Scott Stevens The University of Tennessee Medical Center.

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Presentation transcript:

Scott Stevens The University of Tennessee Medical Center

TRAUMA TEVAR SAVS 07 Puerto Rico Scott Stevens

TEVAR - The New Benchmark For Thoracic Aortic Injuries

OBJECTIVES Spectrum of problem Spectrum of problem Endovascular strategies Endovascular strategies Review outcomes data Review outcomes data Tips, tricks and trouble shooting Tips, tricks and trouble shooting

Blunt Thoracic Aortic Injuries

Mechanism of Injury

Diagnosing Thoracic Aortic Injuries

Open Repair

Thoracic Aorta Trauma Fabian – North American Study Fabian – North American Study Semba and Dake Semba and Dake

Open Repair Percutaneous

TEVAR for Trauma Clinical Data Technical success Technical success Less invasive Less invasive Decreased operative time Decreased operative time Low morbidity Low morbidity Less mortality Less mortality

Clinical Series - Starnes All existing literature All existing literature 235 patients 235 patients Mortality – 6.8% Mortality – 6.8% No reported paraplegia No reported paraplegia Beware of case series Beware of case series

Ott Journal of Trauma 04 Open (12) Endovascular (6) MORTALITY17%0% PARAPLEGIA16%0% LARYNGEAL NERVE 8.3%0%

Kasirajan Annals of Vascular Surgery 04 Mortality Mortality O. R. time O. R. time Length of stay Length of stay

Wellons: Journal of Vascular Surgery Nine patients Nine patients Infra-renal aortic cuffs Infra-renal aortic cuffs No procedural deaths No procedural deaths 100% technical success 100% technical success No paraplegia No paraplegia

Limitations Endoleaks Endoleaks Migration Migration Fistula Fistula Infection Infection No long-term data No long-term data

Technical Considerations Passive hypotension Passive hypotension Address life threatening injuries Address life threatening injuries Study access vessels Study access vessels Position patient for arch images Position patient for arch images Measure distance from access to proximal landing zone Measure distance from access to proximal landing zone

Anatomic Considerations Proximal landing zones – critical Distal landing zones – forgiving Assess arch angulations Watch for pseudo-coarctation

What about the left subclavian? Covered intentionally Covered intentionally Extremity ischemia-rare Extremity ischemia-rare Posterior strokes-rare Posterior strokes-rare Subclavian-carotid, if dominant left vertebral or LIMA graft Subclavian-carotid, if dominant left vertebral or LIMA graft

Tips and Tricks Body floss Stiff wire to pin graft along greater curvature Keep buddy-wire alongside of graft as bailout for carotid Endo “wedgie” Drop MAP mm Hg Adenosine pause

Trouble Shooting Poor apposition along lesser curvature Graft in folding Graft collapse Avoid landing in transition zone Extend proximally Support with second graft or Palmaz stent

Trauma TEVAR -Limitations Graft over sizing Graft over sizing Steep arch transition Steep arch transition In folding of graft In folding of graft Durability – young patients Durability – young patients

Available Devices

Available Devices - Cuffs Brand Working length Graft diameter Graft length AneuRx 55 cm 28 mm 4.O cm Excluder 61 cm 28.5 mm 3.3 cm Zenith 55 cm 32 mm 3.6 cm Endologix 63 cm 28 mm 7.5 cm

High Rent District + Off Label Highly litigious Broad specialty support Prospective institutional support Consider IRB approval

Trauma TEVAR The New Benchmark ? Demanding Compelling data Dramatic shift in therapy Limited devices - judgment

Scott Stevens The University of Tennessee Medical Center

“A Good Retreat is Better Than a Bad Stand” – my brother