TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm: Case report and systematic review

Introduction

Blunt thoracic aortic injury (BTAI) is a potentially life-threatening event. ¹ This injury ranks as the second most common cause of death from blunt injuries. Endovascular therapy has become the predominant approach for patients with BTAI, ² providing a relatively low rates of mortality, stroke, and paraplegia. In patients with BTAI, TEVAR with fenestration is technically challenging. To our knowledge, only a few cases of TEVAR with fenestration for BTAI have been reported. Here we report a case of traumatic aortic pseudoaneurysm located between the brachiocephalic artery (BCA) and left common carotid artery (LCCA), which required TEVAR with fenestrations of all supra-aortic branches to exclude the pseudoaneurysm and preserve the patency of supra-aortic branches. In addition, we performed a systematic review on TEVAR with fenestration for BTAI.

Case report

After approval of Clinical Research Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine (Number: IIT2023-0087), we conducted this case report. The patient’s consent was waived. A 24-year-old man hit by a car was sent to the emergency room. On physical examination, he was unconscious and large ecchymoses especially in the neck and chest were observed all over the body. We carried out a computed tomography (CT) scan of the whole body. There was no cerebral bleeding or fracture to the skull and chest, and no sigh of abdominal organ injuries. Nevertheless, we observed a nasal bone fracture, traumatic wet lung in the right upper lobe, a grade 3 BATI (aortic pseudoaneurysm), and a left femoral fracture. The pseudoaneurysm lied in the aortic arch between the BCA and the LCCA (Figure 1(a) and (b)). During the CT scan, the patient was hemodynamically stable. Both the cardiovascular team, who performed the open repair, and vascular team were called in for emergent consulting. Given the challenge of maintaining hemostasis during open aortic repair, the patient underwent emergent TEVAR with fenestrations of all supra-aortic branches.OPEN IN VIEWER

To begin with, the patients’ bilateral carotid arteries and left brachial artery were exposed for vascular access. The patient’s left common femoral vein and right axillary artery were also exposed for cardiopulmonary bypass. It should be noted that after the traumatic injury, there was also a substantial hematoma around the neck, necessitating considerable caution when dissecting both carotid arteries. After systemic heparinization, digital subtraction angiography (DSA) was performed to confirm the aortic pseudoaneurysm (Figure 1(c),Supplemental Video S1). We then reduced patient’s systolic pressure to 90–100 mmHg and deployed a 22-22-80 mm stent graft (Ankura, LifeTech, China) through the right femoral artery into the descending aorta, with its proximal end located distal to the left subclavian artery. The cardiopulmonary bypass was then turned on, and we deployed a 28-28-150 mm (TAG, Gore, USA) (20% oversize) stent graft covering the entire aortic arch. The distal end of the second stent graft was located in the first stent graft. Cerebral oxygen monitoring did not show a significant decrease in cerebral blood perfusion. Following that, in situ needle fenestration of the LCCA was performed first. A short sheath was placed into the LCCA with its tip achieving the membrane of the stent graft. A liver biopsy needle (21G, 30 cm, BARD), which contained a 0.018-inch guidewire (V-18 ControlWire, Boston Scientific), was advanced through the sheath. Then we removed the needle, used a 4 mm balloon to expand the initial aperture and exchanged the guidewire into a 0.035-inch guidewire and used an 8 mm balloon for further expansion. In the end, a 9*50 mm self-expandable covered stent (Viabahn, Gore, USA) was deployed in the aperture. The dilatation with 8 mm balloon was repeated again to fully expand the covered stent. Fenestration of BCA was performed secondly, similar to the operation performed on the LCCA, with a 4 mm and a 10 mm balloon dilation prior to the deployment of a 13*50 mm covered stent (Viabahn, Gore, USA). A 10 mm balloon dilation was repeated after stent implantation. The angiography was repeated again to confirm the patency of both LCCA and BCA. The cerebral oxygen monitoring also showed no abnormalities. Then, the cardiopulmonary bypass was removed. In terms of LSA fenestration, a flexible needle (21 gauge, Futhrough, Lifetech) was employed from the left brachial artery to create the fenestration in the aortic stent graft, which contained a 0.018-inch guidewire (V-18 ControlWire, Boston Scientific). The aperture was then expanded by a 4 mm and an 8 mm balloon, and a stent (9*50 mm Viabahn, Gore, USA) was implanted. An 8 mm balloon dilation followed stent implantation. The final DSA showed the complete exclusion of the pseudoaneurysm and the patency of all supra-aortic branches (Figure 1(d), Supplemental Video S2). The operative time of the TEVAR with fenestrations was 4 hours and 6 minutes. The total dose-area products, DAP, was 193.0 Gycm3. The contrast volume used in the operation was approximate 200 mL iodixanol (Visipaque, GE Healthcare Ireland). The orthopedic team was then called in to treat the femoral fracture. In the end, the patient’s recovery was unremarkable.

At 1, 7 and 18 months follow-up, the patient was well recovered. Both CTA during the follow-up confirmed the exclusion of the aortic lesion and the patency of branches with no sign of endoleaks (Figure 2).OPEN IN VIEWER

Literature review

Studies compared TEVAR and open aortic repair have shown that TEVAR had superior 30-day mortality rates and lower rates of spinal cord ischemia and acute kidney injury.^2–4 Nevertheless, these studies did not focus on those BATI that need additional fenestration apart from TEVAR. In this systematic review, we identified English articles on TEVAR with fenestrations for BTAI from May 1995 to December 2022 in the PubMed, Scopus, and Embase. Variations of the following search terms were used: blunt, aortic, injury, thoracic endovascular aneurysm repair, stent, and fenestration. The complete search strategy is in the supplementary materials. To find more studies, we manually searched the references of the selected articles. The full-text was reviewed if the abstract mentioned TEVAR for BTAI. Cases were included if there was at least one branch artery received fenestration with stent(s) deployed in this branch.

