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
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Spectrum of problem
Endovascular strategies
Review outcomes data
Tips, tricks and trouble shooting
Blunt Thoracic Aortic Injuries
Mechanism of Injury
Diagnosing Thoracic Aortic Injuries
Diagnosing Thoracic Aortic Injuries
Diagnosing Thoracic Aortic Injuries
Diagnosing Thoracic Aortic Injuries
Open Repair
Thoracic Aorta Trauma - 1997
 Fabian
– North American Study
 Semba
and Dake
Open Repair
Percutaneous
TEVAR for Trauma
Clinical Data
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Technical success
Less invasive
Decreased operative time
Low morbidity
Less mortality
Clinical Series - Starnes
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All existing literature
235 patients
Mortality – 6.8%
No reported paraplegia
Beware of case series
Ott Journal of Trauma 04
Open (12)
Endovascular (6)
MORTALITY
17%
0%
PARAPLEGIA
16%
0%
LARYNGEAL
NERVE
8.3%
0%
Kasirajan
Annals of Vascular Surgery 04
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Mortality
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O. R. time
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Length of stay
Wellons: Journal of Vascular Surgery
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Nine patients
Infra-renal aortic cuffs
No procedural deaths
100% technical success
No paraplegia
Limitations
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Endoleaks
Migration
Fistula
Infection
No long-term data
Technical Considerations
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Passive hypotension
Address life threatening injuries
Study access vessels
Position patient for arch images
Measure distance from access to proximal
landing zone
Anatomic Considerations
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Proximal landing zones – critical
Distal landing zones – forgiving
Assess arch angulations
Watch for pseudo-coarctation
What about the left subclavian?
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Covered intentionally
Extremity ischemia-rare
Posterior strokes-rare
Subclavian-carotid, if
dominant left vertebral
or LIMA graft
Tips and Tricks
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Body floss
Stiff wire to pin graft
along greater curvature
Keep buddy-wire
alongside of graft as
bailout for carotid
Endo “wedgie”
Drop MAP 50-60 mm Hg
Adenosine pause
Trouble Shooting
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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
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Graft over sizing
Steep arch transition
In folding of graft
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
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Highly litigious
Broad specialty support
Prospective institutional
support
Consider IRB approval
Trauma TEVAR
The New Benchmark ?
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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
“A Good Retreat is Better
Than a Bad Stand” – my
brother