Endovascular management of acute blunt traumatic thoracic aortic injury: A single center experience

Endovascular management of acute blunt traumatic thoracic aortic injury: A single center experience Clare L. Bent, FRCR,a Matthew B. Matson, MRCP, FRCR,a Mo Sobeh, MS, FRCS,c Ian Renfrew, MRCP, FRCR,a Rakesh Uppal, BSc, FRCS (CTh),b Michael Walsh, MS, FRCS,c,d Karim Brohi, FRCS, FRCA,c,d and Constantinos Kyriakides, MD, FRCS,c,e London, United Kingdom Background: Traumatic injury of the thoracic aorta is a life-threatening complication in patients who sustain deceleration or crush injuries. The magnitude of force necessary to cause blunt thoracic aortic injury results in a high proportion of concomitant injuries, posing a significant challenge for prioritizing management. Open surgical mortality is increased in the presence of coexisting head, lung, and abdominal injuries. Spinal cord ischemia may occur following aortic cross-clamping and operative hypotension. Endovascular stent-graft placement offers a safe, effective, and timely treatment option. The aim of this study was to assess our single center experience of endovascular repair following acute blunt traumatic aortic injury. Methods: Data from thirteen consecutive patients (mean age, 43.2 years; range, 16 to 84 years) with acute blunt traumatic aortic injury treated by endovascular stent-graft insertion between October 2001 and March 2007 was prospectively collected. Demographics, injury characteristics, technique, and complications were recorded. Follow-up data consisted of computed tomographic angiography and plain chest radiography at regular intervals. Mean and median follow-up after stent-graft implantation were 28.9 and 29 months, respectively. Results: All patients underwent endovascular repair within a median of 9 hours from hospital presentation. Two patients underwent carotico-carotid bypass immediately prior to endovascular stenting during a single anesthetic. Stent-graft implantation was technically successful in all patients. No patient required conversion to open surgical repair of the acute blunt traumatic aortic injury. Procedure-related paraplegia was zero. Complications included proximal migration of initial stent-graft in one patient and iliac artery avulsion in another patient with consequent ilio-femoral bypass. The median hospital stay was 17 days. There were no in-hospital deaths. Conclusion: Endovascular repair is evolving as the procedure of choice for acute blunt traumatic aortic injury. Treatment of lesions that extend into the aortic arch is feasible with extra-anatomical bypass. In our study, endovascular repair of blunt traumatic aortic injury is a safe procedure with low morbidity and a mortality rate of zero. ( J Vasc Surg 2007;46:920-7.)

Thoracic aortic injury following chest trauma is potentially life-threatening. Immediate on-scene mortality is between 80% to 90% irrespective of mechanism, be it penetrating or blunt trauma.1-3 Of those who survive the initial insult, 32% die within 24 hours and 74% within 2 weeks.4 Prompt diagnosis and treatment is therefore essential. Traditionally, surgical repair is the gold standard method of treatment.5 However, complication rates are From the Department of Radiology,a Department of Cardiothoracic Surgery,b Department of Vascular Surgery,c and Department of Trauma Surgery,d Barts and The London NHS Trust and Queen Mary School of Medicine and Dentistrye. Competition of interest: none. Abstract presented in Bent CL, Matson M, Renfrew I, Walsh M, Sobeh M, Kyriakides C. Traumatic injury of the thoracic aorta: an endovascular approach. BJS 2006;93(S1):95-6. Presented in part as “Early Results of Traumatic Aortic Injury Repair” at the Association of Surgeons of Great Britain and Ireland (ASGBI), Annual Scientific Meeting, Edinburgh, United Kingdom, May 3, 2006. Reprint requests: Constantinos Kyriakides, MD, FRCS, Department of Vascular Surgery, Barts and The London NHS Trust, Royal London Hospital, London, E1 1BB UK (e-mail: constantinos.kyriakides@ bartsandthelondon.nhs.uk). CME article 0741-5214/$32.00 Copyright © 2007 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2007.07.032

