Blunt Aortic Injury Research Articles

Large-Bore Transfemoral Arterial Access: Techniques and Troubleshooting

AbstractAortic pathologies such as dissection, aneurysm, or blunt aortic injury have historically been treated via open surgical repair; however, the advent of endovascular stent graft technology has allowed for endovascular aortic repair in more and more patients. With improvements in stent graft technology and delivery systems, more patients are now candidates for endovascular aortic repair; however, many will require large-bore transfemoral arterial access. Percutaneous transfemoral arterial access includes the introduction of a large-bore sheath directly into the iliofemoral arterial system for the deployment of aortic stent grafts. Advancements in percutaneous arterial closure and reductions in device delivery profiles have further refined this technique; however, careful preprocedural planning and technical precision are required to minimize complications. This article covers the fundamentals of large-bore transfemoral arterial access as well as technical pearls for successful outcomes.

Multi-center experience with an off-the-shelf single retrograde thoracic branch endoprosthesis for acute aortic pathology.

The thoracic branch endoprosthesis (TBE®, WL Gore, Flagstaff AZ) offers an off-the-shelf single option for thoracic endovascular aortic repair (TEVAR) of aortic arch pathology with sealing in zones 0-2. This study reports the early outcomes of TBE®-TEVAR for acute indications. Clinical data, imaging, and outcomes of patients treated with TBE®-TEVAR at seven institutions were retrospectively reviewed (March 2017- March 2024). Patients treated for complicated aortic dissection, symptomatic aneurysm/pseudoaneurysm (PSA), or blunt traumatic aortic injury (BTAI) by urgent/emergent repair were included. End-points were 30-day mortality, major adverse events (MAEs: mortality, myocardial infarction, prolonged intubation, stroke, paraplegia, dialysis, or bowel ischemia), and technical success. Of 356 patients treated by TBE®-TEVAR, 107 (69.0% male, mean 60±15 years-old) underwent repair for acute indications including 70 (65%) dissections, 21 (20%) symptomatic aneurysms/PSA and 16 (15%) BTAIs. Eight (8%) patients had repair immediately after open ascending repair of a Type A dissection. Proximal sealing was in zone 2 in 91 patients (89%) and zone 0-1 in 11 patients (11%) who required cervical debranching. Technical success was achieved in all (99%) except one patient with acute dissection and aneurysmal degeneration requiring staged repair. At 30-days, two (2%) patients died and 19 (18%) developed MAEs, including stroke in 6 (6%) and paraplegia in 6 (6%). Five patients (5%; all Zone 2) had retrograde dissections, all treated for acute or subacute dissection, with no mortality. Mean follow up was 55±171 days and 96 (94%) patients had follow-up imaging. Type IA or III endoleak occurred in seven patients (7%), retrograde branch occlusion in one (1%), and eleven (10%) required re-intervention. Cumulative aortic-related mortality was three (3%) from aortic rupture. Urgent/emergent TEVAR with the Gore TBE® device in acute pathology offers low mortality, stroke and paraplegia risk. Longer follow up is needed to assess effectiveness of the repair.

Endovascular intervention in patients with blunt traumatic thoracic aortic injury: Early results

Aim: Mortality rates are high in thoracic aortic injuries caused by blunt trauma. Thoracic endovascular aortic repair (TEVAR) is the most commonly employed surgical strategy for patients with blunt traumatic thoracic aortic injuries (BTTAI) due to its favorable outcomes. This study aims to present our endovascular experience in treating Type B aortic dissections resulting from blunt trauma. Material and Methods: Our retrospective study included 70 patients who underwent TEVAR for Stanford Type B aortic dissection due to blunt aortic injury. Patients who were under 22 and over 70 years of age, those who underwent emergency TEVAR, died in a hospital emergency, and had penetrating aortic injury, head traumas with neurological symptoms and requiring intervention, aortic pathology other than Type B aortic dissection, or aortic rupture were excluded from the study. Results: Of the patients, 34.3% (n=24) were female, and 65.7% (n=46) were male, with a mean age of 48.54±10.00 years. The most common cause of injury was motor vehicle accidents (81.4%, n=57). No statistically significant difference was found between patients regarding the locations of the landing zones (p>0.05). Conclusion: Early outcomes in selected patients demonstrate high survival rates following TEVAR for trauma-induced Type B dissections.

