Aortic Transection Research Articles

Uncomplicated vaginal delivery 5 years after acute traumatic aortic transection and transluminal endovascular aortic repair

We describe the case of a 40-year-old patient who sustained an aortic transection in 2016 following a road traffic accident and had two subsequent full-term pregnancies. This case adds to the literature on pregnancy after endovascular aortic repair.

SURGICAL TREATMENT OF THORACIC AORTA TRANSECTION BY CONTUSIVE TRAUMA: CASE REPORT

Traumatic injuries to the thoracic aorta are rare events with high mortality. Several treatment modalities are described, including: conservative treatment, endovascular techniques, and conventional surgery. The objective of this work is to report the conventional surgical treatment and its evolution of a thoracic aorta transection injury. Case Report: Patient, F.R. 25 years old, victim of blunt motor trauma x shield, was admitted to the unit with chest pain plus signs of shock, a chest CT scan was performed and a grade IV blunt injury to the thoracic aorta and fracture of the right femur were identified, evolving with hypotension, tachycardia and anemia. A posterolateral thoracotomy was performed and, after control and exploration of the hematoma, a lesion with aortic transection was found, with an interposition using a Dacron prosthesis, with a satisfactory clamping time followed by chest drainage. External fixation of the D femur fracture was performed during the same surgery. Red blood cell concentrates were used during the operative period. The patient was admitted to the ICU, on mechanical ventilation, sedated and with amines and blood drains. He developed AKI due to rhabdomyolysis, requiring hemodialysis. A new CT scan showed hemothorax on the right side, and a thoracostomy on the right side was performed on the second day after the first surgery. The patient progressed with weaning from sedation and extubation 5 days after the first surgical procedure, but maintained anemia and mild hypoxia. A new CT scan showed a left hemothorax associated with a small pneumothorax, and a videothoracoscopy was performed on left with evacuation of the clot plus drainage. a good evolution of the condition, with improvement in hematic parameters and renal insufficiency, with gradual removal of the drains. Discharged from hospital without further complications.

Impact of preoperative left pulmonary artery stenting on the Fontan procedure: a retrospective multicentre study.

Left pulmonary artery (LPA) or bifurcation stenoses at Fontan palliation can be very challenging to treat and may also require cardioplegia and aortic transection. Moreover, the low pressure of Fontan circulation and the bulkiness of the aorta increase the risk of a patch angioplasty collapse. Pre-Fontan LPA stenting of stenotic LPAs overcomes those drawbacks therefore the present study aimed to evaluate its advantageous impact on Fontan surgery. A multicentre retrospective analysis was performed on 304 consecutive Fontan patients. The study population was divided into 2 groups (LPA stented, n = 62 vs not stented, n = 242); pre-and postoperative data were compared. LPA-stented patients had a higher prevalence of systemic right ventricle (P = 0.01), hypoplastic left heart syndrome (P = 0.042), complex neonatal palliations (Norwood/Damus-Kaye-Stansel) and surgical LPA patch repair at Glenn (P < 0.001). No differences were found in cross-clamp rates, early (P = 0.29) and late survival (94.6% vs 98.4, P = 0.2) or complications (P = 0.14). Complex palliations on ascending aorta/aortic arch (P = 0.013) and surgical LPA repair at Glenn (P < 0.001) proved to be risk factors for LPA stenting before Fontan at multivariable analysis. The LPA-stented group showed similar outcomes in terms of survival and complications rate compared to patients without LPA stenosis; however, they significantly differ in their higher preoperative risk profile and in their more complex anatomy. Complex neonatal palliations involving ascending aorta or aortic arch may increase the risk of pulmonary branches stenosis requiring stenting; therefore, preoperative stenting of LPA stenoses could help to reduce the surgical risk of complex Fontan procedure by avoiding the need for cross-clamp or complex mediastinal dissections to perform a high-risk surgical repair.

Emergency endovascular stent grafting for aortic transection following a shotgun injury.