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high. In addition, the mechanism of injury involved frequently results in coexisting nonaortic injuries complicating open thoracic surgery. Controversy persists regarding the management of acute and chronic blunt traumatic aortic injury, involving the indications, timing of intervention, and long-term follow-up.3,6 The purpose of this study was to assess the feasibility and outcomes of endovascular repair of acute blunt traumatic aortic injury (ABTAI) in a single center. METHODS We prospectively collected data from all patients with an ABTAI treated in a tertiary referral center with endovascular stent-graft repair between October 2001 and March 2007. During the study interval, 13 patients with an ABTAI treated with endovascular repair were identified. Their mean age was 43.2 years (range, 16 to 84 years) and 11 of the 13 patients (85%) were male. The cause of aortic injury involved a motor vehicle collision in 10 patients, motorcycle crash in two patients and a fall of approximately 20 feet in the final patient. Two additional patients presented with an undiagnosed chronic BTAI and treated with endovascular repair during the study period. Both attended hospital acutely

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Table I. Patient demographics Patient

Age (y)

Sex

Mode of injury

Additional injuries

Interventional delay (h)

1

16

F

RTA

26

2

41

M

RTA

3

27

M

RTA

4

22

M

RTA

5 6

56 53

M M

RTA RTA

7

42

M

RTA

8 9 10 11

56 66 17 84

M F M M

Fall RTA RTA RTA

12 13

43 39

M M

RTA RTA

Pulmonary contusions Bilateral hemothorax Fluid in abdomen due to duodenal injury Pelvic and bilateral femoral fractures Bilateral hemothorax Multiple rib, right scapula and clavicular fractures D10 burst fracture with cord trauma Frontal lobe contusion and subdural hemorrhage Bilateral hemothorax Multiple rib fractures Splenic laceration Tibia and fibula fractures Right pneumo-hemothorax Multiple rib fractures Right scapula fracture Rib fractures Frontal lobe contusion and subarachnoid hemorrhage Bilateral hemothorax Right pneumothorax Multiple right rib fractures Right scapula fracture Cerebral edema Right hemothorax Right tension pneumothorax Multiple right rib fractures, right scapula and clavicular fractures D12 vertebral fracture Right clavicular fracture Bilateral femoral fractures Temporal lobe contusion and subarachnoid hemorrhage Vertebral and rib fractures Hemothorax No additional injury noted Extradural and subdural hemorrhage Right hemopneumothorax Multiple right rib fractures C2, T12 and pelvic fractures Duodenal/adrenal and kidney contusions Open femoral/extremity fractures

10 6

25 6 27

7

27 5 8 81 9 4

F, Female; M, male; RTA, road traffic accident.

with chest pain and demonstrated a calcified thoracic pseudoaneurysm located at the aortic isthmus on radiological imaging. A previous history of a significant chest trauma following a road traffic accident with hospital admission was elicited in both patients; one 30 years7 and the other 15 years previously. Due to their chronicity, these patients were excluded from our study. A further patient died of traumatic aortic injury on arrival to hospital. Diagnosis was confirmed at post-mortem. All patients were initially reviewed and stabilized by the trauma surgery service in concordance with the Advanced Trauma Life Support guidelines.8 Chest radiography demonstrated a mediastinal abnormality in all patients. Aortic injury was diagnosed with computed tomographic (CT) angiography. Aortography was performed in two patients prior to endovascular repair, as CT findings were equivocal. Stent-graft insertion was accepted as the first-line treatment option for ABTAI. The decision to treat with endovascular repair is dependent upon morphology of aortic injury, presence of concomitant injuries complicating open

repair, availability of stent-grafts, and the operator’s preference. No patients underwent open surgical repair during the study period. Concomitant injuries were documented in 12 out of the 13 patients with an ABTAI (92.3%) and are listed in Table I. Patients with coexisting chest injuries had rib fractures and pulmonary contusions (n ⫽ 10). Five patients had coexisting head injuries. Vertebral, pelvic, and extremity fractures were identified in four patients. Three patients had additional intra-abdominal injuries: two had a duodenal laceration, one of which also had a renal contusion, and one patient had a splenic contusion. Injuries were treated in order of threat to life. Nine of 13 patients underwent treatment of acute life-threatening injuries prior to endovascular intervention. Procedures included chest drain insertion (n ⫽ 8), intracranial pressure bolt insertion (n ⫽ 5), laparotomy (n ⫽ 3), and orthopedic intervention (n ⫽ 1). Two adjunctive carotico-carotid bypass procedures were performed prior to endovascular repair during a single anesthetic. One took place in the main

