Please wait a minute...
Reviews in Cardiovascular Medicine  2021, Vol. 22 Issue (3): 1029-1035     DOI: 10.31083/j.rcm2203112
Special Issue: State-of-the-Art Cardiovascular Medicine in Asia 2021
Original Research Previous articles | Next articles
Endovascular repair of traumatic aortic dissection: a single-center experience
Yingliang Wang1, 2, Tongqiang Li1, 2, Jiacheng Liu1, 2, Qin Shi1, 2, Chen Zhou1, 2, Chongtu Yang1, 2, Songjiang Huang1, 2, Yang Chen1, 2, Bin Xiong1, 2, *()
1Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, Hubei, China
2Hubei Key Laboratory of Molecular Imaging, 430022 Wuhan, Hubei, China
Download:  PDF(571KB)  ( 212 ) Full text   ( 14 )
Export:  BibTeX | EndNote (RIS)      
Abstract:

The data on endovascular aortic repair (EVAR) for traumatic aortic dissection (TAD) are lacking. Hence, this study aimed to evaluate the efficacy of EVAR for TAD and report our experience based on patients from our medical center with a relatively long follow-up. A total of 25 consecutive patients with TAD underwent EVAR from October 2015 to October 2020. The demographics, imaging characteristics, clinical features, treatment details, and follow-up results were reviewed. Urgent EVAR was performed in 3 patients (12%), while the remaining 22 patients (88%) underwent delayed EVAR. Systematic heparinization was used in all patients during the endovascular procedure. The EVAR was technically successful in all patients, with no cases converted into open surgery. No death occurred during the perioperative period. One patient presented with a type II endoleak on postoperative 1-month CT images during a mean follow-up of 42.3 ± 17.7 months (5–67.5 months) and showed spontaneous regression of the endoleak without any intervention during the subsequent follow-up. All the patients survived until the time of writing, and none of them showed late endoleak, stent migration, paraplegia, and reintervention. The patients with left subclavian artery covered (n = 8) had no obvious ischemia of the arm and brain. The study results demonstrated that EVAR for TAD proved to be safe and effective, and most patients could undergo delayed EVAR. Systematically heparinization during EVAR under the setting of multi-trauma was safe.

Key words:  Aortic dissection      Endovascular aortic repair      Stent      Trauma     
Submitted:  19 June 2021      Revised:  16 August 2021      Accepted:  17 August 2021      Published:  24 September 2021     
*Corresponding Author(s):  Bin Xiong     E-mail:  herr_xiong@126.com

Cite this article: 

Yingliang Wang, Tongqiang Li, Jiacheng Liu, Qin Shi, Chen Zhou, Chongtu Yang, Songjiang Huang, Yang Chen, Bin Xiong. Endovascular repair of traumatic aortic dissection: a single-center experience. Reviews in Cardiovascular Medicine, 2021, 22(3): 1029-1035.

URL: 

https://rcm.imrpress.com/EN/10.31083/j.rcm2203112     OR     https://rcm.imrpress.com/EN/Y2021/V22/I3/1029

Fig. 1.  Flowchart of inclusion of patients. From October 2015 to October 2020, there were 32 consecutive patients with computed tomography angiography (CTA) confirmed traumatic aortic dissection (TAD). Patients with type A aortic dissection (n = 2), abrupt death after admission (n = 1) and refused to aortic repair (n = 4) were excluded. Finally, 25 TAD patients who underwent EVAR procedure were included in the present study. There were 15 patients with Debakey IIIb dissection, 8 patients with Debakey IIIa dissection occurred, and 2 patients with isolated infrarenal abdominal aortic dissection.

