Abstract No. 486 A single-center experience with endovascular management of aortic transection: unique features in aberrant right subclavian artery

Abstract

The mechanism of traumatic aortic transection usually involves sudden deceleration causing juxtaductal injury at the aortic isthmus secondary to tethering of the arch at this location. Aberrant right subclavian artery (ARSA) is the most common aortic arch variant, with an incidence reported in the literature of 0.5-2.5%. The ARSA typically arises distal to the ostium of the left subclavian artery with a retroesophageal course which causes more distal tethering of the aorta. As such, the pattern of aortic injury in the setting of ARSA is likely to differ from those encountered with a normal arch configuration. Retrospective review of all cases of aortic transection in the setting of trauma at a single-center from 2002 to 2017 identified 22 patients. Clinical data was obtained using electronic medical records. Images were reviewed using PACS. The mechanism of injury was motor vehicle collision in all 22 patients identified with aortic transection in the setting of blunt aortic injury from 2002 to 2017 at a single institution. Surgical repair was performed in 5 patients, 15 underwent percutaneous/hybrid repair, and 2 died without intervention. 20 of 22 patients had normal arch anatomy and the site of injury was at the isthmus. ARSA was present in 2/22 (9%) patients and in both patients the aortic rupture was distal to the ostium of the ARSA. These patients were both managed with aortic endograft placement and either surgical or endovascular right subclavian reperfusion. The aortic isthmus was injured in all patients with conventional arch anatomy, but both patients with ARSA sustained injury more distally beyond the ostium of the ARSA. We hypothesize that the ARSA variant anatomy alters the pattern of injury on the aorta secondary to differences in biomechanics and deceleration forces. This hypothesis could be further evaluated with data from a consortium of trauma centers. The variant anatomy and differences in injury pattern seen with ARSA have management implications, and we also review the special treatment considerations needed in the setting of ARSA with either surgical bypass or covering and fenestrating the ostium to maintain ARSA perfusion.