endovascular treatment of traumatic thoracic aortic … · amabile p et al. surgical versus...
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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
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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
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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
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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.
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Evidence
Less morbidity
and mortality
Possible local
anesthesia and
without heparin
Quick recovery
Graft durability
Surveillance.
Angio CT
Radiation
+ ?
Patients with Long life expectancy
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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%
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: 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
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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
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Collapse endograft
Mestres G, Maeso J, Fernández V, M Matas. Symptomatic collapse of a thoracic aorta
Endoprosthesis. J Vasc Surg. 2006;43:1270-3
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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
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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)
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Endoleaks type III
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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
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P=0,009
WHO AND WHENSHOULD WE OFFER SURGERY ?
Median days delay repair
5,5 days (0 –180 days)
Valle de Hebrón
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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