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Table II. Procedural information Patient

Type of access

Stent type

No. of stents

Size of stent

Cover of LSA origin

LSA patent

1 2 3 4 5 6 7

Surgical cutdown Percutaneous Percutaneous Percutaneous Surgical cutdown Surgical cutdown Percutaneous

Medtronic Medtronic Medtronic Gore Gore Medtronic Gore

1 2 1 1 1 1 4

No Complete Partial No Complete Partial Complete

Yes No Yes Yes No Yes No

8

Percutaneous

Gore

2

No

Yes

Surgical cutdown Percutaneous Surgical cutdown Surgical cutdown Surgical cutdown

BVM Gore Medtronic Medtronic Medtronic

1 1 1 1 1

26 ⫻ 112 mm 28 ⫻ 120 mm (2) 26 ⫻ 115 mm 26 ⫻ 100 mm 34 ⫻ 200 mm 28 ⫻ 120 mm 34 ⫻ 200 mm 31/34/37 ⫻ 150 mm 28 ⫻ 100 mm 34 ⫻ 200 mm 38 ⫻ 145 mm 26 ⫻ 100 mm 34 ⫻ 110 mm 24 ⫻ 115 mm 24 ⫻ 115 mm

No No Partial Complete Partial

Yes Yes Yes No Yes

9 10 11 12 13

LSA, Left subclavian artery.

surgical theaters prior to transfer into the interventional radiology suite for stent-graft insertion; the second patient underwent both carotid bypass and stent-graft insertion in the interventional radiology suite. A further four orthopedic procedures were carried out following completion of endovascular repair. Endovascular stent-graft procedures were performed in the interventional radiology suite under fluoroscopic angiographic control (Phillips Integris Allura, Phillips, Eindhoven, the Netherlands) by a team of dedicated interventionalists including radiologists, and vascular and cardiothoracic surgeons. Four different self-expanding commercially available endovascular stent-grafts were used: Talent LPS and Valiant (Medtronic Vascular; Sunrise, Fla), Excluder (WL Gore and Associates; Sunnyvale, Calif) and Relay (Bolton Medical; Sunrise, Fla). Informed consent was obtained for endovascular treatment from the patient or consultant in charge of their care. The dimensions of the stent-graft used were determined by the anatomical configuration of the aorta as demonstrated on contrast-enhanced helical CT images and angiographic images. Aortic arch morphology, aortic vessel diameter along with the length, and location of lesion all contributed to the selection process. For optimal fixation, all stent-grafts were oversized by 10% to 15% compared with the aortic diameter at landing zone sites. Depending on type of thoracic stent-graft selected, aortic diameters were measured from outer to outer wall (Medtronic Vascular; Sunrise, Fla), or inner to inner wall (WL Gore and Associates; Sunnyvale, Calif; Bolton Medical; Sunrise, Fla) as per recommendations published by stent-graft manufacturer. The younger patients within our cohort, four of whom were under 27 years of age, had small aortic diameters (18 to 20 mm). In these patients, the stent-graft size chosen was based upon the smallest size available. Patients were treated under general anesthesia (n ⫽ 11) or regional anesthesia with sedation (n ⫽ 2). Lumbar drains