Table 1.  Demographics of the traumatic aortic dissection patients.
Variables Value
Age (years), mean ± SD 56.5 ± 8.3
Male/Female, n (%) 20/5 (80/20)
Hypertension, n (%) 7 (28)
Diabetes, n (%) 1 (4)
Trauma type, n (%)
Traffic accident 17 (68)
Falling down 8 (32)
Concomitant injuries, n (%)
Bone fractures 25 (100)
Brain injury 10 (40)
Pulmonary injury 14 (56)
Splenic injury 1 (4)
Pancreatic injury 1 (4)
Renal contusion 3 (12)
SD, standard deviation.
Table 2.  Anatomical characteristics of the traumatic aortic dissection.
Variables Value
Dissection type, n (%)
Debakey IIIa 8 (32)
Debakey IIIb 15 (60)
Abdominal aortic dissection 2 (8)
DIT-LSA (cm), mean ± SD 2.0 ± 1.0
Size of the primary intimal tear (cm), mean ± SD 1.0 ± 0.3
Diameter of proximal landing zone (cm) 25.9 ± 3.0
SD, standard deviation; DIT-LSA, distance between the primary intimal tear and the ostium of the left subclavian artery in patients with Debakey III traumatic aortic dissection.
Table 3.  Treatment details of the traumatic aortic dissection.
Variables Value
Operation time (min), mean ± SD 57.8 ± 8.3
Stent type, n (%)
Talent (Medtronic) 5 (20)
Ankura (Lifetech Scientific) 5 (20)
Aegis (Microport) 12 (48)
E-vita (JOTEC) 3 (12)
Stent length (mm), mean ± SD 158 ± 37.5
Oversizing (%), mean ± SD 10 ± 5
EVAR timing, n (%)
Early 3 (12)
Delayed 22 (88)
LSA covered, n (%) 8 (32)
LSA reconstruction, n (%) 2 (8)
SD, standard deviation; EVAR, endovascular aortic repair; LSA, left subclavian artery.
Fig. 2.  Endovascular aortic repair of a Debakey III traumatic aortic dissection. (A,B) Computed tomography angiography images (including volume-rendering technique) of a patient demonstrating a Debakey III traumatic aortic dissection and an intimal tear distal to the left subclavian artery (namely, aortic isthmus). The distance between the primary intimal tear and the ostium of the left subclavian artery was 0.8 cm. (C,D) Computed tomography angiography images (including volume-rendering technique) 6 months after the endovascular aortic repair, demonstrating that the stents were in good shape, the true lumen was unobstructed, no endoleak occurred, and the thoracic aorta and left subclavian artery were well reconstructed.

Fig. 3.  Endovascular aortic repair of an isolated traumatic abdominal aortic dissection. (A–C) Computed tomography angiography and digital subtraction angiography images of a patient with localized isolated traumatic abdominal aortic dissection; a covered stent was implanted to cover the intimal tear. (D) Computed tomography angiography image 12 months after the endovascular aortic repair, demonstrating that the stent was in good shape, the true lumen was unobstructed, no endoleak occurred, and the abdominal artery was well reconstructed.

