V. Fernández ValenzuelaPresidente da la SEACV

Servicio de Angiología, Cirugía Vascular y Endovascular

Vall d’Hebron Hospitals. Barcelona

Endovascular treatment of

Traumatic Thoracic Aortic

Injuries

INTRODUCTION

>80% deaths on scene

Concomitant injuries

In hospital deaths related aortic

rupture within first 4 hours.

Remaining deaths are due to

associated injuries.

1. Williams JS et al. Aortic injury in vehicular trauma. Ann Thorac Surg 1994;57:726-30.

2. Clancy TV et al. A statewide analysis of level I and II trauma centers for patients with

major injuries. J Trauma 2001;51:346-51.

3. Jamieson WR et al. Traumatic rupture of the thoracic aorta: third decade of experience.

Am J Surg 2002;183:571-5

Classification

Grade I: Intimal Tear

Grade II: Intramural

Hematoma

Grade III: Pseudoaneurysm

Grade IV: Rupture /

extravasation

Azizzadeh A, et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc

Surg 2009;49:1403-8.

I II

III IV

Impact of TEVAR

Open Repair 6-23% 9-50% 0-17%

Endovascular 0% 0-23% 0-2%

Industry

Research

Opportunity

(short lerning curve)

Other specialties

1. Kasirajan K et al. Acute thoracic aortic trauma. Ann Vasc Surg 2003;17:589-95.

2. Ott MC et al. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 56:565-70.

3. Amabile P et al. Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004;40:873-9.

4. Pacini D et al. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005;29:880-4.

5. Stampfl P et al. Mid-term results of conservative, conventional and endovascular treatment… Eur J Vasc Endovasc Surg 2006;31:475-80.

6. Andrassy J et al. Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta. J Trauma 2006; 60:765-71; discussion 771-2.

7. Broux C et al. Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective … Intensive Care Med 2006;32:770-4.

8. Reed AB et al. Timing of endovascular repair of blunt traumatic thoracic aortic transections. J Vasc Surg 2006;43:684-8.

Evidence

Less morbidity

and mortality

Possible local

anesthesia and

without heparin

Quick recovery

Graft durability

Surveillance.

Angio CT

Radiation

+ ?

Patients with Long life expectancy

VALLE DE HEBRON

October 1999 – December 2007 : 19

patients

Men 74%

Median age 31.2 (15-65)

Juxta-Infra subclavian 95%

Distal descending aorta 5%

100%

: EARLY RESULTS: VALLE DE HEBRON

Mortality 30 days 0%

Paraplegia 0%

Acces complications with surgical repair

Intended left subclavian artery oclusion

21%

53%

Z0Z1 Z2 3

4

5

6

7

Valentín Fernández, Gaspar Mestre, Jordi Maeso, et al.

Endovascular treatment of traumatic Thoracic aortic injuries:

Short and medium term follow-up. Ann Vasc Surg 2010; Feb

24(2) 160-6

Medium term: Valle de Hebron

Mortality 0%

Paraplegia 0%

Endoleaks 0%

Carotid-subclavian bypass 11 % 2

Aortic reinterventions 11% 2

Thrombosis endograft

Collapse endograft

Mean 40.12 month (0.3-86.6 m)

Valentín Fernández, Gaspar Mestre, Jordi Maeso, et al. Endovascular

treatment of traumatic Thoracic aortic injuries:

Short and medium term follow-up. Ann Vasc Surg 2010; Feb 24(2)

160-6

Collapse endograft

Mestres G, Maeso J, Fernández V, M Matas. Symptomatic collapse of a thoracic aorta

Endoprosthesis. J Vasc Surg. 2006;43:1270-3

Thrombosis endograft

Alvarez B, Constenla I, Maeso J, Matas M. Late thrombosis of a thoracic

aorta stentGraft: Therapeutic management. J Vasc Surg. 2009 Mar:49(3):774-7

Long-term: Valle de Hebron:

October 1999 – January 2015 : 34 patients

Follow-up 8,2 years (range 12-198 months.) Mortality 0%

Paraplegia 0%

Endoleaks 0%

Carotid-subclavian bypass 5,8 % 2

Aortic reinterventin 5,8% 2

Thrombosis endograft

Collapse endograft

Endoleaks type III 2,9% 1

Intragraft mural trombus 17,4% 6

Fracture of the longitudinal bar 5,8% 2 Marvin E García Reyes, Gabriela Gonçalves Martins, Valentín Fernández Valenzuela et al. Long-Term outcomes

of TEVAR focused on brird-beak and oversizing in blunt traumatic thoracic oartic injury. Ann Vasc Surg (in review)

Endoleaks type III

WHO AND WHENSHOULD WE OFFER SURGERY ?

EAST Guidelines 2000

Early repair SVS Guidelines 2011

Urgent repair >24 h EAST Guidelines 2015

Delay repair when possible ESVS Guidelines 2017**

Type II,III delay repair

Type IV emergency repair

II

III IV

**V. Riambau et al . Management of descending Thoracic aorta diseases.

Clinical Practice Guidelines of the ESVS. Eur J Vasc Endovasc Surg. 2017. 53, 4-52

P=0,009

WHO AND WHENSHOULD WE OFFER SURGERY ?

Median days delay repair

5,5 days (0 –180 days)

Valle de Hebrón

CONCLUSIONS

Endovascular repair of choice.

Good early results and during follow up.

Safely selecting patients for nonoperative or

delayed repair is challenging and requires

accurate assesment of lesion grade

TYPE I: conservative management.

TYPE II, III: delayed repair (semielective)

TYPE IV: emergency treatment