Megan Brenner1, William Teeter, Muhammed Hadud, Melanie Hoehn, James O'Connor, Deborah Stein, Thomas Scalea. 1. From the University of Maryland School of Medicine (M.B., W.T., M.H., J.O.C., D.S., T.S.), Division of Trauma/Critical Care RA Cowley Shock Trauma Center, and Division of Vascular Surgery (M.B., M.H.), University of Maryland School of Medicine, Baltimore, Maryland.
Abstract
BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has largely replaced traditional open aortic repair for anatomically suitable lesions, however, long-term outcomes are unknown. METHODS: All patients who underwent TEVAR from December 2004 to October 2015 at a single tertiary care institution were included. Demographics, injury pattern, operative details, outcomes, and surveillance were reviewed. Follow-up ranged from 2 to 132 months and was obtained from clinic notes and imaging reports. RESULTS: A total of 88 patients underwent TEVAR; all suffered from blunt mechanisms, 72.7% were men. Median age, Injury Severity Score, and Trauma and Injury Severity Score was 47 (19.7), 38 (13.5), 0. 8 (0.34). Injuries included 2% grade II, 90% grade III, and 8% grade IV. Overall mortality was 6.8%, TEVAR-related mortality was 0%. Overall in-hospital complication rate was 57%, whereas TEVAR-related complication rate was 9.1%: four typ 1a endoleaks, two typ 2, and two typ 3. Of the typ 1 endoleaks, all required reoperation, whereas all types 2 and 3 endoleaks resolved on subsequent imaging. The left subclavian artery (LSCA) was intentionally covered at index operation in 19 patients (21.6%), and 7 patients (8%) had partial LSCA coverage. The rate of postoperative left upper extremity ischemia was 0%. Left carotid-subclavian bypasses were performed prophylactically in two patients before LSCA coverage at index operation. Eighty-seven percent of endograft access was by performed by open femoral artery exposure and one via retroperitoneal conduit. Percutaneous TEVAR (pTEVAR) was performed more recently in 11.4% of patients with no complications. Heparin was administered intraoperatively in 23 patients with TBI, and 12 patients were not heparinized; no adverse events or outcomes resulted from its use or lack thereof. First, second, and third surveillance imagings occurred at mean intervals of 14 days, 4 months, and 1 year, respectively. Percent of patients followed at 1, 3, and 5 years from operation was 62.1%, 25%, 13.6%, respectively. CONCLUSION: TEVAR continues to be a feasible treatment modality for blunt traumatic aortic injury with minimal and early device and procedure-specific complications. Follow-up continues to be a significant challenge, and protocols for surveillance imaging are needed. This is the first study to describe access specific outcomes of pTEVAR in trauma patients. Long-term outcomes of TEVAR are still largely unknown; however, these data suggest that it may be at least comparable to open repair. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level V.
BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has largely replaced traditional open aortic repair for anatomically suitable lesions, however, long-term outcomes are unknown. METHODS: All patients who underwent TEVAR from December 2004 to October 2015 at a single tertiary care institution were included. Demographics, injury pattern, operative details, outcomes, and surveillance were reviewed. Follow-up ranged from 2 to 132 months and was obtained from clinic notes and imaging reports. RESULTS: A total of 88 patients underwent TEVAR; all suffered from blunt mechanisms, 72.7% were men. Median age, Injury Severity Score, and Trauma and Injury Severity Score was 47 (19.7), 38 (13.5), 0. 8 (0.34). Injuries included 2% grade II, 90% grade III, and 8% grade IV. Overall mortality was 6.8%, TEVAR-related mortality was 0%. Overall in-hospital complication rate was 57%, whereas TEVAR-related complication rate was 9.1%: four typ 1a endoleaks, two typ 2, and two typ 3. Of the typ 1 endoleaks, all required reoperation, whereas all types 2 and 3 endoleaks resolved on subsequent imaging. The left subclavian artery (LSCA) was intentionally covered at index operation in 19 patients (21.6%), and 7 patients (8%) had partial LSCA coverage. The rate of postoperative left upper extremity ischemia was 0%. Left carotid-subclavian bypasses were performed prophylactically in two patients before LSCA coverage at index operation. Eighty-seven percent of endograft access was by performed by open femoral artery exposure and one via retroperitoneal conduit. Percutaneous TEVAR (pTEVAR) was performed more recently in 11.4% of patients with no complications. Heparin was administered intraoperatively in 23 patients with TBI, and 12 patients were not heparinized; no adverse events or outcomes resulted from its use or lack thereof. First, second, and third surveillance imagings occurred at mean intervals of 14 days, 4 months, and 1 year, respectively. Percent of patients followed at 1, 3, and 5 years from operation was 62.1%, 25%, 13.6%, respectively. CONCLUSION:TEVAR continues to be a feasible treatment modality for blunt traumatic aortic injury with minimal and early device and procedure-specific complications. Follow-up continues to be a significant challenge, and protocols for surveillance imaging are needed. This is the first study to describe access specific outcomes of pTEVAR in traumapatients. Long-term outcomes of TEVAR are still largely unknown; however, these data suggest that it may be at least comparable to open repair. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level V.
Authors: Yaset Caicedo; Linda M Gallego; Hugo Jc Clavijo; Natalia Padilla-Londoño; Cindy-Natalia Gallego; Isabella Caicedo-Holguín; Mónica Guzmán-Rodríguez; Juan J Meléndez-Lugo; Alberto F García; Alexander E Salcedo; Michael W Parra; Fernando Rodríguez-Holguín; Carlos A Ordoñez Journal: Eur J Med Res Date: 2022-10-17 Impact factor: 4.981