INTRODUCTION:Traumatic thoracic aortic transection is a catastrophic sequela of blunt chest injury. Standard treatment is open repair by left thoracotomy. Endovascular repair of the injured thoracic aorta with stent-graft has developed as a viable option. Few case reports of collapse of the stent-grafts have been reported. Rarely, infolding of the stent-graft can occur resulting in severe stenosis and obstruction to blood flow.
CASE PRESENTATION:We report a case of a 24 year old white male who was involved in a motor vehicle accident. Computed tomographic angiography (CTA) of the chest revealed transection of the thoracic aorta at the level of left subclavian artery. He underwent endovascular repair with a stent-graft. A follow up CTA showed no contrast extravasation but infolding as well as collapse of the stent-graft. Patient underwent re-expansion of the stent-graft with balloon angioplasty and a non-covered stent. Partial infolding of the most proximal portion was still noted. A transesophageal echocardiogram revealed partial infolding of the stent-graft with increased velocity suggesting significant stenosis. Patient was then referred to another facility where he underwent a non-covered stent placement that also covered the origin of the left common carotid artery. Patient improved clinically and was discharged home. A follow up CTA a month and a half later revealed patent stent-graft with no infolding and no endoleak. The non-covered stents covered the left common carotid and left subclavian arteries but both showed flow within their lumen. The patient has continued to do well clinically.
DISCUSSIONS:The diagnosis of aortic transection is generally based upon radiographic studies. Finding of mediastinal widening on plain chest radiographs has 90% sensitivity but is nonspecific. Chest CT is only suitable for hemodynamically stable patients. It does not yield detailed information on vascular anatomy and can miss small arterial tears. CT angiography provides better information. TEE offers the advantage of portability and can be performed at the bedside in unstable patients. Angiography is the gold standard for assessing aortic injuries and has the highest resolution of vascular detail. Selection of diagnostic studies must be based upon the stability of the patient, the clinical probability of a serious aortic injury, and the skills and experience of local personnel. Endovascular repair with commercially available and custom-made covered stents has emerged as a viable option to open repair by left thoracotomy with or without the use of partial cardiopulmonary bypass. Endovascular stenting, especially in critically ill patients, reduces the recovery time that associated with thoracotomies. Some studies have suggested low rates of morbidity and mortality. The long-term durability of endovascular repair remains unknown, but early and midterm results appear promising.
CONCLUSION:Endovascular repair of traumatic thoracic aortic transection has developed as an alternative to open repair. Collapse of the stent-grafts has been reported. Even rarely, infolding of the stent-graft causing severe stenosis can occur. Endovascular repair with non-covered stents can be used to satisfactory luminal contour to relieve the obstruction and improve the patency of the stent-graft without compromising blood supply to vital structures and organs.
DISCLOSURE:Muhammad Gill, No Financial Disclosure Information; No Product/Research Disclosure Information