Long Term Outcomes of Endovascular Repair in Blunt Traumatic Aortic Injury: A Twenty Year Multicentre Follow Up Study

This retrospective, multicentre, observational study analysed patients who underwent endovascular repair for blunt traumatic aortic injury at four tertiary trauma referral centres over twenty years. It aimed to determine early and long term survival, analyse aortic and device related complications, and assess the re-intervention rate after endovascular repair for blunt traumatic aortic injury. All patients treated from 1 January 2001 to 31 October 2021 were identified using local hospital registries and two national registries: the Swedish vascular registry (Swedvasc) and Swedish trauma registry (SweTrau). Patient, treatment, and follow up data were extracted from medical records and radiology data by review of congregated imaging. The report was structured according to the STROBE checklist. Ninety five patients were included: 80 were male (84%), median age was 42 years (IQR 27, 64), and median follow up time was 6.1 years (IQR 0.7, 12.4). Thirty day mortality was 16% (15 of 93), 40% of these were caused by traumatic brain injury and 33% of aortic related causes. Estimated overall survival was 57% (SE 6.6) at fifteen years after index treatment. Aortic re-intervention procedures (re-stenting, coiling, or explantation) were performed in 14 of 86 (16%) patients, six of whom underwent stent graft explantation. Seven of the 14 patients (50%) who underwent aortic re-intervention presented with symptoms and six of 14 had a device related complication. All complications that required aortic re-intervention were diagnosed within 18 months after the index procedure. There was no association between injury grade and aortic re-intervention. Thoracic endovascular aortic repair is an effective treatment for patients with blunt traumatic aortic injury needing intervention. It carries low rates of device related complications and mortality, and the long term outcomes are acceptable. As all aortic complications requiring re-intervention were identified during the first two years after index treatment, with half of the patients reporting symptoms, future follow up protocols should be adjusted accordingly.

The optimal management of blunt aortic injury in the young

BackgroundBlunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset. MethodsPatients (1–19 years of age) with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 14-years. Patients were stratified by age group (children [ages 1–9] and adolescents [ages 10–19]) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in adolescents with BAI. ResultsAdolescents undergoing TEVAR had similar morbidity (16.8 vs 12.6 ​%, p ​= ​0.057) and significantly reduced mortality (2.1 vs 14.4 ​%, p ​< ​0.0001) compared to those adolescents managed non-operatively. MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (OR 0.138; 95%CI 0.059–0.324, p ​< ​0.0001). ConclusionsBAI leads to significant morbidity and mortality for both children and adolescents. For pediatric patients with BAI, children may be safely managed non-operatively, while an endovascular repair may improve outcomes for adolescents.

Iliac transposition technique for reconstruction of aortic bifurcation in pediatric blunt abdominal aortic injury

Blunt abdominal aortic injuries, especially in pediatric patients, represents a rare and critical challenge. We report a unique case of a 10-year-old boy who presented after a high-speed motor vehicle collision resulting in injury to the aortic bifurcation, alongside other intra-abdominal trauma. A novel surgical approach for aortoiliac reconstruction in a contaminated field was used. This technique consisted of the mobilization of the distal aorta and common iliac arteries, ligation of right internal iliac artery, and creation of aortoiliac and common to internal iliac artery anastomoses. This method demonstrates a potentially lifesaving technique in select patients.

Predictive factors for size change of aorta in patients with acute blunt traumatic aortic injury.

We aimed to investigate the changes in aorta size, the factors affecting size changes in patients with acute blunt traumatic aortic injury and to evaluate the adequacy of the current 120% thoracic endovascular aortic repair graft oversizing policy. This retrospective review study was conducted using the prospectively collected medical records of 45 patients (mean age: 53.5years, male: 39 patients) with blunt traumatic aortic injury treated at a level 1 trauma center between 2012 and 2021. Aortic diameter was measured by computed tomography angiographic images at four different levels [ascending aorta (A), isthmus (B), descending thoracic aorta (C), and infrarenal aorta (D)] on arrival and follow-up (median time interval, 13days). Associated factors including patient characteristics and hemodynamic parameters on arrival and follow-up were collected to determine their influence on changes in the aorta. The mean diameter of all four aortic levels increased on follow-up computed tomography compared to initial computed tomography (A: + 11.77%, B: + 10.19%, C: + 7.71%, D: + 12.04%). Patient age and injury severity score influenced changes in the diameter of the ascending aorta (P < 0.05). Patient age and blunt traumatic aortic injury grade were significantly associated with changes in the infrarenal aortic diameter (P < 0.05). Three cases of type 1 endoleak were observed at follow-up but all were spontaneously resolved without further intervention at next computed tomography follow-up. In patients with acute blunt traumatic aortic injury, aortic diameter is significantly smaller by about 10% under shock and is not considered a basis for oversizing the currently implemented 120% thoracic endovascular aortic repair graft sizing. However, in young patients under the age of 40, the change is significantly large and subsequent computed tomography follow-up is required.

