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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
TRAUMA TEVARSAVS 07Puerto Rico Scott Stevens
OBJECTIVES • Spectrum of problem • Endovascular strategies • Review outcomes data • Tips, tricks and trouble shooting
Thoracic Aorta Trauma - 1997 • Fabian – North American Study • Semba and Dake
TEVAR for TraumaClinical Data • Technical success • Less invasive • Decreased operative time • Low morbidity • Less mortality
Clinical Series - Starnes • All existing literature • 235 patients • Mortality – 6.8% • No reported paraplegia • Beware of case series
Kasirajan Annals of Vascular Surgery 04 • Mortality • O. R. time • Length of stay
Wellons: Journal of Vascular Surgery • Nine patients • Infra-renal aortic cuffs • No procedural deaths • 100% technical success • No paraplegia
Limitations Endoleaks Migration Fistula Infection No long-term data
Technical Considerations • Passive hypotension • Address life threatening injuries • Study access vessels • Position patient for arch images • Measure distance from access to proximal landing zone
Anatomic Considerations • Proximal landing zones – critical • Distal landing zones – forgiving • Assess arch angulations • Watch for pseudo-coarctation
What about the left subclavian? • Covered intentionally • Extremity ischemia-rare • Posterior strokes-rare • Subclavian-carotid, if dominant left vertebral or LIMA graft
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
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
Trauma TEVAR -Limitations • Graft over sizing • Steep arch transition • In folding of graft • Durability – young patients
High Rent District + Off Label • Highly litigious • Broad specialty support • Prospective institutional support • Consider IRB approval
Trauma TEVAR The New Benchmark ? • Demanding • Compelling data • Dramatic shift in therapy • Limited devices - judgment
Scott Stevens The University of Tennessee Medical Center