Endovascular Management of Thoracic Aortic injury

Dr. Ayman Al-SibaieConsultant of Interventional Radiology

Rashid Hospital Dubai

Thoracic Aortic Pathology• Aortic Aneurysms• Thoracic Aortic Dissection• Aortic Ulcers and IM Hematomas• Traumatic Transection• Other Aortic Pathology

Blunt Thoracic Aortic Injury

Described by Vesalius, 1557 – Fall from horse – Most common distal to L SCA• Motor vehicles involved 92% • Falls, crush injury • Immediate death 60% - 80%

Arthurs et al. JVS. 2009;49:988-94. Demetriades. JACS. 2011;214:247-59.JACS.

Grading Aortic Injury

Azizzadeh, et al. JVS. 2009;49:1403-8.

Patient characteristic

• Young • Healthy • Compliance• Follow-up

Evolution of Management• 1997 – Angio or CTA– Immediate repair – Open surgery• 2013 – CTA– Delayed repair in stable patients – Endovascular when feasible (78%)

Mestral, et al. JACS. 2013;216:1110-1115.

Long-Term Outcomes• 27 patients from 2001-2011 – 4 Zenith TX1/2– 5 Gore TAG/CTAG – 18 Medtronic Valiant/Valiant-Captiva/Talent• LSAcovered15% • 4% endoleak (Type 1) • 7.4% early mortality • 0% paraplegia, stroke, arm ischemia

Martinelli, et al. JVS. 2013;58(3):832-5

Long-Term Outcomes

• Median follow-up 60 months – 22 patients – CTA• Graft infolding: 2 patients – Asymptomatic – Captiva 0.5 yr, Gore TAG 5 yr• Migration 2 patients – Asymptomatic – Zenith, 18 and 24 months

Martinelli, et al. JVS. 2013;58(3):832-5

SVS Clinical Practice Guidelines• Systematic review – 7768 patients

Lee, at al. JVS. 2011;53:187-92.

SVS Guidelines• TEVAR within 24 hours in stable patient – Barring other serious injuries• Expectant management Grade 1 injury – Repair all others• TEVAR in all age groups • Utilize next-generation devices• Selective revascularization LSA

Lee, at al. JVS. 2011;53:187-92.

SVS Guidelines• Systemic heparinization with low dose – Individualized to patient• Spinal drainage not routinely indicated• General anesthesia• Open femoral artery access• Follow-up necessary but not standardized – CTA vs MRA, frequency

Lee, at al. JVS. 2011;53:187-92.

RESCUE Trial• Medtronic Valiant Captiva• Prospective, 20 sites, 50 patients• Blunt thoracic aortic injury• 30-day all-cause mortality• Follow-up 1, 6, 12 months and yearly for 5 years with CTA or MRA

Khoynezhad A, et al. JVS. 2013;57:899-905.

RESCUE Trial• 68% Grade 3 injury, 18% Grade 1• Proximal aortic diameters 18 mm – 34 mm• Distal aortic diameters 18 mm - 42 mm• Partial or complete coverage LSA 58%• 8% early deaths, 1 possible related to device• No endoleaks

Khoynezhad A, et al. JVS. 2013;57:899-905.

TAG 08-02 Study

• Gore Conformable TAG (CTAG)• Prospective, 21 sites, 51 patients• Blunt thoracic aortic injury• 30-day all cause mortality• 30-day freedom from major device events• Follow-up 1 and 6 months, annually for 5 years

Farber M, et al. JVS. 2013;53:187-92..

TAG 08-02 Study• 98% tear >1 cm or more severe• Proximal aortic diameters 17 mm - 33 mm • Distal aortic diameters 16 mm - 34 mm • Partial or complete coverage LSA 63% • 7.8% early deaths, none device related • No MDEs • 2 endoleaks (Type II and unknown)

Farber M, et al. JVS. 2013;53:187-92..

Impact of New Devices• Smaller diameters – 16-mm diameter aorta• Tighter arches• Increased resistance to infolding – 0.4% with Gore TAG, 0% with Gore CTAG• Increased deployment accuracy

Kasirajan, et al. JVS. 2012;55:652-8.

Coverage LSA• 20-mm proximal landing zone (IFU)• Median distance LSA to tear: 13.5 (0-36) mm*• 1/3 patients will get arm claudication – Left vertebral artery <3mm (p<.0001)**• Rarely necessary with current devices – 5-mm landing zone adequate

*Khoynezhad, et al. JVS. 2013;57:899-905.**Antonello M, et al. JVS. 2013;57:684-90.

Follow-Up

• Greatest challenge of TEVAR for trauma• Longest life expectancy • Highly variable patient compliance • Difficult anatomy to image• Structural and physiologic consequences

Imaging Follow-up• CTA at discharge, 3 - 6 months, 1 year – Consider 2 - 5 year intervals – US and European guidelines• What we do (based on Gestalt) – CTA at discharge, 6 months, 1 year – CTA or MRA + CXR every 2 years – After 10 years, consider 5 year intervals

Lee, et al. JVS. 2011;53:187-92. Grabenwoger, et al. Eur Heart J. 2012;33:1558-63.

Physiologic Consequences• Post-endograft HPTN reported 2005 – 80% patients <35 with early HPTN – 36% HPTN at ≥13 months, 18% on Rx• Noncompliant endograft • Increased aortic pulse wave velocity • Increased pulse pressure

Tzilalis, et al. J Endovasc Ther. 2005;12:142-3. Tzilalis, et al. Ann Vasc Surg. 2012;26:462-7.

Aortic Pulse Wave Velocity

Tzilalis, et al. Ann Vasc Surg. 2012;26:462-7.

Case I

Case I

Case II

Case Report II

Case Report II

Case III

Case III

Case III

Summary• TEVAR for ≥Grade 2 injury – Observation Grade 1 injury• Delayed repair in stable patients• New devices resolve structural issues • Follow-up recommendations vague • Long-term outcomes remain unknown