were not used. All patients received intravenous antibiotics for prophylaxis prior to stent-graft deployment. A standard angiographic pigtail catheter was inserted via percutaneous puncture (5F) into the common femoral artery or brachial artery to maintain vascular access and angiographic control throughout the procedure. Surgical exposure (n ⫽ 6) or percutaneous puncture (n ⫽ 6) of a common femoral artery was performed to allow introduction of the stent-graft delivery device. One patient required access via the left common iliac artery during explorative laparotomy due to small caliber vessels unable to accommodate the stent-graft delivery device. For those patients undergoing percutaneous repair, two Perclose suture devices (Abbott Laboratories; Redwood City, Calif) were deployed at this site using a previously described “preclose” technique.9 Initially, angiographic evaluation of the aortic lesion was performed using the pigtail catheter positioned in the ascending thoracic aorta. Digital subtraction angiography (DSA) was then used to visualize exact aortic arch anatomy, location of ABTAI, and the location of the left subclavian artery (LSA). Using the planned access site, a stiff wire, either a Meier (Boston Scientific; Miami, Fla), Lunderquist (Cook Inc; Bloomington, Ind), or Amplatz (Boston Scientific; Miami, Fla), was then advanced into the ascending aorta for guidance of the selected endovascular device. Technical information is listed in Table II. Prior to device insertion, eight of the 13 patients were systemically heparinized during the procedure with a single dose of 5000 international units of heparin; five patients had significant head injuries contraindicating heparin administration. The stent-graft was then introduced and position verified by DSA immediately before stent-graft deployment. At deployment, no pharmacological methods to reduce systolic arterial blood pressure were used. Completion angiography was then performed in all patients to check stent-

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graft position and to confirm complete injury exclusion without evidence of an endoleak. Two patients required carotico-carotid bypass prior to endovascular repair. In one case, this was due to extension of the ABTAI into the aortic arch and in the second, due to a common origin of the LCCA and LSA. In the remaining 11 patients, two required complete coverage of the LSA origin, and four had partial coverage with the uncovered metal struts of the stent-graft (Talent LPS or Valiant) to ensure optimal apposition of the stent-graft with the vessel wall. Five patients had stent-graft implantation distal to the LSA origin. Persistence of blood flow within the LSA could be observed in all patients. Of the four patients with complete coverage of the LSA origin (two with a carotico-carotid bypass due to LCCA and LSA coverage and two with coverage of the LSA origin by the covered portion of the stent-graft), blood flow to the distal LSA occurred via retrograde filling from the ipsilateral vertebral artery. A single stent-graft was required in 10 patients, two stent-grafts for two patients and four stent-grafts for one patient. This patient sustained a traumatic aortic dissection, requiring four stent-grafts due to refilling of the false lumen despite entry-tear coverage. Following removal of procedural equipment, the access site underwent either formal surgical arterial closure or closure with the Perclose sutures in situ, if a percutaneous technique had been used. No further anticoagulation was administered. Follow-up examinations were performed using contrast enhanced computed tomography angiography at 3, 6, and 9 months after implantation. In addition, plain chest radiography was performed on an annual basis to monitor for stent fractures. RESULTS Endovascular repair was performed within a median of 9 hours and mean of 18.5 hours from presentation to hospital and was technically successful in all cases. No patient required conversion to open surgical repair of the ABTAI. No procedure-related paraplegia or stroke occurred. Procedural complications occurred in two patients. The intraoperative and 30-day mortality was zero. Morbidity following ABTAI occurred in 10 out of the 13 patients due to respiratory insufficiency and orthopedic injuries requiring external fixation devices. Procedurerelated morbidity occurred in two patients as a result of complications during stent-graft implantation. In one patient, the external iliac artery was avulsed on removal of the stent sheath following successful deployment of the stent-graft. Bleeding was immediately controlled by the introduction of a proximal occlusion balloon via a femoral artery and an ilio-femoral bypass was performed. The patient was female with a relatively small external iliac artery diameter. However, preprocedure CT had demonstrated vessel diameters sufficient to accommodate the delivery system (⬎7.5 mm).

