DR. AYMAN AL SIBAIE

1. Endovascular Management of
Thoracic Aortic injury
Dr. Ayman Al-Sibaie
Consultant of Interventional Radiology
Rashid Hospital Dubai

2. Thoracic Aortic Pathology
• Aortic Aneurysms
• Thoracic Aortic Dissection
• Aortic Ulcers and IM Hematomas
• Traumatic Transection
• Other Aortic Pathology Traum
a 10%
other
5%
Dissection
25%
TAA
60%

3. Blunt Thoracic Aortic Injury
Described by Vesalius, 1557
– Fall from horse
– Most common distal to L SCA
• Motor vehicles involved 92%
• Falls, crush injury
• Immediate death 60% - 80%
Arthurs et al. JVS. 2009;49:988-94.
Demetriades. JACS. 2011;214:247-59.JACS.

5. Grading Aortic Injury
John Kaufman,
Grading Aortic Injury
Azizzadeh, et al. JVS. 2009;49:1403-8.

10. Patient characteristic
• Young
• Healthy
• Compliance
• Follow-up

11. Evolution of Management
• 1997
– Angio or CTA
– Immediate repair
– Open surgery
• 2013
– CTA
– Delayed repair in stable patients
– Endovascular when feasible (78%)
Mestral, et al. JACS. 2013;216:1110-1115.

12. Long-Term Outcomes
• 27 patients from 2001-2011
– 4 Zenith TX1/2
– 5 Gore TAG/CTAG
– 18 Medtronic Valiant/Valiant-Captiva/Talent
• LSAcovered15%
• 4% endoleak (Type 1)
• 7.4% early mortality
• 0% paraplegia, stroke, arm ischemia
Martinelli, et al. JVS. 2013;58(3):832-5

13. Long-Term Outcomes
• Median follow-up 60 months
– 22 patients
– CTA
• Graft infolding: 2 patients
– Asymptomatic
– Captiva 0.5 yr, Gore TAG 5 yr
• Migration 2 patients
– Asymptomatic
– Zenith, 18 and 24 months
Martinelli, et al. JVS. 2013;58(3):832-5

14. SVS Clinical Practice Guidelines
• Systematic review
– 7768 patients
Lee, at al. JVS. 2011;53:187-92.

15. SVS Guidelines
• TEVAR within 24 hours in stable patient
– Barring other serious injuries
• Expectant management Grade 1 injury
– Repair all others
• TEVAR in all age groups
• Utilize next-generation devices
• Selective revascularization LSA
Lee, at al. JVS. 2011;53:187-92.

16. SVS Guidelines
• Systemic heparinization with low dose
– Individualized to patient
• Spinal drainage not routinely indicated
• General anesthesia
• Open femoral artery access
• Follow-up necessary but not standardized
– CTA vs MRA, frequency
Lee, at al. JVS. 2011;53:187-92.

17. RESCUE Trial
• Medtronic Valiant Captiva
• Prospective, 20 sites, 50 patients
• Blunt thoracic aortic injury
• 30-day all-cause mortality
• Follow-up 1, 6, 12 months and
yearly for 5 years with CTA or MRA
Khoynezhad A, et al. JVS. 2013;57:899-905.

18. RESCUE Trial
• 68% Grade 3 injury, 18% Grade 1
• Proximal aortic diameters 18 mm – 34 mm
• Distal aortic diameters 18 mm - 42 mm
• Partial or complete coverage LSA 58%
• 8% early deaths, 1 possible related to device
• No endoleaks
Khoynezhad A, et al. JVS. 2013;57:899-905.

19. TAG 08-02 Study
• Gore Conformable TAG (CTAG)
• Prospective, 21 sites, 51 patients
• Blunt thoracic aortic injury
• 30-day all cause mortality
• 30-day freedom from major device events
• Follow-up 1 and 6 months, annually for
5 years
Farber M, et al. JVS. 2013;53:187-92.
.

20. TAG 08-02 Study
• 98% tear >1 cm or more severe
• Proximal aortic diameters 17 mm - 33 mm
• Distal aortic diameters 16 mm - 34 mm
• Partial or complete coverage LSA 63%
• 7.8% early deaths, none device related
• No MDEs
• 2 endoleaks (Type II and unknown)
Farber M, et al. JVS. 2013;53:187-92.
.

21. Impact of New Devices
• Smaller diameters
– 16-mm diameter aorta
• Tighter arches
• Increased resistance to infolding
– 0.4% with Gore TAG, 0% with Gore CTAG
• Increased deployment accuracy
Kasirajan, et al. JVS. 2012;55:652-8.

22. Coverage LSA
• 20-mm proximal landing zone (IFU)
• Median distance LSA to tear:
13.5 (0-36) mm*
• 1/3 patients will get arm claudication
– Left vertebral artery <3mm (p<.0001)**
• Rarely necessary with current devices
– 5-mm landing zone adequate
*Khoynezhad, et al. JVS. 2013;57:899-905.
**Antonello M, et al. JVS. 2013;57:684-90.

23. Follow-Up
• Greatest challenge of TEVAR for trauma
• Longest life expectancy
• Highly variable patient compliance
• Difficult anatomy to image
• Structural and physiologic consequences

24. Imaging Follow-up
• CTA at discharge, 3 - 6 months, 1 year
– Consider 2 - 5 year intervals
– US and European guidelines
• What we do (based on Gestalt)
– CTA at discharge, 6 months, 1 year
– CTA or MRA + CXR every 2 years
– After 10 years, consider 5 year intervals
Lee, et al. JVS. 2011;53:187-92.
Grabenwoger, et al. Eur Heart J. 2012;33:1558-63.

25. Physiologic Consequences
• Post-endograft HPTN reported 2005
– 80% patients <35 with early HPTN
– 36% HPTN at ≥13 months, 18% on Rx
• Noncompliant endograft
• Increased aortic pulse wave velocity
• Increased pulse pressure
Tzilalis, et al. J Endovasc Ther. 2005;12:142-3.
Tzilalis, et al. Ann Vasc Surg. 2012;26:462-7.

26. Aortic Pulse Wave Velocity
John Kaufm
Aortic Pulse Wave Velocity
Tzilalis, et al. Ann Vasc Surg. 2012;26:462-7.

27. Case I

28. Case I

29. Case II

30. Case Report II

31. Case Report II

32. Case III

33. Case III

34. Case III

35. Summary
• TEVAR for ≥Grade 2 injury
– Observation Grade 1 injury
• Delayed repair in stable patients
• New devices resolve structural issues
• Follow-up recommendations vague
• Long-term outcomes remain unknown