Emergency endovascular stent grafting for aortic transection following a shotgun injury.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR

BackgroundAortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft.Case presentationA 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway.ConclusionAortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

Pseudoaneurysm After Endovascular Repair of Aortic Transection

Pseudoaneurysm After Endovascular Repair of Aortic Transection

Surgical Repair of Acute Traumatic Aortic Transection Using Partial or Left Heart Bypass: Our Experience of Six Cases

Aortic transection following blunt trauma chest is one of the main life-threatening situations requiring early intervention. The endovascular approach is now preferred; however, in some conditions, an open approach is warranted. We describe our experience of dealing with acute traumatic transection in six such patients over the past 3 years.

O064 Management of acute aortic syndrome with evolving individualized precision medicine solutions: lesson learned over two decades and literature review

Abstract Introduction Thoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndromes (AAS) management using minimally invasive and adaptive surgical techniques. Methods This is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Amongst 96 with symptomatic aortic thoracic pathologies, 71 had AAS. Our primary endpoint was combined aneurysm and cardiovascular-related mortality. Results There were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA)) with a mean age of 69. All AAH received optimal medical therapy (OMT) and TAT underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had aortic dissection, of which 31 developed TAA. These 58 received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed left subclavian chimney graft with TEVAR in 12 patients. Average follow-up was 78.2 months, and 11 patients (15.5%) had combined aneurysm and cardiovascular-related mortality. None had stroke or bowel ischaemia. 26% developed endoleaks, and 15% required re-intervention (type II &amp; III). Four patients had paraplegia (5.7%) and succumbed to death from renal failure. Eight IMH patients on OMT died within 30 days. Conclusion Acute aortic hematoma necessitates close monitoring and early intervention. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Our experience shows that minimally invasive techniques could be a viable option for AAS.

Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review.

Thoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades. This is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality. There were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation. Acute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.

Aortic Injury From High-Speed Deceleration Against a Lap Belt in a 10-year-Old.

Traumatic aortic injuries in children and adolescents are rare, and even more rare are blunt traumatic injury to the abdominal aorta in this population. Therefore, there are few reports discussing the presentation and repair of such injuries, especially within the pediatric population. We report the successful repair of traumatic abdominal aortic transection in a 10-year-old female after a high speed MVC. She arrived in extremis with a seatbelt sign and was taken emergently for damage control laparotomy with subsequent postoperative CT findings of aortic transection/dissection at L3 with active extravasation. She immediately underwent open thrombectomy of the bilateral iliac arteries, and repair of her aortic injury with a 12 × 7mm Hemashield interposition graft extending just distal to the IMA and 1cm proximal to the aortic bifurcation. There are little data regarding long-term outcomes of pediatric patients undergoing different aortic repair techniques, and further research is needed.

In Situ Laser Fenestrations of Aortic Endografts for Emergent Aortic Disease

In situ laser fenestration (ISLF) is a novel endovascular technique which allows customization of a standard stent graft to a patient's anatomy. While most reported cases involve revascularization of the left subclavian artery (LSA), some centers have now reported their initial experience treating branches of the visceral aorta for aortic aneurysms. The aim of this study is to examine the adoption of ISLF in emergent aortic pathology at a specialized aortic center. Between December 2020 and February 2022, all patients who underwent ISLF as part of endovascular intervention for complex aortic pathology at a university hospital were identified. Cases were collected from a prospective aortic database with additional information obtained from a retrospective review of electronic hospital records. Fifteen patients (11 men and 4 women) underwent emergency ISLF, with a median age of 76years. Eleven presented with symptomatic or ruptured aortic aneurysms, three with acute complicated aortic dissections and 1 aortic traumatic transection. Most aortic aneurysms were thoraco-abdominal (n=7), with 1 arch, 1 thoracic, 1 supra-renal, and one-juxta-renal aortic aneurysm. ISLF was performed to revascularize the LSA in 8 cases, and branches of the reno-visceral aorta in 7 cases. All LSA ISLF cases had left brachial artery exposure. Femoral access was percutaneous in 14 of 15 cases. Technical success was 96.3% (26/27)). Median ischemic times were: superior mesenteric artery 7min, renal arteries 22min, and celiac trunk 43.5min. There were 2 early aortic/fenestration related reinterventions. There was no stroke and 1 death caused by heparin-induced thrombocytopenia within 30days. The majority of patients did not require intensive care admission (n=8). The median intensive care unit stay was 0days and hospital length of stay 18days. There was no fenestration endoleak or reintervention post discharge with a median follow-up of 168days. ISLF is a promising new technique that can show excellent technical results in experienced aortic centers, even during the learning curve. While custom-made devices with reinforced fenestrations are preferred in nonemergent situations, ISLF is a feasible option for complex aortic pathology in the acute setting when open surgery is not feasible.