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In a second patient, a proximal endoleak was identified during completion angiography. The proximal stent-graft to aortic wall seal was felt to be suboptimal due to incomplete graft self-expansion and possible under-sizing. To rectify this, an attempt was made to balloon this segment. On doing so, the stent-graft itself became dislodged and migrated into the ascending aorta proximal to the arch vessels, maintaining supra-aortic vessel perfusion. A second graft of a larger diameter was subsequently implanted in the correct position with a good radiological result (Fig 1, a b, and c). To minimize risk of distal migration of the initial stent-graft this was retrieved through an ascending aortic arteriotomy via a mini-sternotomy incision without the need to use cardiac bypass (this patient had a concomitant D12 vertebral fracture). There were no cases of groin infection or hematoma. Of the four patients with intentional occlusion of LSA during stent-graft insertion, three experienced intermittent symptoms of discoloration and paresthesia of the left upper limb in the immediate postoperative period. Despite this, none has subsequently developed vertebrobasilar or left arm ischemia necessitating revascularisation via carotidsubclavian bypass or transposition. Median hospital stay was 17 days (range: 4 to 58 days). Procedural-related morbidity did not lengthen in-hospital stay. Both patients with procedural complications suffered orthopedic injuries (one patient with pelvic fractures and bilateral femoral fractures; one patient with a D12 vertebral fracture and spinal cord injury) requiring extensive rehabilitation. During follow-up (mean: 28.9 months; median: 29 months; range: 4 to 67 months) all patients were alive without endoleak, stent migration, stent collapse, false aneurysm expansion, or rupture. One patient underwent an additional surgical procedure 7 months following ABTAI due to the identification of a coexisting traumatic aortic root-right ventricular fistula (Fig 2) identified during the endovascular procedure, which was confirmed on transoesophageal echocardiography. This finding has previously been reported10 following blunt chest trauma. DISCUSSION Patients diagnosed with traumatic rupture of the thoracic aorta typically present with multiple concomitant injuries complicating traditional surgical management. Mortality rates for emergent open surgical repair for ABTAI range from 15% to 30% in contemporary studies.11-13 Operative requirements including lateral positioning in patients with vertebral or spinal cord injuries (with paraplegia rates ranging from 2.3% to 25.5%);14,15 thoracotomy and single lung ventilation in the presence of lung contusions, frequently (24% to 65%) resulting in prolonged respiratory insufficiency and infectious complications;2,16,17 and finally high level systemic heparinization in those with multiple concomitant injuries, all increase the risk of morbidity. The development of endovascular techniques has led to a number of small studies examining the technical feasibility and outcome of endovascular repair in ABTAI.18,19 The

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Fig 1. A 56-year-old male with an acute blunt traumatic aortic injury following a fall from height. a, Aortic angiography demonstrates a pigtail catheter traversing the left subclavian artery (LSA) allowing angiographic control during stent-graft deployment. A guidewire with an undeployed stent-graft is positioned at the level of the LSA origin. b, Aortography demonstrates migration of the deployed stent-graft to a position proximal to the supra-aortic vessels. c, Supra-aortic vessel perfusion is seen. A second undeployed stent-graft is inserted and positioned at the LSA origin ready for deployment.

majority have demonstrated lower morbidity and mortality rates in comparison to open surgical techniques advocating its use.20 Despite this, endovascular treatment for trauma is logistically as well as technically challenging requiring ex-

peditious imaging, multidisciplinary input, and an available stock of equipment. Standardized sizes of thoracic stent-grafts are currently available for emergencies; however, these sizes remain lim-

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Fig 2. A 16-year-old female with an acute blunt traumatic aortic injury. Early perfusion of the pulmonary arteries is seen during aortography secondary to a traumatic aortic root-right ventricular fistula which was repaired electively 6 months following injury.

