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UCSF Vascular Symposium 2012April 27, 2012

W. Anthony Lee, MD, FACSDirector of Endovascular Services

Christine E. Lynn Heart and Vascular InstituteBoca Raton, Florida

Disclosures� Cook Medical: research grant support,

consulting, honorarium, travel stipend� Bolton Medical: consulting, honorarium� This presentation will discuss off-label use

of medical devices

Traumatic Aortic Disruption� Mechanism:

Acceleration/deceleration injury� Intimal tear �� Transmural

disruption� Location: Ligamentum

arteriosum� Associated poly-trauma (long

bone, pelvic fractures, solid organ injury, closed head injury, pulmonary contusion)� Outcome associated with early

hemodynamic (in)stability

SVS Clinical Practice Guidelines� Systematic review and meta-analysis (Knowledge and

Encounter Research Unit, Mayo Clinic)� 7768 patients in 139 studies� 112 case series (>10 cases): median 15 cases� 27 comparative observational nonrandomized studies� 77% males� Mean f/u: 2 years

Non-operative Open EndovascularAge (yrs) 39 36 39ISS 36 34 40Time interval to tx (hrs) --- 16 19LSA coverage (%) --- --- 30

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Systematic Review: Key Findings� Mortality (p<0.01)� Non-operative 46%� Open 19% (correlated w/ ISS)� Endovascular 9%

Non-operative

Open Endo p

Stroke (%) 2 3 3 NSSCI (%) 3 9 3 0.01Renal failure 5 8 3 0.01Infections 5 13 5 0.01Secondary procedures --- 6 10 0.07

Failures of TEVAR� Endoleak 60%� Stent graft collapse 11%� Intraoperative rupture 2%� Iliac artery injury 1%� Aortic perforation 1%� Unspecified 25%

Comparative Analysis: Open vs. TEVAR� 27 studies� Mortality: RR 0.61 (0.46-0.80)� SCI: RR 0.34 (0.16-0.74)� For BOTH open and TEVAR� Longer lag time associated with

improved survival� No difference between urgent and

delayed repair

Consensus Opinion on Select Issues (Grade 2, Level C)� Most repairs should be performed

<24 hours� Expectant management for type I

(minimal aortic injury/periadventitial hematoma)� TEVAR suitable for young patient

with good anatomy� Selective SCA revascularization for

zone 2 deployments in traumatic TEVAR

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Consensus Opinion on Select Issues (Grade 2, Level C)� Routine heparin anticoagulation during

TEVAR� Spinal drainage NOT required� General anesthesia preferred� Open (vs. percutaneous) femoral exposure� No consensus on optimal follow-up strategy

Conclusion� Based on the systematic review of the

available literature, the Committee suggeststhat endovascular repair of traumatic thoracic aortic injuries be performed preferentially over open surgical repair or non-operative management (Grade 2, Level C)

Technical Issues� Optimal TAD imaging� Endograft sizing� Aortic growth� Left subclavian artery management� Arch conformation

Optimal TAD Imaging� H/N/C/A/P CTA� Cardiac gating (aortic pulsatility ↓ with

class III/IV shock)� Posterior (vertebral) circulation� Access� IVUS� Equivocal CTA findings� More sensitive than angiography� (TEE/angiography)

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Endograft Sizing� Aortic diameter and volume status

of polytrauma victim� Aortic diam ↓ 38% (class III/IV shock)� Aortic diam ↑ 13% a�er resuscita�on� Endograft infolding associated with

oversizing� 60% related to traumatic TEVAR � 0.4% overall incidence� 33% device oversizing

Aortic Size Increase over Time� Forbes et al (J Vasc Surg, July 2010)� 21 patients� Prox thoracic aortic dilation: 0.74-0.83 mm/year� Hartley et al (Ann Vasc Surg, Sept 2009)� 1000 Chest CTA examined� Variables: age, gender, HTN, COPD, race, DM,

tobacco� Prox desc TA: 22.9 mm (<40 yrs) vs. 27.1 mm

(≥40 yrs)

Left Subclavian Artery Management Vertebral Anatomy

� L vert dominant in 60-65% (A)� PICA anatomy� 1-2% comp R vert

disjunction (B)� 3-4% atretic R vert (C)� SVS-CPG: No

revascularization in emergent cases� L SCA chimney stent

A

C

B

L R

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Arch Conformation Conclusions� TEVAR has become (de facto) standard of

care for traumatic aortic disruption� Therapy limited by � Device considerations� Uncertain natural history of the endografted

segment