TEVAR FOR! THORACIC AORTIC TRAUMA"
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1 10th HKL Vascular Surgery Conference and Workshop" TEVAR FOR! THORACIC AORTIC TRAUMA" Dr Hanif Hussein" Vascular and General Surgeon" Department of Surgery" Hospital Kuala Lumpur"
2 Source: MIROS!
3 Thoracic Aortic Injury" Highly fatal" Second cause of blunt trauma death" Clancy TV, et al. J Trauma. 2001;51: % on scene death! 85% Death at the scene" 1% per hour / next 48 hrs" Parmley L, et al. Circulation 1959;17: ! 50% survivors die within 24 hrs" Jamieson WR et al. Am J Surg 2002;183:571-5!
4 Anatomy" Thoracic Aorta" Deep within chest wall" Rib cage and its musculature" Surrounding organs" Heart and Lungs"
5 Thoracic Aortic Injury" High velocity, high impact, blunt injury" MVA, fall from height" Associated" Head, chest, intra-abd injuries" Long-bone fractures"
6 Patho-Physiology" Acceleration-deceleration injury" Aortic isthmus after LSCA" Mobile heart and aortic arch" Fixed aortic isthmus" Rapid increase in intraluminal pressure - rupture"
7 Grades of TAI" Vancouver Classification"
8 Grades of TAI"
9 Grades of TAI" Benjamin et al. J Vasc Surg 2012;55:47-54!
10 Aortic Injury" Grades 1 & II" Asymptomatic" CT diagnosis" Grades III & IV" Widened mediastinum" High mortality"
11 Diagnosis" Autopsy" High index of suspicion" Mechanism of injury" Car vs motorbike" Impact of injury" High speed" Extent of injury" Poly trauma" Head, intra-abd injury"
12 Diagnosis" Chest X-Ray" Widened mediastinum" 1st, 2nd ribs fracture" Hemothorax" CT Scan" Incidental" Pseudoaneurysm distal to LSCA" Dissection flap... " Contrast leak - late sign"
13 Management"
14 Initial management" Resuscitation - ATLS" Imaging" CTA for TEVAR protocol" Manage life-threatening conditions" Head injury" Intra-abdominal injury" Repair of aortic injury"
15 Open Repair" Postero-lateral thoracotomy" Single lung ventilation" Concomitant thoracic, intraabd, head injury" Cardio-pulmonary bypass" Blood loss" Lung complications" Mortality (0-54%)" Paraplegia (0-36%)"
16 EV Aortic Repair" First aneurysm surgery (Rae)" Open aneurysm repair" EVAR (Parodi)" TEVAR"
17 EV Aortic Repair" Endoluminal stent graft for aortic disruption (Dake)"
18 TEVAR" Annals Thorac Surg 2007;84: ! Annals Thorac Surg 2008;85: !
19 TEVAR" J Vasc Surg 2012;56:74-80! J Vasc Surg 2007;46:934-40!
20 TEVAR vs OR" TEVAR is more advantageous over open repair " Mortality rate" Paraplegia" Intra-operative blood loss" Major complications" Hospital stay"
21 Disadvantages" Pseudoaneurysm at puncture site" Iliac artery thrombosis" Retroperitoneal hematoma" Stent-related complications" Off-label usage of stent" Conformable GORE TAG" Long-term results?"
22 HKL Experience" 5 patients between " All male, yrs age range" MVA"
23 HKL Experience" Polytrauma in 4/5 : ISS 5-41" Laparotomy (splenectomy) - 2" Craniotomy - 1" ORIF of femur - 1"
24 HKL Experience" Site : Distal to left subclavian artery" Medtronic Valiant stent" LSA covered in 2/5 patients" No revascularisation procedure" No ischaemic symptoms" No endoleak on F/U ( 2-5 yrs )"
25 Case 1 - Post-Stenting"
26 Case 3 - Pre-op CTA"
27 TAI Mx Guidelines" Systematic review of 7768 patients" Lower mortality rates" Lower SCI and ESRF" Lower risk of graft infection"
28 SVS Guidelines" Timing" Urgent / other injuries treated / before discharge" Grade of injury" All grade II to IV" Endovascular - if suitable anatomy" Selective revascularisation of LSA"
29 Conservative Tx" Ann Thorac Surg 2002;73: ! 30 of 145 patients" 15 had delayed surgery" 15 non-op"
30 Conservative Tx" Delayed op (15)" 3 deaths" Non-op (15)" 5 died of severe head injuries" 10 survived at 2.5 yrs (6 mths - 5 yrs)"
31 Conservative Tx"
32 Conservative Tx" 140 Blunt aortic injuries" Intimal flaps, large intimal tear, pseudoaneurysm" Not worsened" 65% healed" Benjamin et al. J Vasc Surg 2012;55:47-54!
33 Conclusion" BLUNT TRAUMATIC AORTIC INJURY" Highly fatal injury" High index of suspicion for diagnosis" TEVAR should be considered first"
34 ! THANK YOU! DRIVE SAFELY"
account for 10% to 15% of all traffic fatalities majority fatal at the scene 50% who survive the initial injury die in the first 24 hours 90% die
account for 10% to 15% of all traffic fatalities majority fatal at the scene 50% who survive the initial injury die in the first 24 hours 90% die within the first month if aorta not repaired 30-90% overall
EVAR and TEVAR: Extending Their Use for Rupture and Traumatic Injury. Conflict of Interest. Hypotensive shock 5/5/2014. none
EVAR and TEVAR: Extending Their Use for Rupture and Traumatic Injury Bruce H. Gray, DO MSVM FSCAI Professor of Surgery/Vascular Medicine USC SOM-Greenville Greenville, South Carolina none Conflict of Interest
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