430 Experience of Blunt Aortic Injury at a Major Trauma Centre: A Retrospective, Single-Centre Study

430 Experience of Blunt Aortic Injury at a Major Trauma Centre: A Retrospective, Single-Centre Study

Beyond the Slopes and Highways: Endovascular Repair of Blunt Traumatic Aortic Injuries after Skiing versus Motor Vehicle Accidents.

Background: Blunt traumatic aortic injury (BTAI) is a potentially fatal condition, typically resulting from high-velocity trauma. To date, little is known about this type of injury among skiers, who form the largest patient cohort with aortic injuries in the alpine region of Tyrol, Austria. Methods: This retrospective, single-center study at the University Hospital of Innsbruck analyzed patients who underwent endovascular treatment for blunt traumatic aortic injury from 2005 to 2023. Patient data were extracted from electronic and digitalized medical history records. Subsequent analyses compared the baseline characteristics and clinical results of the skiing accident (SA) group to the motor vehicle accident (MVA) group. Results: A total of 48 BTAI patients receiving TEVAR were included, 25 (52%) from SAs versus 23 (48%) from MVAs, who were predominantly male (92% vs. 78.3%). Despite similar preoperative risk profiles and ASA Scores (1.44 vs. 1.74) and no marked differences in BTAI injury grades or the affected aortic zones, significant disparities emerged: the SA group experienced shorter median ICU stays (3 vs. 11 days, p = 0.0007), fewer concomitant injuries (5 vs. 7, p = 0.005), and lower Injury Severity Scores (ISSs) (29 vs. 33, p = 0.003) than their MVA counterparts. The presence of rib fractures alongside other thoracic injuries, such as lung injury, pneumothorax, or hemothorax, was strongly correlated with BTAI in patients following skiing accidents (OR = 128.5). Conclusions: The injury severities and locations of BTAI in SA patients were comparable to those in MVA patients, indicating similar mechanisms of thoracic trauma. However, the SA patients experienced fewer concurrent pelvic and extremity fractures, had less post-procedural morbidity, and required shorter ICU stays. The presence of rib fractures combined with other thoracic injuries strongly suggests BTAI. These indicators should lead to prompt imaging and appropriate therapy.

A systematic review of blunt abdominal aortic injury and analysis of predictors of death.

At present, research on blunt abdominal aortic injury (BAAI) is limited, with the majority being case reports. Consequently, there is a significant knowledge gap concerning this condition. To address this, we conducted a systematic review by extensively searching major databases. We included all literature that provided individual (non-identifiable) data on BAAI patients, irrespective of the study design. Furthermore, we undertook regression analyses to identify predictors of death after BAAI. The search yielded 2,099 results, leading to the inclusion of 102 case reports and one conference abstract. Using the Joanna Briggs Institute (JBI) checklist for assessment, all studies were deemed of medium to high quality. In total, 133 patients were included, with a median age of 34 years, and 73.7% being male. The predominant clinical manifestation was pain, reported in 65.6% of patients. The most frequently observed aortic lesion severity was grade A (intimal tear or intramural hematoma) at 46.9%, and the most common lesion location was zone III (infrarenal aorta) in 88.3% of cases. The overall mortality after BAAI was 15.3%. Multivariate regression analyses revealed the following predictors of death after BAAI: lower limb ischemia (relative risk [RR] = 7.137, 95% confidence interval [CI] 1.154 - 44.161), cardiopulmonary arrest (RR = 10.250, 95% CI 1.452 - 72.344), and injuries to body parts other than the abdomen and lumbar spine (RR = 2.593, 95% CI 1.189 - 5.655). In conclusion, this review provides a detailed quantitative summary of BAAI's clinical manifestations, diagnosis, treatment, and prognosis, emphasizing its high mortality rate and identifying three critical variables as predictors of death.

Early survival benefit of a low-profile endograft in blunt traumatic aortic injury

ObjectiveThe aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. MethodsA prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality. ResultsThe cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. ConclusionsRelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.

Endovascular Repair Blunt Thoracic Aortic Injury in Adolescent: A Case Series.

