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Endograft Repair of Traumatic Thoracic Aortic Tears is First Line Therapy for Appropriately Selected Patients
R. Calhoun1, A. Kelsey1, J. Laird2, V. Rodriguez1, W. Pevec1, A. Nasseri1, J. Young1. 1Dept. of Surgery, Division of Cardiothoracic, Univ California Davis Medical Center, Sacramento, CA, 2Dept. of Medicine, Div. of Cardiology, Vascular Center, UC Davis, Sacramento, CA,
BACKGROUND:
Traumatic Thoracic Aortic Tears (TTAT) remains a lethal problem with most victims dying at the scene of the injury. The treatment of the aortic injury component to these complex patients is in evolution with the advent and commercialization of thoracic aortic stent grafts. Herein, we evaluate our recent experience with endograft therapy for TTAT and compare it to a contemporary cohort of patients treated with the traditional open thoracotomy technique.
METHODS:
These data represent a retrospective review of a prospectively collected aortic database. The study period is from 1/03 to 1/08 for the open group and 10/05 to 1/08 for the endograft group. The open group was performed primarily with partial cardiopulmonary bypass and the stent group mostly via a femoral artery cutdown. The groups were compared using a Student’s T-test or a Wilcoxon Rank Sum test.
RESULTS:
During the study period 15 patients (ages 14-84, mean 43) underwent endograft repair or attempt for TTAT vs. 21 patients (ages 18-75, mean 41) had open repair. There were no significant differences between the endograft and open groups with respect to mean injury severity score (ISS) (35.6 vs. 43.9), age [43 (14-85) vs. 41.5 (18-75)] or median time from admission to operation (37.2 vs. 8.5 hrs) respectively. However, the endograft group did have a significantly shorter procedure time and less intraoperative blood transfusions compared to the open cohort (Table 1). There was a non-significant trend towards decreased time on the ventilator, decreased time in the ICU and decreased total hospital stay in the endograft group compared to the open group.
Table 1 | Endograft | Open | p value | | Procedure Time hrs | 4.3 | 6.3 | 0.01 | | Transfusions | 1.1 | 7.9 | 0.001 | | Ventilator days | 11 | 25 | 0.41 | | ICU days | 6 | 41 | 0.10 | | LOS days | 24 | 30 | 0.16 |
CONCLUSIONS:
Conclusion: The treatment of TTAT is in evolution with a trend towards minimally invasive endograft approaches. Our data suggest that the early results with endografts for TTAT are excellent with some advantages with respect to decreased operating room time and blood transfusion requirement. There was one peri-operative death and one major complication in our first 15 consecutive patients. The short-term results, with a median follow-up of > 9 months, are also good having detected no stent migrations, delayed endoleaks or other stent related immediate or delayed complications with serial surveillance visits and CT scans. We now consider endograft therapy for TTAT the first line therapy unless there is an anatomical contraindication.
Table 2 | Stent n=15 | Open n=21 | | Death | 1 | 4 | | Paraplegia | 0 | 0 | | CVA | 0 | 0 | | TVC Paralysis | 0 | 3 | | Vascular | 0 | 0 | | Renal Failure/HD | 0 | 4 | | Vent Depend/Trach | 0 | 4 | | Re-intervention/re-op | 3 | 0 |
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