TEVAR is Superior to Open Repair for Blunt Aortic Injury Royce Calhoun, MD, Stephanie Mayberg, PA-C, Bill Pevec, MD, Danh Nguyen, PhD^, Lisa Mu^ J. Nilas Young, MD John Laird, MD o Division of Cardiothoracic Surgery o Division of Cardiology ^Department of Biostatistics University of California Davis Medical Center Royce Calhoun, MD, Stephanie Mayberg, PA-C, Bill Pevec, MD, Danh Nguyen, PhD^, Lisa Mu^ J. Nilas Young, MD John Laird, MD o Division of Cardiothoracic Surgery o Division of Cardiology ^Department of Biostatistics University of California Davis Medical Center

Blunt Aortic Injury 75% patients die at scene of accident 5% are unstable and die shortly after accident 25% of remainder die of other injuries Traditional approach to repair has been emergent open repair - Paraplegia 2-19%, Mortality 15-35% Current trend is appropriately timed urgent repair with an evolving endovascular role - Paraplegia 0%, Mortality 0-17% 75% patients die at scene of accident 5% are unstable and die shortly after accident 25% of remainder die of other injuries Traditional approach to repair has been emergent open repair - Paraplegia 2-19%, Mortality 15-35% Current trend is appropriately timed urgent repair with an evolving endovascular role - Paraplegia 0%, Mortality 0-17%

Methods Comparison of open repair vs. stent for TTAT 1999 to 2011 First thoracic aortic stent was October 2005 Exclusively stent repair for last 4 years Comparison of open repair vs. stent for TTAT 1999 to 2011 First thoracic aortic stent was October 2005 Exclusively stent repair for last 4 years

Approach Open - n=35 - Thoracotomy, L groin 30 - Partial bypass 24 - Full bypass 7 - DHCA 4 - Thoracotomy, Gott shunt 1 Open - n=35 - Thoracotomy, L groin 30 - Partial bypass 24 - Full bypass 7 - DHCA 4 - Thoracotomy, Gott shunt 1 Endograft - n=40 - Femoral (cut down) 33 - Iliac (RP with graft) 2 - Infrarenal Aorta (4 RP, 1 Lap) 5

Stent Graft Results Stents Used - 7 TAG - 1 C-TAG - 17 Excluder Cuffs - 4 AneuRx Cuffs - 2 Talent - 9 TX2 36/40 immediate technical success 39/40technical success after re-interventions Complete coverage of traumatic tear with no stent migration or endoleaks at most recent follow-up Stents Used - 7 TAG - 1 C-TAG - 17 Excluder Cuffs - 4 AneuRx Cuffs - 2 Talent - 9 TX2 36/40 immediate technical success 39/40technical success after re-interventions Complete coverage of traumatic tear with no stent migration or endoleaks at most recent follow-up

Case 17 YO male, ejected from car Intracranial bleed, multiple orthopedic injuries, splenic and liver lacerations Bilateral severe pulmonary contusions pO 2 55 on 100% FIO 2 with 20 PEEP Comminuted aortic tear 17 YO male, ejected from car Intracranial bleed, multiple orthopedic injuries, splenic and liver lacerations Bilateral severe pulmonary contusions pO 2 55 on 100% FIO 2 with 20 PEEP Comminuted aortic tear

Results EndograftOpenp Patients40 (33 male)35 (30 male) Age ISS Admit to OR (hrs) 5722 <0.01 Procedure time (hrs) <0.01

Results EndograftOpenp Transfusions1.99.1<0.01 ICU (days) Ventilator (median days) LOS (days) F/U (mos) 23 18

Major Adverse Events Endograft n=40 Open n=35 Death37 Paraplegia00 CVA00 Renal Failure requiring dialysis 24 Subclavian Steal20 Vascular Access13 Re-intervention/re-op65

Conclusions Endovascular stents for BAI can be performed safely with excellent short and mid-term results Time from admission to intervention of BAI is increased in the stent group with no increased mortality Stents for BAI are associated with decreased OR times and intraoperative blood transfusions compared to open Endovascular stents for BAI can be performed safely with excellent short and mid-term results Time from admission to intervention of BAI is increased in the stent group with no increased mortality Stents for BAI are associated with decreased OR times and intraoperative blood transfusions compared to open