ited. With a younger patient population presenting following trauma in comparison to those with degenerative aortic disease, the tighter curvature of the aortic arch and smaller caliber of both the aorta and iliac arteries present significant challenges to the design and engineering of current stentgraft devices. The tighter curvature of the aortic arch affects endovascular repair in two ways. The anatomical angulation may be too acute to accommodate stiff wires such as the Lunderquist. The lack of degenerative vascular disease elsewhere allows alternatives such as the Amplatz wire to be used without difficulty. Second, the tight curvature increases the risk of an inadequate proximal seal. Concern centers on the longitudinal flexibility of the semi-rigid stent-graft design. As a result, many stentgrafts are not flexible enough to conform to an acutely angulated distal aortic arch and proximal descending aorta. Such an inability to gain optimal apposition with the vessel wall may lead to the development of an endoleak or “wind sock” effect promoting distal migration.21

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With the smallest aortic stent-graft in manufacture measuring 22 mm (Bolton Medical; Sunrise, Fla), significant over-sizing occurs in young patients with smaller aortic diameters. Case reports have highlighted that oversizing can result in stent-graft collapse – a complication which resulted in the voluntary withdrawal of the Gore TAG endoprosthesis in 2001.22-24 This alone may complicate endovascular repair as an acute treatment option. The majority of patients sustain ABTAI located within the proximal descending segment, with 90% to 95% at the aortic isthmus.25 Cover of the LSA origin may therefore be necessary to lengthen the proximal neck sealing zone. Despite many studies reporting LSA origin coverage during endovascular repair, it is not without complication.26 Consequently, if time permits, optimal preprocedural work-up should include Duplex assessment of the extra-cranial circulation to ensure antegrade blood flow in the right vertebral artery. In the presence of retrograde flow, it would be prudent to perform left carotid-subclavian bypass prior to stent-grafting to minimize the risk of an infarct involving the vertebrobasilar and posterior circulation. In the absence of head injury or bleeding diathesis, all patients at our institution undergo intra-arterial administration of 5000 international units of heparin prior to stent-graft insertion. During endovascular repair, the large caliber stent-graft delivery sheath almost occludes the arteries leading to the aorta. In accordance with nontraumatic endovascular aortic repair, the purpose of heparin administration is therefore to prevent thrombus formation in these arteries, in addition to the lumen of the sheath.27 This in turn will minimize the risk of embolism. During the study, no thromboembolic complications were observed. A major complication experienced in our cohort involved iliac artery avulsion and occurred in one patient (7.7%). This correlates with previously published literature.20,28 The delivery devices used for introduction of aortic stent-grafts are of large profile; therefore, preprocedural assessment of the iliac arteries is mandatory to ensure the vessel caliber is sufficient (minimum 7.5 mm) to accommodate the delivery system. One possible explanation for such a complication may involve vascular spasm secondary to irritation of the vessel wall during guidewire and catheter manipulation. A hypothesis based on the initial successful delivery of the stent-graft system, followed by avulsion upon removal, when the external iliac artery was observed to be tightly contracted around the delivery device. This complication is frequently observed in young females where the vessel wall is soft and more compliant with longitudinal pulling forces, resulting in an increased risk of rupture. Accepting that the vessels may appear of small caliber in the presence of hypovolemia, when measured to be less than 7.5 mm, use of an iliac or aortic conduit may be considered via a retroperitoneal incision. In the event of iliac artery avulsion, insertion of a proximal occlusion balloon via either femoral artery is a life-saving maneuver, allowing control of hemorrhage until ilio-femoral bypass grafting is completed. With this in mind, it is vital that a range of stent-graft sizes is available,

