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Thoracic Endovascular Aortic Repair (TEVAR) in Traumatic Thoracic Aortic Transection

The development of thoracic endovascular aortic repair (TEVAR) has allowed a minimally invasive approach for management of an array of thoracic aortic pathologies. Initially utilised in the treatment of aortic aneurysmal disease, indications of TEVAR have expanded to include treatment of Type B aortic dissection with malperfusion or rupture, traumatic aortic transection, and penetrating aortic ulcer (PAU). Although there are no randomised controlled trials directly comparing TEVAR to open surgery, numerous studies suggest that TEVAR is associated with decreased morbidity compared with open repair. Benefits of the endovascular approach include avoidance of thoracotomy or sternotomy incision, avoidance of aortic cross-clamping, decreased blood loss and decreased end-organ ischemia. Case Study A 49-year-old hypertensive, non-diabetic male patient presented in the Emergency of Medanta-Patna one week after a road traffic accident with persistent pain on the left side of his chest. He had a fractured femur for which intramedullary (IM) nailing was done at another centre followed by strapping for multiple rib fractures. At the same centre, he had undergone an electrocardiogram (ECG), which was normal. His contrast-enhanced CT (CECT) scan of the chest showed posterior mediastinal haematoma along with chest wall haematoma. Hence, he was referred for further evaluation and management of haemothorax to Medanta - Patna. Post evaluation, a CT aortogram was done that showed aortic transection at the level of isthmus of aorta, which is a usual site for high-velocity traumatic injury in the aorta due to its anatomical location. In high-velocity road traffic accidents, rapid deceleration of upper body due to impact of encountered object(s) causes shearing stress on the aortic wall. The CT aortogram showed contained rupture of descending thoracic aorta at the level of isthmus. His serum creatinine was 1.5 mg/dl and ultrasound whole abdomen was normal. Echocardiography (ECHO) showed normal LV function with no pericardial collection. After the diagnosis of aortic transection, the patient was planned for urgent intervention. After discussing the risks and benefits of open surgery and endovascular therapies, the patient consented for endovascular procedure. Patient was evaluated in the intensive care unit (ICU) and was taken up for TEVAR under general anaesthesia. Vascular access was achieved through right femoral artery. Pigtail catheter was used to delineate and measure the rupture extent and stent size. This was followed by deployment of stent over 0.035 system over stiff amplaz wire. Deployment of stent was uneventful. Post deployment testing showed left subsclavian artery covered. Right femoral artery was repaired and distal pulses were palpable. Post procedure, the patient was shifted to the ICU. His left upper limb remained normal. Patient was observed in the ICU for 24 hours and kept on relevant medicines. On Day 2, patient was shifted to the ward and discharged from the hospital on Day 3 of the procedure. On second followup after one month, the patient was doing well.
Dr. Sanjay Kumar
Cardiac Care
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