4/19/2013 Disclosures Current Management of Consultant: WL Gore, Medtronic, Cordis Acute Aortic Injuries Research Grants: WL Gore, Cook, Cordis, Medtronic, Boston Scientific, Abbott Michel Makaroun MD Edwards Life Sciences, Bolton, Lombard Co-Director, UPMC Heart and Vascular Institute Professor and Chief, Division of Vascular Surgery University of Pittsburgh School of Medicine Acute Aortic Injuries Thoracic Aortic Injuries � Location � US: >8000/year Thoracic � High Prehospital Mortality (80%) � Abdominal � � 1200-1500 reach hospital alive � Mechanism: � 30% die from aortic injury Penetrating � Blunt � Site: Majority at isthmus of aorta � Iatrogenic Injuries to aorta and its branches � � 70-80% have associated injuries � Severity Intimal tear � Non fatal Unrecognized lesions � Contained injury develop false aneurysms over time. � Free disruption into cavity � 1
4/19/2013 Transection Diagnosis: Angiography Aortic Transection: Diagnosis Transection Diagnosis: TEE Transection Diagnosis: CT Scan 2
4/19/2013 Traumatic Aortic Transection Traumatic Aortic Transection Standard Open repair Benefits of TEVAR � Left Thoracotomy � Possible under Local anesthesia � Single lung ventilation � No cross clamping � Systemic Anticoagulation � Short procedure � Aortic Cross Clamping � Minimal or No Anticoagulation � Possible left Heart Bypass FS: Use of Thoracic Endografts Acute Aortic Trauma: Challenges FS: 45 year old Male / MVA accident Multiple Injuries: Long bone/ Abdomen 21-22 mm aorta 26mm Thoracic Endograft � Small Access vessels � Small Aortic Diameter � Acute Arch Curvature � Tapering lumens 3
4/19/2013 JT: Use of Cuffs for Transection JT: Use of Aortic Cuffs for Transection JT: 29 year old Female / ATV vs Tree accident JT: 29 year old Female / ATV vs Tree accident Multiple Injuries: Head/ Abdomen / Pulmonary / Spine Multiple Injuries: Head/ Abdomen / Pulmonary / Spine Distal Aorta: 17.2 mm Proximal Aorta: 17.7 mm 23 mm Aortic cuffs Traumatic Aortic Transection Traumatic Aortic Transection Potential Drawbacks of TEVAR Potential Drawbacks of TEVAR � Possible residual endoleak and bleeding � Possible residual endoleak and bleeding � Possible migration or fistula formation � Possible migration or fistula formation � Young Patients � Young Patients � No Long term durability data/ Long FU � No Long term durability data/ Long FU � Approved grafts only available recently � Approved grafts only available recently � Graft Collapse APR 08: 9 Year FU � Graft Collapse Causes: Oversizing and poor apposition Causes: Oversizing and poor apposition 4
4/19/2013 Traumatic Aortic Transection Traumatic Aortic Transection Potential Drawbacks of TEVAR Potential Drawbacks of TEVAR � Possible residual endoleak and bleeding � Possible residual endoleak and bleeding � Possible migration or fistula formation � Possible migration or fistula formation � Young Patients � Young Patients � No Long term durability data/ Long FU � No Long term durability data/ Long FU � Approved grafts only available recently � Approved grafts only available recently � Graft Collapse � Graft Collapse Causes: Oversizing and poor apposition Causes: Oversizing and poor apposition New Approved Device Modification Despite All The Actual and The Theoretical Shortcomings What are the Results? 5
4/19/2013 Traumatic Aortic Transection Standard Open Repair Single Center Series over 27 years Clamp and Sew Distal Perfusion Open results Attar et al Ann Thor Surg 1999 Paraplegia Mortality Paraplegia Mortality � 263 patients over 27 years � Operative Mortality Von Oppell (94) 19.0% 16.0% 6.1% 15.0% � 1971-1975 19% 87 studies � 1976-1984 36% 1492 pts � 1985-1994 26% Kadali (91) 28.5% 3.8% � 1995-1998 16% � Paraplegia 17% J Vasc Surg 2006: 43 (2): A22-A29 Standard Open Repair Traumatic Aortic Transection Prospective Multicenter AAST trial Fabian et al J Trauma 1997 � 274 patients over 2.5 years from 50 centers � From injury to thoracotomy: 16.5 hours � Mortality 31% two thirds from Aortic source � Paraplegia � Full Bypass 4.5% � Partial Bypass 7.7% � Clamp and Saw 16.4% J Vasc Surg 2006: 43 (2): A22-A29 6