CO29 The Very Long-Term Durability of TEVAR for Traumatic Aortic Transection Determined by Real-World Evidence

CO29 The Very Long-Term Durability of TEVAR for Traumatic Aortic Transection Determined by Real-World Evidence

Disparities in reporting and representation by sex, race, and ethnicity in endovascular aortic device trials.

Vulnerable populations, including women and racial and ethnic minorities, have been historically underrepresented in clinical trials. We, therefore, studied the demographics of patients enrolled in pivotal endovascular aortic device trials in the United States. We queried the Food and Drug Administration (FDA) medical devices database for all FDA-approved endografts for the treatment of aortic aneurysms, transections, and dissections from September 1999 to November 2021. These included abdominal endovascular aortic repair (EVAR), thoracic EVAR (TEVAR), fenestrated EVAR (FEVAR) devices, and dissection stents. Multiple cases of approval for expanded indications were included separately. The primary outcomes included the proportion of trials reporting participant sex, race, and ethnicity and the proportion of enrolled participants across sex, racial, and ethnic groups. The FDA provided 29 approvals from 29 trials of 24 devices: 15 EVAR devices (52%), 12 TEVAR devices (41%), 1 FEVAR device (3.4%), and 1 dissection stent (3.4%). These trials had included 4046 patients. Of the 29 trials, all had reported on the sex of the participants, and the median female enrollment was 21% (interquartile range [IQR], 11%-34%). The EVAR trials had the lowest female enrollment (11%; IQR, 8.7%-13%) compared with 41% (IQR, 27%-45%) in the TEVAR trials, 21% in the FEVAR trial, and 34% in the dissection stent trial (P< .01 for the difference). Only 52% of the trials had reported the three most common racial groups (White, Black, Asian), and only 48% had reported Hispanic ethnicity. The TEVAR trials were the most likely to report all three racial groups and Hispanic ethnicity (92% and 75%, respectively), while the EVAR trials had the lowest reporting rates (13% and 20%, respectively). Where reported, the median enrollment of racial and ethnic groups across the trials was as follows: Black patients, 9.8% (FEVAR, 0%; EVAR, 1.9%; TEVAR, 12%; dissection stent, 25%; P= .01); Asian patients, 2.4% (EVAR, 0.6%; FEVAR, 2.4%; TEVAR, 2.5%; dissection stent, 11%; P= .24); and Hispanic patients, 3.8% (EVAR, 1.3%; FEVAR, 2.4%; TEVAR, 3.9%; dissection stent, 4.1%; P= .75). Racial and ethnic minority groups were underrepresented and underreported in pivotal aortic device trials that led to FDA approval. Female patients were also underrepresented in these aortic trials, especially for EVAR. These data suggest the need for standardization of reporting practices and minimum thresholds for minority and female participation in pivotal trials to promote equitable representation.