The search strategy identified 2444 articles, of which 51 studies were selected for full-text review after screening title and abstract. 6 articles were included after the full-text review with another two articles added manually. Finally, 8 articles with 8 patients were included (Figure 3). Their information was presented in the supplementary materials. Their mean age was 40 years (range, 23–69), and 6 patients (75%) were male. 4 patients (50%) were diagnosed with Grade III BTAI, 3 patients (37.5%) were diagnosed with Grade IV BTAI, and 1 patient (12.5%) was diagnosed with Grade II BTAI. 3 patients (37.5%) had injuries to the aortic isthmus (defined as the junction between the aortic arch and the thoracic descending aorta), ² 4 patients (50%) had injuries to the aortic arch, and 1 patient (12.5%) had injuries to both sites. The majority of patients (6, 75%) only received single fenestration, whereas one patient received two fenestrations, and one patient had fenestrations of all supra-aortic branches. In terms of techniques, 3 patients (37.5%) underwent fenestrations in vitro, 5 patients (62.5%) underwent in situ fenestrations (2 needle fenestrations; 2 laser-assisted fenestrations; and 1 in situ fenestrations without details). Additional chimney technique was used in 2 patients for LCCA. The LSA was sacrificed in 2 patients (25%). In 1 patient (12.5%), the LCCA was revascularized by LCCA-LSA bypass. All the patients received emergent TEVAR. During the perioperative period, one patient (12.5%) had concurrent liver and kidney damage from a car accident and died on the eighth postoperative day due to acute renal injury and acute liver injury. During a mean follow-up of 8 months (range, 6–12), all other patients survived and their recovery was unremarkable.OPEN IN VIEWER

Discussion

The guidelines recommend conservative management for patients with grade I BTAI, while grade II to IV should be repaired. ² Endovascular repair is now the first-line treatment for the majority of patients with high BTAI grade. Several studies showed that TEVAR reduced patient mortality and procedure-related complications compared to open surgery.^5,6

TEVAR was approved by the FDA for the repair of thoracic descending aortic aneurysms in 2005. ⁷ Nowadays, TEVAR has become one of the feasible treatments for dissection and aneurysms involving the descending aorta and/or the aortic arch.^8,9 To obtain an adequate proximal landing zone, sacrificing the left subclavian artery can be considered and is safe in most situations. Subsequently, several reconstruction techniques including chimney and fenestration have been developed. The chimney technique is effective to reestablish blood flow. Nevertheless, it is associated with a relatively high risk of endoleak. On the other hand, fenestration has better outcomes and a lower risk of endoleak. ¹⁰ Compared to fenestration in vitro, in situ fenestration takes less time to perform. In situ fenestration provides an effective reconstruction of branch arteries with a relatively low risk of complications, and is especially suitable for emergency situations. With fenestrations of all supra-aortic branches, TEVAR is able to extend the proximal landing zone into the ascending aorta, making it possible to exclude lesions in the aortic arch.

As for aortic arch injuries, endovascular repair remains challenging. In order to prevent intraoperative cerebral embolism, cerebral blood flow must be preserved during the exclusion of the aortic lesion. Furthermore, when the proximal landing zone is located in the ascending aorta, the stent graft delivery may be difficult due to the large curvature of the aortic arch and the stiffness of the stent graft. In severe situation, a bird-beak configuration between the stent graft and the aorta may happen, which is a risk factor of future aortic complication. ¹¹ Among those patients in our systematic review, the majority received single fenestration, typically for the reconstruction of the left subclavian artery. Fenestrations of all supra-aortic branches were extremely rare. Multi-branch fenestrations significantly increase the technical difficulties and increase the operation time. Stents in the branches may lead to arterial stiffness and endoleak, as well as other unintended physiological implications. Each extra fenestration increases the corresponding risk. Moreover, the patient in this case suffered a concurrent substantial hematoma around the neck. Exposure of the bilateral arteries in the hematoma was difficult and prone to bleeding.

The patient in this case report successfully received in situ needle fenestrations of all branches of the aortic arch, with no stent-related complications occurring during the follow-up. This method provides a feasible treatment for patients with BTAI involving the aortic arch. The systematic review of TEVAR with fenestrations for BTAI also revealed a high technical success rate and promising short-term results. It is worth mentioning that several recent studies show that BTAI patients who underwent TEVAR without fenestrations have good long-term radiological outcomes ¹² and a low incidence of mid- and long-term reintervention. ¹³ The fenestration, which may damage to the integrity of the stent graft, causes a concern on long-term durability. In addition, there might be selection bias in terms of whether patients underwent TEVAR and the tendency of patients who failed the procedure not to publish. Therefore, a multicenter prospective cohort including a large number of patients with a long-term follow-up is needed to verify these results.

Conclusion

TEVAR with fenestration is feasible for treating BTAI involving the aortic arch in selected patients.

Supplemental Material

Supplemental Material

Supplemental Material