4/19/2013 Traumatic Aortic Transection Traumatic Aortic Transection Endo Results 17 Reports Technical Follow-up Author Year Patients Success (%) Endograft type Mortality Paraplegia (months) Bortone 2002 10 100% Gore NA None 14 Orend 2002 11 92% Gore, Talent NA None 14 Thompson 2002 5 100% Gore, custom 0 None 20 Fattori 2002 11 100% Gore, Talent 0 None 20 Lachat 2002 12 100% Gore, Talent 1 None 9 Kasirajan 2003 5 100% Gore, Talent, homemade 0 None 10 Karmy-Jones 2003 11 100% AneuRx cuff, Ancure, Talent, homemade NA None 16 Iannelli 2004 3 100% Gore NA None 13 Wellons 2004 9 100% AneuRx cuff, Excluder cuff 0 None 6 Kato 2004 6 100% Homemade NA None 6 Scheinert 2004 10 100% Gore, Talent NA None 17 Czermak 2004 12 92% Gore, Talent NA None 9 Morishita 2004 7 100% Homemade NA None 12 Neuhauser 2004 10 100% Gore, Talent, Vanguard NA None 26 Ott 2004 6 100% Talent 0 None 16 Uzieblo 2004 4 100% Talent NA None 8 Bortone 2004 14 100% Talent, Gore, Zenith, Endofit NA None 14 Total 146 99% 1 of 48 (2%) None Patients Technical Success Mortality Paraplegia J Vasc Surg 2007; 46:928-33 Total 146 99% 2% 0 J Vasc Surg 2006: 43 (2): A22-A29 J Vasc Surg 2012;56:74-80 Traumatic Aortic Transection Traumatic Aortic Transection TEVAR vs Open Thoracotomy at UPMC 1999-2011 TEVAR at UPMC 1999 - 2011 � 41 open Repairs 1999- January 2011 � 50 TEVAR Mortality 19.5% � 8 deaths � 38 Men and 12 women � 2 Paraplegia Paraplegia 4.4% � Mean Age: 39 years � 50 TEVAR : 46 Acute within 3 days of injury Youngest 17 years Oldest 79 years Mortality 6.1% � three death � Grafts Paraplegia 0% � No paraplegia � Thoracic endografts: 34 TAG / 3 TX2 / 2 Talent Last Open Case Jan 2007: 18 year old with isolated injury � Abdominal Cuffs: 9 Excluder / 2 AneuRx 8 hour procedure, massive bleeding and Death Since Feb 2007 All Transections Rx by TEVAR 7
4/19/2013 Traumatic Aortic Transection Traumatic Aortic Transection TEVAR at UPMC 1999 - 2011 TEVAR at UPMC 1999 - 2011 � No conduits. 6 percutaneous Lessons Learned From Early Results � No Iliac artery Injuries. � ONLY 10 LSA coverage (20%) � TEVAR is Superior to open repair for aortic trauma � Only 2 delayed LCS bypass � Conduits are almost never needed � No Arm ischemia or related strokes � Coverage of L. Subclavian artery is rarely needed � Two strokes: (Unrecognized associated injury to the � Use of abdominal cuffs is feasible and quite safe Innominate artery, Fat embolus) � Mean FU 27 months. Longest 11 years. Traumatic Aortic Transection Traumatic Aortic Transection TEVAR at UPMC 1999 - 2011 Conclusions: Comparison between the two AAST studies in Compared to the 1997 Survey Graft Related Complications: 8 patients (16%) 1997 and 2007 showed a major shift in the diagnosis of the aortic injury, with the widespread use of CT scan and the � 4 isolated graft collapses treated with second TEVAR Open Repair 100% almost complete elimination of aortography and TEE. The 35% � 1 conversion @ 6 m after graft collapse and AEF concept of delayed definitive repair has gained wide acceptance. Endovascular repair has replaced open repair to a great extent. � 1 conversion @ 3 yrs for Sx dynamic Carotid obstruction Mortality 22% 13% These changes have resulted in a major reduction of mortality � 1 conversion @ 2yrs for Carotid obstruction. No Sxs and procedure-related paraplegia but also a significant increase of graft related complications. � 1 conversion @ 18 months for arm hypertension Paraplegia 8.7% 1.6% No DEATHS or PARAPLEGIA J Trauma 2008;64:1415-19 8
4/19/2013 WM: Open Conversion for Collapse and AEF WM: Open Conversion for Collapse and AEF WM: 50 year old Man with Sky diving accident Multiple Injuries: Long bones, pelvis, abdominal, chest, spine WM: 50 year old with Sky diving accident and Closed head Injury Multiple Injuries: Long bones, pelvis, abdominal, chest, spine and Closed head Injury July 10 Oct 18 Dec 6 WM: Open Conversion for Collapse and AEF WM: Open Conversion for Collapse and AEF Jan 3 Dec 8 POST BALLOON POST BALLOON Esophagectomy and In Situ Subsequent Reconstruction Substernal Stomach Rifampin One Year Later Pull-up Impregnated Graft 9
4/19/2013 LS: Conversion for dynamic obstruction of LCCA LS: Conversion for dynamic obstruction of LCCA LS: 17 year old Female / Car accident LS: 27 month FU: Left Amaurosis and Light headedness Multiple Injuries: Pelvic and facial fractures / To and Fro motion in Left CCA on Duplex Bladder and Liver injuries / Intracranial injuries Angiogram and Pressure measurement in LCCA 27 months LCCA SAP 15mmHg < Proximal Aorta TAG 26 x 10 BC: Conversion for obstruction of Aorta BC: Conversion for obstruction of Aorta BC: 21 year old Male / Snowmobile accident BC: 22 year old Male / Snowmobile accident Multiple Injuries: Diaphragm / Abdomen / Pulmonary Multiple Injuries: Diaphragm / Abdomen / Pulmonary 22mm Aorta / 26mm TAG’s 10 months Later. SEVERE Hypertension R Arm 180/110 1 month CT: Collapse of inner graft 10
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