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along with equipment to deal with procedural complications within the emergency endovascular setting. The second major type of complication involved proximal migration of the stent-graft as a result of under-sizing and ballooning of the proximal stent-graft seal. In the trauma setting, we oversize the stent-graft used by 10% to 15% of the diameter measured on CT imaging or aortography, as opposed to a 15% to 20% oversize for aneurysmal disease. This discrepancy is due to a less aggressive approach recommended in trauma patients, where the thoracic aorta is of normal caliber and the intima friable following ABTAI. However in trauma, the potential for stent-graft under-sizing is increased due to hypovolemia causing a relatively smaller aortic caliber and sympathetic overdrive resulting in vasoconstriction – an observation contrasting to published reports where extensive over-sizing (⬎50%) has been noted as a potential complication.29 These factors all need to be considered when selecting an appropriate stent-graft. At our institution, ballooning is reserved for malposition or type 1 endoleaks to minimize the risk of further aortic injury, which could result in catastrophic retrograde dissection. Long-term follow-up remains necessary to assess both stent-graft durability and progression of aortic disease. With a younger population involved in trauma, follow-up protocols may need refinement to minimize risk of radiation exposure. Current recommendations involve annual plain chest radiography combined with interval CT scanning to monitor for stent fractures and endoleaks from the day the stent-graft is inserted. Consequently, cumulative radiation exposure is potentially hazardous. Although the usage of endovascular stentgrafts in ABTAI offers significant advantages, further development into smaller sizes, lower profiles and stent-grafts that generate fewer artefacts during magnetic resonance imaging assessment would be beneficial. CONCLUSION Endovascular repair is rapidly becoming the procedure of choice for ABTAI. Even in the presence of extension of injury into the aortic arch, endovascular management remains a feasible option with extra-anatomical bypass. As a less invasive therapeutic option to standard surgical techniques, it is highly advantageous for polytrauma patients. Procedure-related morbidity remains low with no published case of paraplegia in trauma. In those patients with few concomitant injuries, such a procedure could also allow earlier ambulation post trauma and a reduction in hospital stay. In the absence of long-term follow-up regarding stent-graft durability and in those patients requiring definitive open thoracic surgery, endovascular repair could act as an intermediate measure until the patient is stable enough to undergo such a procedure. AUTHOR CONTRIBUTIONS Conception and design: CB, MM, CK Analysis and interpretation: CB, MM, MS, IR, RU, MW, KB, CK Data collection: CB Writing the article: CB, KB, CK

Critical revision of the article: CB, MM, MS, IR, RU, MW, KB, CK Final approval of the article: CK Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: CK REFERENCES 1. Pierangeli A, Turinetto B, Galli R, Calderara L, Fattori R, Gavelli G. Delayed treatment of isthmic aortic rupture. Cardiovasc Surg 2000;8: 280-3. 2. Gammie JS, Shah AS, Hattler BG, Kormos RL, Peitzman AB, Griffith BP, et al. Traumatic aortic rupture: diagnosis and management. Ann Thorac Surg 1998;66:1295-300. 3. Galli R, Pacini D, Di Bartolomeo R, Fattori R, Turinetto B, Grillone G, et al. Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta. Ann Thorac Surg 1998;65:461-4. 4. Ferrari E, Tozzi P, von Segesser L. Thoracic aorta emergencies: is the endovascular treatment the new gold standard? Interact CardioVasc Thorac Surg 2006;5:730-4. 5. Creasy JD, Chiles C, Routh WD, Dyer RB. Overview of traumatic injury of the thoracic aorta. Radiographics 1997;17:27-45. 6. Lebl DR, Dicker RA, Spain DA, Brundage SI. Dramatic shift in the primary management of traumatic thoracic aortic rupture. Arch Surg 2006;141:177-80. 7. Tai N, Renfrew I, Kyriakides C. Chronic pseudoaneurysm of the thoracic aorta due to trauma: 30-year delay in presentation and treatment. Injury Extra 2005;36:475-8. 8. American College of Surgeons. Advanced Trauma and Life Support Course For Physicians. 7th ed. Chicago: Committee on Trauma, American College of Surgeons, 2004. 9. Morasch MS, Kibbe MR, Evans ME, Meadows WS, Eskandari MK, Matsumura JS, et al. Percutaneous repair of abdominal aortic aneurysm. J Vasc Surg 2004;40:12-6. 10. Siavelis HA, Marsan R, Marshall WJ, Maull K. Aortoventricular fistula secondary to blunt trauma: a case report and review of the literature. J Trauma 1997;43:713-5. 11. Fabian TC, Richardson JD, Croce MA, Smith JS, Rodman G, Kearney PA, et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma 1997;42: 374-83. 12. Turney SZ, Attar S, Ayella R, Cowley RA, McLaughlin J. Traumatic rupture of the aorta: a five-year experience. J Thorac Cardiovasc Surg 1976;72:727-32. 13. Crowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shanskar BS. Rupture of the thoracic aorta caused by blunt trauma. J Thorac Cardiovasc Surg 1990;100:652-61. 14. Attar S, Cardarelli MG, Downing SW, Rodriguez A, Wallace DC, West RS, et al. Traumatic aortic rupture: recent outcome with regard to neurologic deficit. Ann Thorac Surg 1999;67:959-64. 15. von Oppell UO, Dunne TT, De Groot MK, Zilla P. Traumatic aortic rupture: 20-year meta-analysis of mortality and risk of paraplegia. Ann Thorac Surg 1994;58:585-93. 16. Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS. Traumatic rupture of the thoracic aorta: cohort study and systematic review. J Vasc Surg 2001;34:1029-34. 17. Razzouk AJ, Gundry SR, Wang N, del Rio MJ, Varnell D, Bailey LL. Repair of traumatic aortic rupture: a 25-year experience. Arch Surg 2000;135:913-8. 18. Wellons ED, Milner R, Solis M, Levitt A, Rosenthal D. Stent-graft repair of traumatic thoracic aortic disruptions. J Vasc Surg 2004;40: 1095-100. 19. Orford VP, Atkinson NR, Thomson K, Milne PY, Campbell WA, Roberts A, et al. Blunt traumatic aortic transection: the endovascular experience. Ann Thorac Surg 2003;75:106-12. 20. Stone DH, Brewster DC, Kwolek CJ, LaMuraglia GM, Conrad MF, Chung TK, et al. Stent-graft versus open surgical repair of the thoracic aorta: mid-term results. J Vasc Surg 2006;44:1188-97.