[1] Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor’s Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) European Journal of Vascular and Endovascular Surgery. 2017; 53: 4–52.
[2] Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: Clinical practice guidelines of the Society for Vascular Surgery. Journal of Vascular Surgery. 2011; 53: 187–192.
[3] Hundersmarck D, van der Vliet QMJ, Winterink LM, Leenen LPH, van Herwaarden JA, Hazenberg CEVB, et al. Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. European Journal of Trauma and Emergency Surgery. 2020. (in press)
[4] Kapoor H, Lee JT, Orr NT, Nisiewicz MJ, Pawley BK, Zagurovskaya M. Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management. RadioGraphics. 2020; 40: 1834–1847.
[5] Harky A, Bleetman D, Chan JSK, Eriksen P, Chaplin G, MacCarthy-Ofosu B, et al. A systematic review and meta-analysis of endovascular versus open surgical repair for the traumatic ruptured thoracic aorta. Journal of Vascular Surgery. 2020; 71: 270–282.
[6] Cheng Y, Cheng C, Wang S, Wu VC, Chu P, Chou A, et al. Long-term Outcomes of Endovascular and Open Repair for Traumatic Thoracic Aortic Injury. JAMA Network Open. 2019; 2: e187861.
[7] Li S, Cai W, Li X, Qiu J, Li Q, Shu C. Thoracic endovascular aortic repair for traumatic type B aortic dissection: a 5-year experience from a single center. International Angiology. 2017; 36: 316–321.
[8] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Medicine. 2007; 4: e296.
[9] Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. the Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal. 2014; 35: 2873–2926.
[10] Fox N, Schwartz D, Salazar JH, Haut ER, Dahm P, Black JH, et al. Evaluation and management of blunt traumatic aortic injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. 2015; 78: 136–146.
[11] Pang D, Hildebrand D, Bachoo P. Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. Cochrane Database of Systematic Reviews. 2019; 2: CD006642.
[12] Kaneyuki D, Asakura T, Iguchi A, Yoshitake A, Tokunaga C, Tochii M, et al. Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience. European Journal of Cardio-Thoracic Surgery. 2019; 56: 307–312.
[13] Prendes CF, Stana J, Schneidwind KD, Rantner B, Konstantinou N, Bruder J, et al. Blunt traumatic thoracic aortic injuries: a retrospective cohort analysis of 2 decades of experience. Interactive CardioVascular and Thoracic Surgery. 2021; 33: 293–300.
[14] Maggisano R, Nathens A, Alexandrova NA, Cina C, Boulanger B, McKenzie R, et al. Traumatic rupture of the thoracic aorta: should one always operate immediately? Annals of Vascular Surgery. 1995; 9: 44–52.
[15] Marcaccio CL, Dumas RP, Huang Y, Yang W, Wang GJ, Holena DN. Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury. Journal of Vascular Surgery. 2018; 68: 64–73.
[16] Estrera AL, Miller CC, Guajardo-Salinas G, Coogan S, Charlton-Ouw K, Safi HJ, et al. Update on blunt thoracic aortic injury: fifteen-year single-institution experience. The Journal of Thoracic and Cardiovascular Surgery. 2013; 145: S154–S158.
[17] Steuer J, Björck M, Sonesson B, Resch T, Dias N, Hultgren R, et al. Editor’s Choice – Durability of Endovascular Repair in Blunt Traumatic Thoracic Aortic Injury: Long-Term Outcome from Four Tertiary Referral Centers. European Journal of Vascular and Endovascular Surgery. 2015; 50: 460–465.
[18] van Prehn J, van Herwaarden JA, Muhs BE, Arnofsky A, Moll FL, Verhagen HJM. Difficulties with endograft sizing in a patient with traumatic rupture of the thoracic aorta: the possible influence of hypovolemic shock. Journal of Vascular Surgery. 2008; 47: 1333–1336.
[19] Bae M, Jeon CH, Kwon H, Kim JH, Choi SU, Song S. Evaluation of Zone 2 Thoracic Endovascular Aortic Repair Performed with and without Prophylactic Embolization of the Left Subclavian Artery in Patients with Traumatic Aortic Injury. Korean Journal of Radiology. 2021; 22: 577–583.
[20] Gennai S, Leone N, Andreoli F, Munari E, Berchiolli R, Arcuri L, et al. Influence of Thoracic Endovascular Repair on Aortic Morphology in Patients Treated for Blunt Traumatic Aortic Injuries: Long Term Outcomes in a Multicentre Study. European Journal of Vascular and Endovascular Surgery. 2020; 59: 428–436.
[21] Lee C, Huang J, Yang T. Experience of endovascular repair of thoracic aortic dissection after blunt trauma injury in a district general hospital. Journal of Thoracic Disease. 2016; 8: 1149–1154.
[22] Son S, Jung H, Cho JY, Oh T, Do YW, Lim KH, et al. Mid-term outcomes of endovascular repair for traumatic thoracic aortic injury: a single-center experience. European Journal of Trauma and Emergency Surgery. 2019; 45: 965–972.
