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V. Fernández ValenzuelaPresidente da la SEACV
Servicio de Angiología, Cirugía Vascular y Endovascular
Vall d’Hebron Hospitals. Barcelona
Endovascular treatment of
Traumatic Thoracic Aortic
Injuries
INTRODUCTION
>80% deaths on scene
Concomitant injuries
In hospital deaths related aortic
rupture within first 4 hours.
Remaining deaths are due to
associated injuries.
1. Williams JS et al. Aortic injury in vehicular trauma. Ann Thorac Surg 1994;57:726-30.
2. Clancy TV et al. A statewide analysis of level I and II trauma centers for patients with
major injuries. J Trauma 2001;51:346-51.
3. Jamieson WR et al. Traumatic rupture of the thoracic aorta: third decade of experience.
Am J Surg 2002;183:571-5
Classification
Grade I: Intimal Tear
Grade II: Intramural
Hematoma
Grade III: Pseudoaneurysm
Grade IV: Rupture /
extravasation
Azizzadeh A, et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc
Surg 2009;49:1403-8.
I II
III IV
Impact of TEVAR
Open Repair 6-23% 9-50% 0-17%
Endovascular 0% 0-23% 0-2%
Industry
Research
Opportunity
(short lerning curve)
Other specialties
1. Kasirajan K et al. Acute thoracic aortic trauma. Ann Vasc Surg 2003;17:589-95.
2. Ott MC et al. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 56:565-70.
3. Amabile P et al. Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004;40:873-9.
4. Pacini D et al. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005;29:880-4.
5. Stampfl P et al. Mid-term results of conservative, conventional and endovascular treatment… Eur J Vasc Endovasc Surg 2006;31:475-80.
6. Andrassy J et al. Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta. J Trauma 2006; 60:765-71; discussion 771-2.
7. Broux C et al. Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective … Intensive Care Med 2006;32:770-4.
8. Reed AB et al. Timing of endovascular repair of blunt traumatic thoracic aortic transections. J Vasc Surg 2006;43:684-8.
Evidence
Less morbidity
and mortality
Possible local
anesthesia and
without heparin
Quick recovery
Graft durability
Surveillance.
Angio CT
Radiation
+ ?
Patients with Long life expectancy
VALLE DE HEBRON
October 1999 – December 2007 : 19
patients
Men 74%
Median age 31.2 (15-65)
Juxta-Infra subclavian 95%
Distal descending aorta 5%
100%
: EARLY RESULTS: VALLE DE HEBRON
Mortality 30 days 0%
Paraplegia 0%
Acces complications with surgical repair
Intended left subclavian artery oclusion
21%
53%
Z0Z1 Z2 3
4
5
6
7
Valentín Fernández, Gaspar Mestre, Jordi Maeso, et al.
Endovascular treatment of traumatic Thoracic aortic injuries:
Short and medium term follow-up. Ann Vasc Surg 2010; Feb
24(2) 160-6
Medium term: Valle de Hebron
Mortality 0%
Paraplegia 0%
Endoleaks 0%
Carotid-subclavian bypass 11 % 2
Aortic reinterventions 11% 2
Thrombosis endograft
Collapse endograft
Mean 40.12 month (0.3-86.6 m)
Valentín Fernández, Gaspar Mestre, Jordi Maeso, et al. Endovascular
treatment of traumatic Thoracic aortic injuries:
Short and medium term follow-up. Ann Vasc Surg 2010; Feb 24(2)
160-6
Collapse endograft
Mestres G, Maeso J, Fernández V, M Matas. Symptomatic collapse of a thoracic aorta
Endoprosthesis. J Vasc Surg. 2006;43:1270-3
Thrombosis endograft
Alvarez B, Constenla I, Maeso J, Matas M. Late thrombosis of a thoracic
aorta stentGraft: Therapeutic management. J Vasc Surg. 2009 Mar:49(3):774-7
Long-term: Valle de Hebron:
October 1999 – January 2015 : 34 patients
Follow-up 8,2 years (range 12-198 months.) Mortality 0%
Paraplegia 0%
Endoleaks 0%
Carotid-subclavian bypass 5,8 % 2
Aortic reinterventin 5,8% 2
Thrombosis endograft
Collapse endograft
Endoleaks type III 2,9% 1
Intragraft mural trombus 17,4% 6
Fracture of the longitudinal bar 5,8% 2 Marvin E García Reyes, Gabriela Gonçalves Martins, Valentín Fernández Valenzuela et al. Long-Term outcomes
of TEVAR focused on brird-beak and oversizing in blunt traumatic thoracic oartic injury. Ann Vasc Surg (in review)
Endoleaks type III
WHO AND WHENSHOULD WE OFFER SURGERY ?
EAST Guidelines 2000
Early repair SVS Guidelines 2011
Urgent repair >24 h EAST Guidelines 2015
Delay repair when possible ESVS Guidelines 2017**
Type II,III delay repair
Type IV emergency repair
II
III IV
**V. Riambau et al . Management of descending Thoracic aorta diseases.
Clinical Practice Guidelines of the ESVS. Eur J Vasc Endovasc Surg. 2017. 53, 4-52
P=0,009
WHO AND WHENSHOULD WE OFFER SURGERY ?
Median days delay repair
5,5 days (0 –180 days)
Valle de Hebrón
CONCLUSIONS
Endovascular repair of choice.
Good early results and during follow up.
Safely selecting patients for nonoperative or
delayed repair is challenging and requires
accurate assesment of lesion grade
TYPE I: conservative management.
TYPE II, III: delayed repair (semielective)
TYPE IV: emergency treatment