Mid-term Results Of Thoracic Endovascular Aortic Repair On Zone 2 Landing For Blunt Thoracic Aortic Injury
Shuhei Miura, Dr..
Teine Keijinkai Hospital, Sapporo, Japan.
BACKGROUND There is no standard timing of delayed repair for blunt thoracic aortic injury (BTAI). Complying with the BTAI grade proposed by Society for Vascular Surgery, we perform elective thoracic endovascular aortic repair (TEVAR) even for the grade III (pseudoaneurysm) without secondary sign of injury (SSI), following the treatment of other trauma injuries. METHODS Stent-graft (SG) was placed more proximal beyond the left subclavian artery (LSA) as zone 2 landing TEVAR for BTAI to use the non-injured aorta as a proximal neck. LSA was aggressively preserved by physician-modified fenestrated TEVAR (F-TEVAR), if anatomically possible. Otherwise, LSA was simply covered. We report early and mid-term results of this strategy. RESULTS From 2008 through 2017, 12 patients (53±21year, 8 male) underwent zone 2 TEVAR for BTAI within a median of 8.4 day (0-36) of injury. The injuries were caused by 10 traffic accidents (9 cars, 2 motorcycles) and 2 fall accidents. The mean Injury Severity Score and Trauma and Injury Severity score were 20.8±7.0 and 0.7±0.2, respectively. All the aortic injuries were categorized into the grade III with pseudoaneurysm. Emergency TEVAR was performed in 6 patients (50%) with SSI (5: extensive mediastinal hematoma, 1: pseudocoarctation) and elective TEVAR was in 6 patients (50%) without SSI. The injuries of other organs were 4 cases of intracranial injury (33%), 6 cases of lung injury (50%), 7 cases of multiple rib fracture (58%), 5 cases (42%) of intraperitoneal organ injury and 4 cases of pelvic fracture (33%), 1 mediastinum injury (8%). Successful deployment was achieved in all patients. LSA was preserved in 7 patients (58%) by F-TEVAR, whereas it was intentionally covered in 5 patients (42%) on emergency TEVAR. The following factors had significant differences between emergency and elective TEVAR: Preoperative FDP value (59.8 vs.14.3: p =0.04), operation time (90.1 vs. 122.0 min: p=0.06), Initial heparin injection dose (2416 vs. 4500 unit: p=0.04), bleeding (405±591 vs. 107±205ml: p=0.05). Although hospital mortality due to traumatic intraperitoneal bleeding was observed in one patient (8%), there were no TEVAR-related complications as stroke, spinal cord ischemia and retrograde type A aortic dissection. In the follow-up periods of mean 25 months [0-83], there were a type II endoleak from intercostal artery, and 1 patient (8%) who had the symptoms of arm claudication required LSA revascularization by additional axillo-axillary bypass grafting postoperatively on 16 months, however, there was no case of aorta-related mortality. CONCLUSIONS In the case of Grade III without SSI, our strategy of delayed repair could be acceptable. Zone 2 TEVAR for BTAI might be promising since the preservation of LSA flow by F-TEVAR ensures the reliable surgical outcomes.
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