Blunt traumatic aortic injury (BTAI) is a rare occurrence in adolescents, yet it is associated with a high mortality rate necessitating immediate treatment. Although endovascular repair has become the preferred treatment for such injuries in adults, its effectiveness in adolescents remains uncertain. Blunt traumatic aortic injury typically presents with concomitant injuries to other organs and carries a high perioperative mortality rate with operative repair (OR). In this report, we describe the treatment of 3 clinical cases of BTAI in adolescents using thoracic endovascular aortic repair (TEVAR). These cases contribute pertinent evidence supporting the efficacy of intravascular repair for BTAI. Operative repair (OR) remains the gold standard for treating BTAI in adolescents. Nevertheless, TEVAR therapy presents a viable alternative for patients with multiple injuries in whom anticoagulation is contraindicated. Further long-term observation is necessary to assess the lasting effects of TEVAR therapy. This study has provided insights into endovascular repair for adolescent BTAT, offering clinicians significant reference material for choosing treatment strategies for adolescent BTAT. The study aims to demonstrate the safety and effectiveness of endovascular repair treatments in a series of clinical cases involving adolescent BTAI.

Using machine learning to predict outcomes of patients with blunt traumatic aortic injuries.

The optimal management of blunt thoracic aortic injury (BTAI) remains controversial, with experienced centers offering therapy ranging from medical management to TEVAR. We investigated the utility of a machine learning (ML) algorithm to develop a prognostic model of risk factors on mortality in patients with BTAI. The Aortic Trauma Foundation registry was utilized to examine demographics, injury characteristics, management and outcomes of patients with BTAI. A STREAMLINE (A Simple, Transparent, End-To-End Automated Machine Learning Pipeline Facilitating Data Analysis and Algorithm Comparison) model as well as logistic regression (LR) analysis with imputation using chained equations was developed and compared. From a total of 1018 patients in the registry, 702 patients were included in the final analysis. Of the 258 (37%) patients who were medically managed, 44 (17%) died during admission, 14 (5.4%) of which were aortic related deaths. Four hundred forty-four (63%) patients underwent TEVAR and 343 of which underwent TEVAR within 24 hours of admission. Among TEVAR patients, 39 (8.8%) patients died and 7 (1.6%) had aortic related deaths ( Table 1 ). Comparison of the STREAMLINE and LR model showed no significant difference in ROC curves and high AUCs of 0.869 (95% confidence interval, 0.813-0.925) and 0.840 (95% confidence interval, 0.779-0.900) respectively in predicting in-hospital mortality. Unexpectedly, however, the variables prioritized in each model differed between models. The top 3 variables identified from the LR model were similar to that from existing literature. The STREAMLINE model, however, prioritized location of the injury along the lesser curve, age and aortic injury grade. Machine learning provides insight on prioritization of variables not typically identified in standard multivariable logistic regression. Further investigation and validation in other aortic injury cohorts are needed to delineate the utility of ML models. Prognostic and Epidemiological; Level III.

Blunt Aortic Injury and a Liver Laceration after a Motor Vehicle Collision

An 80 year old male restrained driver was involved in a motor vehicle collision when his vehicle struck a tree. The patient was transported to a level 1 trauma center. He was alert and able to follow commands. He gave a past history of hypertension and hypothyroidism. His medications included dilantin and thyroxine but he could not recall the names of the blood pressure medications. The initial vital signs were as follows: Blood pressure – 145/85, Pulse – 73, Respiration -20. The oxygen saturation was 92%. The Glasgow coma Scale score was 15.

Anatomic Feasibility of In-Situ Fenestration for Isolate Left Subclavian Artery Preservation during Thoracic Endovascular Aortic Repair Using an Adjustable Needle Puncturing System.

To evaluate the feasibility of thoracic endovascular aortic repair (TEVAR) using the Ankura™ device (Lifetech Scientific, Shenzhen, China) with left subclavian artery (LSA) in-situ fenestration (ISF) using an adjustable puncture device system. It is a single center, retrospective, financially unsupported cohort study of TEVAR performed from 16 February 2007 to 10 January 2023. Inclusion criteria were isolate LSA revascularization for elective or urgent/emergent "zone 2" TEVAR, and the availability of the preoperative computed tomography angiography. Post-hoc analysis identified 52 TEVARs. There were 39 (75.0%) males, and 13 (25.0%) females: median age was 74.5 years (IQR, 65.5-78). Index TEVAR was performed for atherosclerotic aneurysm in 27 (51.9%) cases, dissection-related diseases in 18 (34.6%), penetrating aortic ulcer in 5 (9.6%), and blunt traumatic aortic injury in 2 (3.8%). Access-vessel feasibility rate of TEVAR using the Ankura™ device would have been 98.1% (51/52). Considering the morphology of the aortic arch, ISF TEVAR feasibility would have been 61.5% (32/52). Binary logistic regression analysis identified LSA angulation (OR: 1.1, 95%CI: 1.03-1.14, p = 0.003) to be associated with ISF feasibility using this endograft and a self-centering adjustable needle-based puncture device. Potential feasibility of TEVAR using the Ankura™ endograft with ISF using a self-centering adjustable needle system was 61.5%. Left subclavian artery angulation seems to be the most important and limiting anatomical constraint.

Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury

SVS Grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury. A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with PRISMA guidance. Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% CI 6.7% - 14.9%) for all-cause mortality, 2.9% (95% CI 1.1% - 5.7%) for aorta-related mortality and 3.3% (95% CI 1.4% - 6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8). Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data supports nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.

Thoracic branch endoprosthesis repair of grade 3 blunt aortic injury in the setting of an aberrant retroesophageal right subclavian artery

Thoracic branch endoprosthesis repair of grade 3 blunt aortic injury in the setting of an aberrant retroesophageal right subclavian artery

Surgeon-Modified Fenestrated Stent-grafts for Zone 2 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injury: Early and Midterm Results.

Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery. Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period. The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I. TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA. Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis.

Blunt aortic injury is the second most prevalent cause of patient fatalities post-trauma, closely following head injuries as the leading cause. In recent years, thoracic endovascular aortic repair (TEVAR) has evidently improved survival rates and reduced complications in patients suffering from blunt traumatic aortic injury (BTAI) in comparison to open surgery and non-operative management. It is difficult to characterize the appropriate criteria for the timing of TEVAR, whether early or delayed for BTAI, considering the discrepancies related to timing. Electronic databases, including PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase, were searched through April 2023. The primary outcomes were short-term mortality and hospital and intensive care unit (ICU) stays. Time to TEVAR, acute respiratory distress syndrome, sepsis, deep vein thrombosis, delayed stroke, and renal failure were also evaluated. We included a total of seven studies, comprising 4177 patients who met the inclusion criteria. Short-term mortality was significantly higher in the early TEVAR group (RR: 1.86; 95% confidence interval (CI); (1.26-2.74); p<0.001; I2=33%). In contrast, the ICU length of stay was significantly shorter in the early group (mean difference: -2.82 days; 95% CI; (-4.09 - -1.56); p<0.0001; I2=55%). There was no significant difference between both groups in the presenting profile or postoperative complications. Patients undergoing delayed TEVAR had markedly lower mortality rates but a longer ICU stay. The need for future studies with more robust designs is imperative to investigate the factors influencing the timing of repair and the associated outcomes.

Endovascular reconstruction of aortic bifurcation for aortic pseudoaneurysm in a pediatric trauma patient

Endovascular treatment options for vascular injury in pediatric patients are quite limited owing to concerns regarding long-term durability and the lack of devices suitable for the pediatric anatomy. However, in rare circumstances, open surgical therapy will not be an option, and patients will require unconventional endovascular solutions for lifesaving or limb-saving therapies. In the present report, we describe an endovascular treatment of a pediatric patient for whom initial surgical management of a blunt abdominal aortic injury had failed, with subsequent development of an aortic pseudoaneurysm. A 10-year-old girl had presented after a high-speed motor vehicle accident with a seatbelt sign. Multiple abdominal injuries were identified, including blunt aortic injury, significant devitalization of the small bowel, colonic perforation with fecal contamination, multiple lumbar spine fractures, and pulmonary contusions. The patient developed bilateral lower extremity ischemia from the aortic injury and had initially undergone open repair. One month later, the patient had developed a pseudoaneurysm of the aorta near the aortic bifurcation. Because of the hostile abdomen and ensuing short gut syndrome, the pseudoaneurysm was managed using endovascular techniques. The limb of an Excluder internal iliac branch endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ) was used as the endograft. The aortic bifurcation was raised and reconstructed using four Viabahn self-expanding stents (W.L. Gore & Associates). The completion angiogram showed complete resolution of the pseudoaneurysm. The follow-up computed tomography angiogram showed widely patent stent grafts with complete resolution of the pseudoaneurysm. Endovascular management of traumatic vascular injuries in pediatric patients is feasible. The likelihood of reintervention in the future is high with patient growth. However, it is a viable option in lifesaving or limb-saving situations in which open repair is high risk.