TEVAR for traumatic aortic tear: The Queensland experience.Adeli B, Gale J, Boyne N, McGahan T, Jackson M, Golledge J, Wu R, Buckenham T, Walker PJ. Department of Vascular Surgery, Royal Brisbane & Women’s Hospital,University of Queensland, Department of Surgery and Centre for Clinical Research, Brisbane, Australia.
TEVAR has become an established treatment for traumatic aortic tears(TAT) in many centres worldwide.No individual centre has a large experience with this condition.
The aim of this project wasto establish a Queenslandregistry to document theclinical presentation,procedural outcomes, andfollow-up results of TEVARfor traumatic aortic injury.
Funding was obtained from the CONROD-RACS TraumaFellowship to establish a state-wide registry with theagreement and participation of the Vascular Surgery Unitsthroughout Queensland. Agreement was obtained from the New Zealand Registry toallow us to mirror their data set.Inclusion criteria blunt traumaExclusions deaths before intervention penetrating trauma (eg GSW, fish bone)
Data was collected on aretrospective basis on patientsalready treated, and for new casesthe data is being collected on aprospective basis.Data sheets and a SPSS databasewere developed Patient demographics & risk factors Trauma aetiology Procedural details including adjunctive procedures Outcomes
Between 1996 and 2010 38 patients underwentTEVAR for blunt TATmean age 43 years (range 17-78)80% (n=30) male36 acute < 2 weeks 2 chronic 33 , 155 days
MVA 19MBA 10Falls 4Crush injury 3 2x work related 1x farm machineryPush bike 1Hang glider towed by car 1
All had significant associated injuries, predominantlymusculoskeletal and lung injury.40% haemodynamically unstable at some stagepreoperatively; five patients had a systolic BP <100mmHg recorded pre-op in hospital.GCS was normal in 63%.ASA grade: ASA1 18% ASA2 9% ASA3 27% ASA4 46%
Patient IDMean time between admission and surgery was 180 hr, 12 min (range 34mins - 155 days); Median 11 hours, 19 minsFor the acute (<2 week) patients 55 hours, 5 minutes
42% (n=15) had their TEVAR on the day of admission34% (n=13) had their TEVAR on day two.One half had surgery outside normal hours.
All procedures were performed under GA in a: Surgical Theatre 22 Endovascular Suite 10 Radiology Suite 6
Femoral in 36 cases (95%)Iliac in two patients one direct CIA access one iliac conduit
Cook Zenith TX2 22Cook TBE 3Medtronic Talent 8WL Gore TAG 3 mean of 1.1 devices one prosthesis in 35 patients, 2 in 2 patients, 3 in 1 patient
left SCA wascovered in 11cases (29%)no other archvessels werecovered
Two patients required ilio-femoral bypass graftsfor iliac vessel injury.No patient required conversion to open repair.
Mean procedure time was 2 hrs and 15 mins(median 2:01; range 59 mins – 4:45) Patient ID
no procedures were abandonedno conversions to open repair2 patients required further stent-grafting during their initialadmission for proximal and distal endoleaks1 perioperative death due to multisystem failure (2.6%)morbidity occurred in 23 patients (42%).
Graft related 2 endoleaks required further stenting – 1 endoleak persistsNeurological There was no instance of paraparesis / paraplegia 1 TIA ( blurred vision in right eye for few minutes)Other 4 patients had groin / access site complications 1 infection and 3 fluid collection/haematoma 4 post implantation fever with no defined sepsis 4 prolonged ventilation and 2 others suffered pneumonia 1 patient suffered a PE and received an IVC filter 2 patients developed ARF (not requiring dialysis)
Mean hospital stay was 49 days (median 27, range 3 - 328 days) Patient ID
FU range 10 days– 11 years37 alive at last FU17 lost to FU (refuse travel / treatment / reviews elsewhere)Mean FU for 20 patients still under surveillance = 20.4months1 persisting endoleak – no further treatment so far1 left CCA-SCA bypass for arm claudication and subclaviansteal symptoms @ 2years post TEVAR1 left CCA-SCA bypass for arm claudication @ 5 weeks –complicated by post-op Horner’s syndrome1 persistent L thigh numbness from groin incision @ 28 weeks
The early results of TEVAR for TAT in Queensland patients arecomparable to those reported by other centers around the worldLow in hospital and 30 day mortality (2.6%)No paraplegiaLow stent graft related complication rateNo MigrationSignificant hospital LOSConcerning loss to FU (45%)
Long-term surveillance will enable us to determine the late outcomeand durability of this technique particularly in younger individuals.In the future, it is hoped to combine with the NZ Registry, and ultimatelyto expand to a bi-national online registry including all states andterritories and encompassing all indications for TEVAR as already occursin NZ.