Jordi Maeso

Endovascular Treatment of Traumatic Thoracic Aortic Injuries: Short- and Medium-term Follow-up

BACKGROUND Successful thoracic endovascular aortic repair (TEVAR) with low rates of complications has been referred to in the treatment of traumatic thoracic aortic injuries; however, we still do not know the long-term behavior. In this series, short- and intermediate-term results of TEVAR of traumatic aortic injuries are analyzed. METHODS The clinical charts and courses of 20 patients (mean age, 31.8 years; age range, 15-65 years; 14 [70%] men) with traumatic thoracic aortic injuries treated with TEVAR were retrospectively reviewed. Mean delay from trauma to intervention was 15 days (range, 0-180 days). RESULTS The initial success rate was 100%, with no deaths or intraoperative leaks, although in 4 (20%) patients, injuries were repaired in the arterial access site. The mean postoperative follow-up was 43.53 months (range, 5.5-108.0 months). Four (20%) patients required reintervention: 2 postoperative revascularizations of the left subclavian artery (20% of the patients in whom the ostium was intentionally occluded) and 2 aortic reinterventions (endovascular treatment of a collapsed stent graft and open repair after thrombosis of another stent graft). All reinterventions were successfully performed and no additional complications were registered during follow-up. Asymptomatic findings related to the stent graft included lack of proximal device-wall apposition in 8 patients (40%), intragraft mural thrombus formation during the first 6 months in 7 patients (35%), and an asymptomatic fracture of the longitudinal reinforcing bar of the stent graft 4 years later in 1 patient (5%). CONCLUSION Although not completely exempt of complications, TEVAR provides a reliable method for the treatment of traumatic thoracic aortic injuries with good results in the short- and medium-term follow-up. All complications have been treated successfully. Long-term evolution of lack of proximal device-wall apposition and intragraft mural thrombus formation should be closely monitored to prevent long-term complications.

Transcervical carotid stenting with flow reversal is a safe technique for high-risk patients older than 70 years.

BACKGROUND Recent evidence regarding carotid revascularization advises against carotid angioplasty and stenting (CAS) in patients aged >70 years with conventional risk for carotid endarterectomy (CEA). The poor outcome of transfemoral CAS in this age group may be explained by the anatomic characteristics of the aortic trunk and supra-aortic vessels in elderly patients, as well as by a high prevalence of aortic arch atheromatosis. Transcervical CAS with flow reversal for cerebral protection avoids these unfavorable characteristics. This study analyzed the short-term and middle-term results of transcervical CAS with flow reversal in patients aged >70 years at high risk for CEA. METHODS Between January 2006 and January 2011, 219 cases of >70% carotid artery stenosis in high-risk patients aged >70 years (55.7% asymptomatic and 44.3% symptomatic) were treated by transcervical CAS. All patients underwent complete neurologic examination by a stroke neurologist before and after the procedure. Primary end points were stroke, death, or myocardial infarction (MI), technical success, and complications at 30 days. During follow-up, we analyzed the rate of restenosis ≥50% and ipsilateral stroke. Data were collected prospectively and outcome was analyzed in all cases, including technical failures. RESULTS The 30-day combined stroke/death/MI rate was 2.2% (stroke, 1.8%; stroke/death, 2.2%; and MI, 0.45%). In symptomatic patients, stroke/death/MI was 5.1% (stroke, 4.1%; stroke/death, 5.1%). None of the asymptomatic patients suffered stroke, MI, or death postoperatively. Technical success was 96.3% (four inability to cross lesion, two major common carotid dissections, one failed preangioplasty, one stent thrombosis). One cervical hematoma required surgical drainage. At follow-up (18.8 ± 16.9 months), cumulative (standard error) incidence of >70% restenosis was 3% (1%) at 1 year and 8% (3%) at 2 and 3 years. Only one patient experienced ipsilateral stroke during follow-up. Overall survival (standard error) was 94% (2%) at 1 year and 90% (3%) at 2 and 3 years. CONCLUSIONS In our experience, transcervical CAS with flow reversal is a safe technique for treating carotid stenosis in patients aged >70 years. We believe that avoiding the aortic arch and tortuous supra-aortic vessels is responsible for the favorable results in this study.

Incidence and Evolution of Mural Thrombus in Abdominal Aortic Endografts

BACKGROUND The aims of this study were to analyze the predictive factors for intragraft mural thrombus formation and evolution during follow-up after endovascular treatment of abdominal aortic aneurysms and to evaluate its relationship with the subsequent appearance of complications. METHODS A retrospective study was performed by selecting those patients who underwent endovascular repair of an abdominal aortoiliac aneurysm between June 1998 and September 2004, with a minimum follow-up of 24 months. Preoperative clinical data, anatomical characteristics of the aneurysm, and endograft type were analyzed. In addition, clinical evaluation and abdominal computed tomography angiography (CT scans) performed at 1, 6, 12, and 24 months after the surgery were reviewed. RESULTS Eighty-nine patients were submitted for endovascular aneurysm repair in this period, and 75 completed the 24-month follow-up. Eighteen patients developed intragraft mural thrombus (24% incidence), 13 (72.2%) appearing at 1 month of follow-up, and up to 16 (88.9%) appearing during the first 6 months. Logistic regression analysis showed that the lumen percentage of mural thrombus in the native aorta and the use of aortouniiliac endografts were independent predictors of intragraft mural thrombus formation (odds ratio, 1.065; 95% confidence interval, 1.022-1.110, and odds ratio, 8.014; 95% confidence interval, 1.598-40.181, respectively). No spontaneous regression of the thrombus was observed. The area of intragraft mural thrombus had increased at 12 and 18-24 months after their diagnosis (Wilcoxon signed rank test, p = 0.028 and 0.028, respectively). The presence of intragraft mural thrombus was associated with a greater tendency to endograft body or branch occlusion (5 of 18 cases with intragraft mural thrombus (27.8%) versus 1 of 57 cases without it (1.8%), (p = 0.003). CONCLUSION Intragraft formation of mural thrombus is a common finding during the follow-up of abdominal aortic endografts, particularly in aneurysms with large mural thrombus of the native aorta, and is associated with the use of aortouniiliac endografts. The area occupied by the mural thrombus was shown to gradually increase during follow-up and was associated with a greater tendency for endograft occlusion.

Late thrombosis of a thoracic aorta stent graft: Therapeutic management

The case of a 17-year-old adolescent boy with severe polytrauma is reported. Among other injuries, he presented with aortic rupture distal to the origin of the subclavian artery with no bleeding into the mediastinum. The lesion was repaired by placement of a Cook TX2 endovascular graft (Cook Incorporated, Bloomington, Ind). One year later, he was hospitalized with acute heart failure. Computed tomography angiography showed nearly complete stent graft occlusion and no evidence of altered integrity of the device. A right axillofemoral bypass was performed, allowing conversion to successful definitive repair consisting of an extra-anatomic bypass from the ascending aorta to the supraceliac abdominal aorta.