Endovascular Repair of Traumatic Thoracic Aortic Disruptions with "Stacked" Extension Cuffs

ENDOVASCULAR REPAIR OF TRAUMATIC THORACIC AORTIC DISRUPTIONS WITH "STACKED" EXTENSION CUFFS
Objective: Endovascular stent graft repair of a traumatic thoracic aortic disruption is rapidly becoming an accepted alternative to open surgical repair. The use of currently approved thoracic stent grafts, especially in younger patients with small, "steep" tapered aortas remains a concern due to acute endograft collapse and enfolding. The objective of this study, the largest report to date, was to evaluate the results of TTAD treated with abdominal aortic "stacked" extension cuffs, with follow-up extending to 44 months.
Methods: 29 patients with multi-system trauma (age range, 15 to 61; mean 31.4 years) were seen after motor vehicle accidents between January 1, 2003 and September 1, 2007. Chest x-ray findings warranted thoracic CT scans, which revealed disruptions of the thoracic aorta. Intraoperative arteriograms in all patients and IVUS (n = 17) delineated the extent of the aortic injuries and identified a "landing zone" (range 1.5 to 4.0 cms) distal to the subclavian artery, but proximal to the tear. The repairs were performed with Excluder (n = 15), AneuRx (n = 13), and Zenith (n = 1) aortic extension cuffs. A femoral artery approach was used in 25 patients and a suprainguinal retroperitoneal iliac approach in four. All patients underwent thoracic CT scans during follow-up.
Results: In all patients the stent-graft cuffs successfully excluded the traumatic disruptions: 23 patients had two cuffs, 5 three cuffs and one, 4 cuffs. The aorta adjacent to the injury mean diameter was 18.5mm (range 17 - 24mm). No subclavian arteries were covered. Two patients required an additional cuff for exclusion of the Type I endoleaks at the distal attachment site within two months of initial endograft repair. There were no procedure-related deaths; two patients died of other injuries. At follow-up extending to 40 months (range 3 to 44 months) two distal Type I endoleaks occurred which required open operative repair: one due to infection and one aortic size disparity. CT in all other survivors demonstrated no device related complications, endoleaks or cuff migrations.
Conclusion: Stent-graft repair of traumatic thoracic aortic disruptions is technically feasible. The technique of "stacked" aortic cuffs provides an acceptable option when urgent therapy is needed, when patients are deemed high-risk for open operative repair, or until thoracic endografts are designed which can safely treat focal, smaller aortic diameter injuries.