Akut aort transeksiyonlarının endovasküler tedavisinde başarıyı etkileyen faktörler

Amaç: Bu çalışmada Akut Aort Transeksiyonu tanısıyla 2002 – 2018 yılları arasında endovasküler tedavi ile tedavi edilmiş hastaların sonuçları ve başarıyı etkileyebilecek faktörleri sunmak amaçlanmıştır.&#x0D; Gereç ve Yöntem: Çalışmaya toplam 17 hasta dahil edilmiş olup retrospektif olarak planlanmıştır. Hastaların tüm verilerine dosyaları taranarak ulaşılmış ve tüm hastaların demografik verileri kaydedilmiştir. Çalışmaya dahil edilen tüm hastalardan yazılı onam belgesi alınmıştır. Hastaların travma şekilleri ve cinsiyet oranları yüzdelik olarak hesaplanmıştır. Kesin tanı için kontrastlı torakoabdominal bilgisayarlı tomografi çekilerek endovasküler tedavi açısından değerlendirme yapılmıştır. Endovasküler tedaviye uygun görülen tüm hastalara ilk 24 saat içinde müdahale edilmiştir.&#x0D; Bulgular: Çalışmamıza dahil edilen hasta grubunun evrelemesinde büyük çoğunluğu evre 4 hastalar oluşturmakta olup etiyolojide en büyük sebebin araç içi trafik kazaları olduğu göze çarpmaktadır. Çalışmaya dahil edilen 17 hastanın 2’si erken dönemde 1’i takip sürecinde kaybedilmiştir. Endovasküler tedavinin komplikasyonları olarak bilinen greftte migrasyon, psödoanevrizma ve greftte kıvrılma gibi komplikasyonlar ile karşılaşılmamıştır. On yedi hastanın 12’sinde sol subklaviyen arter kapatılmış olmasına rağmen sadece ikisine karotis – subklaviyen baypas uygulama ihtiyacı oluşmuştur.&#x0D; Sonuç: Konvansiyonel cerrahiye oranla endovasküler tedavinin düşük mortalite ile uygulanabiliyor olması akut aort transeksiyonlarında mortaliteyi azaltmaktadır. Müdahalenin ilk 24 saatte, bu konuda deneyimli merkezlerde yapılması ve greft seçiminde aort çapının %10’unun aşılmaması, balon dilatasyonundan kaçınılması tedavi başarısını etkileyen en önemli faktörlerdendir.

A RARE DİAGNOSİS AFTER A TRAFFİC ACCİDENT AORTİC TRANSECTİON

Traumatic aortic transection is mostly seen in blunt injury and associated with motor vehicle accidents. %80-%85 of the patients with the aortic transection die at the scene of the incident and the rest of the patients who is delivered to the hospital ,have %20 mortality rate. Even with the endovascular repair, these patients have considerably high mortality. On the other hand the diagnosis and the prognosis of aortic transection has been continously improving. &#x0D; Furthermore the treatment requires a combination of pharmacological and surgical techniques and the endovascular treatment playing a very important role in definitive repair. &#x0D; In this report we present a patient who is admitted to the ER after an in-vehicle car accident.&#x0D; The possibility of aortic injury should always be considered in cases admitted to hospital due to trauma, and if there is any suspicion, necessary examinations should be performed also cardiovascular surgeon should be consulted immediately.

GORE® TAG® conformable thoracic stent graft for the treatment of descending aortic pathologies.

Endovascular repair of the descending thoracic aorta has gained widespread acceptance as a primary treatment modality for thoracic aortic disease due to its minimally invasive approach and improved survival rates. GORE® TAG® Conformable Thoracic Stent Graft was designed for descending thoracic aortic aneurysms, penetrating ulcers, aortic transections and type B aortic dissections, which are accepted indications for endovascular therapy. The aim of this review is to summarize the clinical literature, focusing mainly on the publications that came from manufacturer's pre-market and post-market studies. Including the Global Registry for Endovascular Aortic Treatment (GREAT), sponsored by WL Gore & Associates (Flagstaff, AZ, USA), which is a large database of endovascular repair of various thoracic, abdominal and thoraco-abdominal aortic pathologies to identify and evaluate only those with isolated thoracic aortic pathology (arch and descending thoracic).