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21. Hoffer EK, Karmy-Jones R, Bloch RD, Meissner MH, Borsa JJ, Nicholls SC, et al. Treatment of acute thoracic aortic injury with commercially available abdominal aortic stent-grafts. J Vasc Interv Radiol 2002; 13:1037-41. 22. Neschis DG, Moaine S, Gutta R, Charles K, Scalea TM, Flinn WR, et al. Twenty consecutive cases of endografts repair of traumatic aortic disruption: lessons learned. J Vasc Surg 2007;45:487-92. 23. Idu MM, Reekers JA, Balm R, Ponsen KJ, de Mol BA, Legemate DA. Collapse of stent-graft following treatment of traumatic thoracic aortic rupture. J Endovasc Ther 2005;12:503-7. 24. Steinbauer MG, Stehr A, Pfister K, Herold T, Zorger N, Topel I, et al. Endovascular repair of proximal endograft collapse after treatment of thoracic aortic disease. J Vasc Surg 2006;43:609-12. 25. Akins CW, Buckley MJ, Dagget W, McIlduff JB, Austen WG. Acute traumatic aortic disruption of the thoracic aorta: a 10-year experience. Ann Thorac Cardiovasc Surg 1981;31:305-9.

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26. Riesenman PJ, Farber MA, Mendes RR, Marston WA, Fulton JJ, Keagy BA. Coverage of the left subclavian artery during thoracic endovascular aortic repair. J Vasc Surg 2007;45:90-4. 27. Noriyuki K, Dake M, Craig Miller D, Semba C, Scott Mitchell R, Razavi M, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology 1997;205:657-62. 28. White RA, Donayre CE, Walot I, Lippmann M, Woody J, Lee J. Endovascular exclusion of descending thoracic aortic aneurysms and chronic dissections: initial clinical results with the AneuRex device. J Vasc Surg 2001;33:927-34. 29. Hoornweg LL, Dinkelman MK, Goslings JC, Reekers JA, Verhagen H, Verhoeven Elm, et al. Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multicenter analysis of 28 cases in The Netherlands. J Vasc Surg 2006;43:1096-102. Submitted May 9, 2007; accepted Jul 24, 2007.