Thoracic endovascular aortic repair for traumatic aortic transection

Abstract

Traumatic transection of the thoracic aorta is a highly morbid injury. Treatment may be delayed while attention focuses on concomitant injuries. Thoracic endovascular aortic repair (TEVAR) is effective but remains controversial in these often-young patients. We reviewed our experience in acute and subacute treatment of these injuries with TEVAR. A retrospective analysis of five men and five women who underwent TEVAR for aortic transection from 1999 to 2007 was conducted. Procedures were performed with standard endovascular techniques. Follow-up included computed tomography at 1 month and yearly thereafter. Mean age was 44 years (range, 20 to 84 years). Motor vehicle accidents accounted for 7 injuries, a snowmobile accident for 1, skydiving for 1, and balloon angioplasty of a coarctation for 1. Average diameter of the proximal landing zone was 25 mm (range, 23 to 29 mm). Mean external iliac size was 10 mm (range, 7 to 15 mm), and no conduits were required. Immediate technical success was 90%, with no 30-day mortality. Seven patients underwent repair acutely (< or =24 hours) and three patients subacutely (range, 4 days to 2 months) for pseudoaneurysm. Four patients had procedures for concomitant injuries before their transection was repaired (3 laparotomies and a fixation for open fracture). One endoleak was noted, which resolved by the 1-month follow-up. The lone device-related complication was an endograft collapse at 5 months managed by repeat endografting, which was complicated by aortoesophageal fistula requiring esophagectomy and open reconstruction. No iliac injuries occurred. At 20-months of mean follow-up (range, 2 to 70 months), all patients are alive and well. TEVAR for traumatic aortic transection is feasible, with good initial success. Repair can be delayed in selected cases. Continued surveillance is necessary to ensure good long-term outcomes in these young patients. Care must be taken when performing TEVAR for this off-label indication because these devices are designed for the larger aortic diameters of aneurysm patients.