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Long-term outcomes of thoracic endovascular aortic repair: A single institution’s 11-year experience

Brenner, Megan MD, MS; Teeter, William MD, MS; Hadud, Muhammed; Hoehn, Melanie MD; O’Connor, James MD; Stein, Deborah MD, MPH; Scalea, Thomas MD

Journal of Trauma and Acute Care Surgery: April 2017 - Volume 82 - Issue 4 - p 687–693
doi: 10.1097/TA.0000000000001365
AAST Plenary Papers
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CME

BACKGROUND Thoracic endovascular aortic repair (TEVAR) has largely replaced traditional open aortic repair for anatomically suitable lesions, however, long-term outcomes are unknown.

METHODS All patients who underwent TEVAR from December 2004 to October 2015 at a single tertiary care institution were included. Demographics, injury pattern, operative details, outcomes, and surveillance were reviewed. Follow-up ranged from 2 to 132 months and was obtained from clinic notes and imaging reports.

RESULTS A total of 88 patients underwent TEVAR; all suffered from blunt mechanisms, 72.7% were men. Median age, Injury Severity Score, and Trauma and Injury Severity Score was 47 (19.7), 38 (13.5), 0. 8 (0.34). Injuries included 2% grade II, 90% grade III, and 8% grade IV. Overall mortality was 6.8%, TEVAR-related mortality was 0%. Overall in-hospital complication rate was 57%, whereas TEVAR-related complication rate was 9.1%: four typ 1a endoleaks, two typ 2, and two typ 3. Of the typ 1 endoleaks, all required reoperation, whereas all types 2 and 3 endoleaks resolved on subsequent imaging. The left subclavian artery (LSCA) was intentionally covered at index operation in 19 patients (21.6%), and 7 patients (8%) had partial LSCA coverage. The rate of postoperative left upper extremity ischemia was 0%. Left carotid-subclavian bypasses were performed prophylactically in two patients before LSCA coverage at index operation. Eighty-seven percent of endograft access was by performed by open femoral artery exposure and one via retroperitoneal conduit. Percutaneous TEVAR (pTEVAR) was performed more recently in 11.4% of patients with no complications. Heparin was administered intraoperatively in 23 patients with TBI, and 12 patients were not heparinized; no adverse events or outcomes resulted from its use or lack thereof. First, second, and third surveillance imagings occurred at mean intervals of 14 days, 4 months, and 1 year, respectively. Percent of patients followed at 1, 3, and 5 years from operation was 62.1%, 25%, 13.6%, respectively.

CONCLUSION TEVAR continues to be a feasible treatment modality for blunt traumatic aortic injury with minimal and early device and procedure-specific complications. Follow-up continues to be a significant challenge, and protocols for surveillance imaging are needed. This is the first study to describe access specific outcomes of pTEVAR in trauma patients. Long-term outcomes of TEVAR are still largely unknown; however, these data suggest that it may be at least comparable to open repair.

LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV; therapeutic study, level V.

From the University of Maryland School of Medicine (M.B., W.T., M.H., J.O.C., D.S., T.S.), Division of Trauma/Critical Care RA Cowley Shock Trauma Center, and Division of Vascular Surgery (M.B., M.H.), University of Maryland School of Medicine, Baltimore, Maryland.

Submitted: August 1, 2016, Revised: October 15, 2016, Accepted: October 19, 2016, Published online: January 26, 2017.

This paper was presented at the 76th annual meeting of the American Association for the Surgery of Trauma, September 13–16, 2016, in Waikoloa, Hawaii.

Address for reprints: Megan Brenner, MD, MS, RPVI FACS, Division of Trauma/Critical Care, RA Cowley Shock Trauma Center Division of Vascular Surgery, University of Maryland, 22 S. Greene St., Baltimore, MD 21201; email: mbrenner@umm.edu.

© 2017 Lippincott Williams & Wilkins, Inc.