Invited Commentary

Abstract

The management of traumatic aortic injury (TAI) has shifted considerably during the past decade from immediate open repair through a left thoracotomy to delayed endovascular repair (TEVAR) [1Lee W.A. Matsumura J.S. Mitchell R.S. et al.Endovascular repair of thoracic aortic injury: clinical practice guidelines of the Society of Vascular Surgery.J Vasc Surg. 2011; 53: 187-192Abstract Full Text Full Text PDF PubMed Scopus (411) Google Scholar]. However, TEVAR for TAI using early-generation stents was associated with adverse events inherent to a disease that affects young individuals with a small-diameter aorta and an acute-angled aortic arch, and a technology in infancy: stiff and poorly conformable stents with sharp bare components. The end result was a high incidence of adverse events such as stent collapse, type I proximal endoleak, and perforation. The outstanding outcomes reported by Zipfel and colleagues [2Zipfel B. Chiesa R. Kahlberg A. et al.Endovascular repair of traumatic thoracic aortic injury: final results from the Relay Endovascular Registry for Thoracic Disease.Ann Thorac Surg. 2014; 97: 774-781Abstract Full Text Full Text PDF Scopus (31) Google Scholar] summarizing the results of TEVAR in 40 patients with TAI treated in 22 European centers with use of the new-generation Relay stent reflect both the learning curve of the operators and improved stent technology. The authors chose the aortic arch (Z1 and Z2) as the proximal landing zone in 40% of cases, minimized oversizing, and used balloon dilation in only 2 patients (5%). These technical details, together with an improved stent technology, resulted in a procedural success rate of 100% and no case of stent collapse, type I endoleak, or perforation. Use of the shortest possible stent accounted, most likely, for the lack of postprocedural spinal cord injury. Similar outcomes were recently reported in the RESCUE trial, wherein a different type of newer-generation stent was used [3Khoynezhad A. Azizzadeh A. Donayre C.E. Matsumoto A. Velazquez O. White R. on behalf of the RESCUE investigatorsResults of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial).J Vasc Surg. 2013; 57: 899-905Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar]. These results are far superior compared to historical reports of open repair. Two points must be emphasized. The first is the frequent lack of a stent of adequate size. In the RESTORE registry, oversizing occurred in 30% of cases and resulted in the single midterm adverse event of penetration of the distal end. Use of a stent of inadequate size (usually too large) might occur either because it is not commercially available or because it is not stocked by the hospital. These factors must be addressed by the industry and trauma centers to optimize results. The second point is the short follow-up time. Although the 2-year results of the RESTORE registry are outstanding, lack of long-term follow-up in the very young patient is a major limitation. Nevertheless, the data of the RESTORE and similar recent trials strongly support the concept that TEVAR should be the approach of choice for TAI. Endovascular Repair of Traumatic Thoracic Aortic Injury: Final Results From the Relay Endovascular Registry for Thoracic DiseaseThe Annals of Thoracic SurgeryVol. 97Issue 3PreviewIn blunt thoracic aortic injury, thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to open chest surgery. New reliable and accurate stent grafts have widened the endovascular treatment options. We report our experience with the Relay stent graft Bolton Medical, Sunrise, FL; Barcelona, Spain) for treatment of this injury. Full-Text PDF