was proximally and distally controlled. In this case, the left axillary artery was exposed for direct placement of the LSA stent to avoid the use of radial access at the left wrist fracture.
After ultrasound-guided arterial and venous access was obtained, the patient was systemically heparinized. A bypass was then performed using a 6 mm polytetraflouroethylene propaten graft from the right common carotid artery to the second portion of the RSA.
After completion of the right carotid to subclavian bypass, the same procedure as described above was performed for deployment of the 34 mm × 15 cm TBE Aortic Component with a 15 mm × 6 cm LSA stent over a “through and through” wire passed from the left axillary artery. A aortography on completion demonstrated wide patency of the left subclavian branch and no signs of an endoleak. A CT angiogram obtained on post-operative day 1 demonstrated the expected persistent type II endoleak from retrograde flow related to the aberrant RSA (Supplementary Video 4). On post-operative day 2 the patient underwent the planned second stage of the intervention: successful coil embolization of the remnant pseudoaneurysm along the origin of the aberrant RSA. The patient was discharged home on post-operative day 9.
Ethical approval was not required. Informed consent was obtained from both patients in this case series.
The surgical management of BTAI continues to evolve. Historic management of BTAI prior to the endovascular era involved open repair via thoracotomy, aortic cross-clamping, and left-heart bypass, or deep hypothermic circulatory arrest. The advent of TEVAR ushered in a new era of management of BTAI with substantially reduced mortality and morbidity for patients [
Contraindications to left subclavian artery coverage in thoracic endovascular aortic repair (TEVAR) [
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Presence of left internal mammary artery coronary artery bypass graft Termination of the left vertebral artery in a posterior inferior cerebellar artery (PICA) Dominant left vertebral artery or occlusion of the right vertebral artery Functioning left arm arteriovenous fistula Prior infrarenal aortic repair with ligation or coverage of lumbar arteries Planned long-segment (20 cm) coverage of the descending thoracic aorta Hypogastric artery occlusion |
Non-revascularization of the LSA in TEVAR is associated with increased risk of stroke and spinal cord ischemia [
In trauma patients where proximal TEVAR and LSA revascularization is required, cervical debranching has been the intervention of choice. Complications due to cervical debranching procedures are not insignificant and can be observed in up to 30% of patients [
The TBE device has allowed vascular surgeons to electively treat proximal aortic arch pathology while maintaining perfusion to the LSA with excellent results to date in experienced centers [
This report demonstrates two successful percutaneous endovascular repairs of BTAI using the Gore TBE device to preserve left subclavian perfusion. Off-the-shelf branched thoracic endografts in BTAI should be considered by experienced TEVAR trauma centers in patients requiring LSA revascularization with appropriate anatomy who are at increased risk of complications from either Zone 2 TEVAR coverage alone or cervical debranching procedures. Widespread access to these devices will allow for further review of outcomes in this challenging patient population.
All the authors mentioned in the manuscript have agreed to authorship, read and approved the manuscript, and given consent for submission and subsequent publication of the manuscript.
The authors declare that they have read and abided by the JEVTM statement of ethical standards including rules of informed consent and ethical committee approval as stated in the article.
Available online at https://doi.org/10.26676/jevtm.33826.
Video of pre-operative computed tomography scan for case report 1.
Video of post-operative computed tomography scan for case report 1.
Video of pre-operative computed tomography scan for case report 2.
Video of post-operative computed tomography scan for case report 2.