[23] Yoon WJ, Mani K, Wanhainen A, Rodriguez VM, Mell MW. Anatomic feasibility of off-the-shelf thoracic single side-branched endograft in patients with blunt traumatic thoracic aortic injury. Journal of Vascular Surgery. 2021. (in press)
[24] Antonello M, Menegolo M, Maturi C, Dall’antonia A, Lepidi S, Frigo AC, et al. Intentional coverage of the left subclavian artery during endovascular repair of traumatic descending thoracic aortic transection. Journal of Vascular Surgery. 2013; 57: 684–690.e1.
[25] Sepehripour AH, Ahmed K, Vecht JA, Anagnostakou V, Suliman A, Ashrafian H, et al. Management of the left subclavian artery during endovascular stent grafting for traumatic aortic injury - a systematic review. European Journal of Vascular and Endovascular Surgery. 2011; 41: 758–769.
[26] Klocker J, Koell A, Erlmeier M, Goebel G, Jaschke W, Fraedrich G. Ischemia and functional status of the left arm and quality of life after left subclavian artery coverage during stent grafting of thoracic aortic diseases. Journal of Vascular Surgery. 2014; 60: 64–69.
[27] Makaloski V, Widenka H, Schönhoff F, Spanos K, Wyss TR, Schmidli J. Efficacy and Safety of Heparinization before Deployment of Endograft for Blunt Traumatic Aortic Injury in Severely Injured Patients. Annals of Vascular Surgery. 2021; 75: 341–348.
[28] Ho VT, George EL, Rothenberg KA, Lee JT, Garcia-Toca M, Stern JR. Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury. Journal of Vascular Surgery. 2021; 74: 71–78.
[1] Danni Feng, Jian Ke, Sufang Huang, Xiaorong Lang. A scoping review of exercise-based cardiac rehabilitation for patients with aortic dissection[J]. Reviews in Cardiovascular Medicine, 2021, 22(3): 613-624.
[2] Dan Ke, Xi He, Chaogui Lin, Lianglong Chen. Comparison of standard versus modified stenting technique for treatment of tapered coronary artery lesions[J]. Reviews in Cardiovascular Medicine, 2021, 22(3): 931-938.
[3] Tao Yi, Zi-Wen Zhao, Liang-Long Chen. Over-expansion of second-generation drug-eluting stents, risk of restenosis, and relation to major adverse cardiac events[J]. Reviews in Cardiovascular Medicine, 2020, 21(3): 481-487.
[4] Tomasz Jędrzejczak, Paweł Rynio, Rabih Samad, Anita Rybicka, Agata Krajewska, Piotr Gutowski, Arkadiusz Kazimierczak. Complete Entry and Re-entry Neutralization protocol in endovascular treatment of aortic dissection[J]. Reviews in Cardiovascular Medicine, 2020, 21(1): 129-137.
[5] Fengju Liu, Lianjun Huang. Usefulness of ultrasound in the management of aortic dissection[J]. Reviews in Cardiovascular Medicine, 2018, 19(3): 103-109.
[6] William Finch, Michael S. Lee. Percutaneous Coronary Intervention for Coronary Bifurcation Lesions[J]. Reviews in Cardiovascular Medicine, 2017, 18(2): 59-66.
[7] Carlos E. Velasco, Mahir Patel, Jaime Mogollon, Jerrold M. Grodin, Robert C. Stoler. Myocardial Infarction Related to Trauma[J]. Reviews in Cardiovascular Medicine, 2015, 16(4): 261-264.
[8] Jeremy P. Berman, Sanjum S. Sethi, Michael E. Farkouh. Strategies for Management of Stable Coronary Disease in Type 2 Diabetes Mellitus[J]. Reviews in Cardiovascular Medicine, 2013, 14(S1): 50-58.
[9] René Bombien, George T. Pisimisis, Ali Khoynezhad. An Update on Endovascular Management of Acute Thoracic Aortic Disease and Future Directions[J]. Reviews in Cardiovascular Medicine, 2013, 14(2-4): 99-106.
[10] Danielle Runyan, Rony Gorges, Dustin Feldman, Peter A. McCullough, Shukri David, Souheil Saba. Long-term Follow-up of Lesion-specific Outcomes Comparing Drug-eluting Stents and Bare Metal Stents in Diseased Saphenous Vein Grafts[J]. Reviews in Cardiovascular Medicine, 2013, 14(1): 1-8.
[11] Ali Khoynezhad, Carlos E. Donayre, Rodney A. White. Endovascular Management of Acute Complicated Type B Aortic Dissection in North America[J]. Reviews in Cardiovascular Medicine, 2012, 13(4): 176-184.
[12] Jason Kahn, Gary S. Mintz, Kim Dalton, Yael L. Maxwell, Laura A. McKeown, Martin B. Leon, Gregg W. Stone. Highlights from the 23rd Annual Transcatheter Cardiovascular Therapeutics Scientific Symposium, November 7-11, 2011, San Francisco, CA[J]. Reviews in Cardiovascular Medicine, 2012, 13(2-3): 124-136.
[13] Tom A. Lassar, Daniel I. Simon, Kevin Croce. Optimizing Antiplatelet Therapy Following Percutaneous Coronary Intervention: Clinical Pathways for Platelet Function Testing[J]. Reviews in Cardiovascular Medicine, 2011, 12(S1): 23-33.
[14] Michael S. Lee, Will Finch, Giora Weisz, Ajay J. Kirtane. Cardiac Allograft Vasculopathy[J]. Reviews in Cardiovascular Medicine, 2011, 12(3): 143-152.
[15] Michael S. Lee, Jenna Nguyen. Treatment Options for Patients With Left Main Coronary Artery Disease[J]. Reviews in Cardiovascular Medicine, 2011, 12(2): 77-83.
No Suggested Reading articles found!