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Scott Stevens The University of Tennessee Medical Center

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 Endovascular strategies Review outcomes data Tips, tricks and trouble shooting.

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Scott Stevens The University of Tennessee Medical Center

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  1. Scott Stevens The University of Tennessee Medical Center

  2. TRAUMA TEVARSAVS 07Puerto Rico Scott Stevens

  3. TEVAR - The New Benchmark For Thoracic Aortic Injuries

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

  5. Blunt Thoracic Aortic Injuries

  6. Mechanism of Injury

  7. Diagnosing Thoracic Aortic Injuries

  8. Diagnosing Thoracic Aortic Injuries

  9. Diagnosing Thoracic Aortic Injuries

  10. Diagnosing Thoracic Aortic Injuries

  11. Open Repair

  12. Thoracic Aorta Trauma - 1997 • Fabian – North American Study • Semba and Dake

  13. Open Repair Percutaneous

  14. TEVAR for TraumaClinical Data • Technical success • Less invasive • Decreased operative time • Low morbidity • Less mortality

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

  16. Ott Journal of Trauma 04

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

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

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

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

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

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

  23. 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 50-60 mm Hg • Adenosine pause

  24. 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

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

  26. Available Devices

  27. Available Devices - Cuffs

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

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

  30. Scott Stevens The University of Tennessee Medical Center

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

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

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