Potential Long-Term Complications of Endovascular Stent Grafting for Blunt Thoracic Aortic Injury

Abstract

Blunt thoracic aortic injury (BTAI) is a rare, but lethal, consequence of rapid deceleration events. Most victims of BTAI die at the scene of the accident. Of those who arrive to the hospital alive, expedient aortic intervention significantly improves survival. Thoracic endovascular aortic repair (TEVAR) has been accepted as the standard of care for BTAI at many centers, primarily due to the convincing evidence of lower mortality and morbidity in comparison to open surgery. However, less attention has been given to potential long-term complications of TEVAR for BTAI. This paper focuses on these complications, which include progressive aortic expansion with aging, inadequate stent graft characteristics, device durability concerns, long-term radiation exposure concerns from follow-up computed tomography scans, and the potential for (Victims of Modern Imaging Technology) VOMIT.

Patient demographics and cardiovascular risk factors differentially influence geometric remodeling of the aorta compared with the peripheral arteries

“…A number of factors contribute to significantly lower short-term morbidity and mortality with endovascular aortic surgery compared to open surgery(4,5), and many of these factors have popularized the use of endovascular techniques for repair of more peripheral arteries in both civilian(6) and military trauma populations(7). Despite superior short-term results however, the potential for long-term complications in younger patients remains a significant concern(9). Arterial remodeling, resulting in diameter enlargement and elongation of arteries over time, can result in device migration, endoleaks, and reconstruction failure, predisposing to morbidity, mortality and expensive reinterventions(9).…”

“…Despite superior short-term results however, the potential for long-term complications in younger patients remains a significant concern(9). Arterial remodeling, resulting in diameter enlargement and elongation of arteries over time, can result in device migration, endoleaks, and reconstruction failure, predisposing to morbidity, mortality and expensive reinterventions(9). Though the effects of aging on certain parts of the vasculature have been reported previously(10,12), in this study we have comprehensively determined the dimensions and shapes of all major arteries in the chest, abdomen, pelvis and upper thigh, and included additional analysis on how these morphological parameters are influenced by age and comorbidities.…”

“…As the indications and complexity of endovascular operations have increased, the need for detailed knowledge of the dimensions and shape of the main arteries of the body and how they change with age and disease has become a key consideration in the development of minimally invasive devices and techniques to treat each of the arterial territories. Currently, most endovascular devices have been designed to treat vascular disease in the elderly, but frequently these devices are also used to treat traumatic injuries in young, otherwise healthy patients(6-9). Translation of these devices and methods to new patient populations raises concerns regarding the long-term integrity of endovascular repairs in these groups, as young arteries grow and remodel over time.…”

One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial)

“…23 A 40-year-old trauma patient may live 30 years; the cumulative radiation dose from annual follow-up of 210 mSv significantly increases the risk of malignancy. 24 The most recent clinical practice guidelines of the Society for Vascular Surgery 3 report that opinions among committee members ''varied widely'' regarding imaging frequency and type, leaving no clear-cut guideline for follow-up imaging. Rimon and colleagues 25 reviewed 33 CTA examinations of 7 patients over a mean follow-up of 6.3 years.…”

Intravascular ultrasound is a critical tool for accurate endograft sizing in the management of blunt thoracic aortic injury

“…7 However, this recommendation was based on "very low quality of evidence," and the long-term durability of TEVAR in this population of patients is unknown. 8 Several factors differentiate TEVAR for BTAI from TEVAR for thoracic aortic dissection or aneurysm. Trauma patients, being generally younger than older patients with aortic disease, have smaller and more compliant, tapering aortas that will remodel, calcify, thicken, dilate, and lengthen with age.…”