Endovascular stent grafts and aortic rupture: a case series

BACKGROUND: Endovascular stent grafts (EVSGs) offer an alternative in the management of traumatic rupture of the aorta, particularly in patients who are at prohibitive operative risk. METHODS: We conducted a retrospective review of 11 cases managed by EVSGs over a 4-year period. EVSGs were defined as "noncommercial" (graft material hand sewn over metallic stents) or "commercial" (grafts marketed for infrarenal aortic or thoracic aneurysms). Data collected included the difference between endovascular stent graft length, tear length (apposition length), and location relative to the left subclavian artery. RESULTS: EVSGs (three noncommercial and eight commercial, including AneuRx cuff six], Talent one], and Ancure aortic tube graft one]) were used in 11 patients. Six were placed less than or equal to 8 hours from injury, one after 14 hours, three after 5 days, and one 10 years after injury. Routes of access included femoral (four), iliac (three), and abdominal aorta (four). Average landing zone diameter was 18.8 +/- 3.5 mm, distance from the left subclavian artery was 2.85 +/- 2.1 cm, and tear length was 1.54 +/- 1.0 cm. In four cases, the apposition length was less than 2 cm. There were two cases of persistent endoleak and two cases of endoleak noted and treated at deployment. Persistent endoleak occurred in two of three noncommercial EVSGs. Endoleak occurred in three of four cases when apposition length was less than 2 cm, one of which was treated successfully at the time of placement by deploying extension grafts. Endoleak occurred in two of six cases when deployment was within 2 cm of the origin of the left subclavian artery. In one case of persistent endoleak, open repair was performed 3 weeks later when the patient had stabilized. Ultimately, there were three deaths, two caused by severe closed head injury and one caused by respiratory failure. CONCLUSION: Endovascular stent grafts can be placed emergently. Commercial grafts result in better results than noncommercial grafts. Available "cuff extenders" are sufficient for the majority of aortic injuries but often require deployment via the iliac or aorta because of the shorter delivery system. Tears more than 1.5 cm resulting in apposition length less than 2 cm or those near or in the curvature of the aorta are associated with increased endoleak risk. The ideal thoracic EVSG would be available in 5-, 7.5-, 10-, and 15-cm lengths and mounted on a system 80 cm in length.