TEVAR and Delayed Left Subclavian Artery Chimney for Thoracic Aortic Transection

A 57 years old male presented to the ED with blunt trauma due to a high fall. On presentation the patient was unstable (Systolic BP- 70, HR -120). The procedure was performed in two sessions. An emergency deployment of a Zenith Alpha (COOK Medical) thoracic endo-graft in the descending thoracic aorta with intentional covering of the left subclavian artery. The patient was stabilized in ICU. Due to left upper limb ischemia a parallel "chimney" Be-Graft (BENTLEY) covered balloon expandable stent was deployed in the left subclavian artery (retrograde approach) after 24 hours from the index procedure. Patient was mobilized with complete recovery after 48 hours. Completion CTA revealed complete resolution of the thoracic rupture with patent left subclavian "chimney" stent.

TEVAR and Delayed Left Subclavian Artery Chimney for Thoracic Aortic Transection

TEVAR and Delayed Left Subclavian Artery Chimney for Thoracic Aortic Transection

Short-term results of chimney stent revascularization of left subclavian artery and Zone 2 thoracic endovascular aortic repair for patients with aortic dissection or transection

Background In this study, we present the short-term results of revascularization of left subclavian artery with the chimney technique in patients with aortic dissection or transection who underwent Zone 2 thoracic endovascular aortic repair. Methods A total of 11 patients (6 males, 5 females; mean age: 56.4±11.5 years; range, 38 to 76 years) who underwent Zone 2 thoracic endovascular aortic repair procedure and left subclavian artery revascularization with the chimney technique between April 2017 and January 2020 in our clinic were retrospectively analyzed. All patients were followed at one, three, six months and one year with computed tomography angiography. Results The mean follow-up was 19.7±14.5 (range, 6.3 to 45.8) months. Endoleak occurred in one (9%) patient and gutter leak occurred in three (27%) patients. The mean endoleak-free (including gutter leak) time was 19.9±5.4 (95% confidence interval: 9.36-30.34) months. No mortality occurred in any of the patients. No occlusion occurred in the chimney grafts. Conclusion The chimney revascularization technique is an alternative to other revascularization techniques of the left subclavian artery during thoracic endovascular aortic repair.

Endovascular Intervention in Blunt Traumatic Aortic Injury: Experience in Ramathibodi Hospital

Background: Blunt thoracic aortic injury (BTAI) or transection is associated with high morbidity and mortality. Current standard practice recommended endovascular repair over open surgical repair, especially in patients with suitable anatomy. Objective: The authors reviewed our center experiences with endovascular repair of BTAI. Materials and Methods: Medical records of patients with BTAI treated with endovascular repair in the past 7 years at Ramathibodi Hospital were reviewed. Baseline demographic data, Injury Severity Score (ISS) at index events, procedure details and follow-up evaluation of clinical symptoms and imaging were obtained and analyzed. Results: From September 2014 to May 2020, 10 patients (8 men, 2 women) with mean age of 44.9+22.8 years (range 13 to 90), and mean ISS of 35.7+16.1 (range 20 to 66), were diagnosed with BTAI. Nine of them underwent uneventful endovascular repair, while one patient experienced iatrogenic cardiac tamponade. All endovascular repair procedures were performed under general anesthesia, and none of the patients received heparin due to multiple co-trauma or undergoing operation for other associated injuries. Endovascular stent grafts covered left subclavian arteries in 8 of 10 patients. There was no immediate complication in term of dead, post-procedural stroke or paraplegia as well as no symptom of left arm claudication or ischemia was reported. Mean follow-up duration was 25.5+24 months (range 2 to 73), with at least one computerized tomography angiography (CTA) performed in each patient. Neither endoleak nor stent migration were documented. Conclusion: Despite the small number of patients at our center, endovascular repair of BTAI appeared to be safe and had satisfactory outcomes. However, further long-term follow-up is needed for evaluation of durability and late complications. Keywords: BTAI; Endovascular stent