Ministry of Health

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 ©Copyright
 Published: 28/11/2011

Is there a role for endoluminal stenting
 in the treatment of the ruptured thoracic aorta?
Mr Andrew Hill
Vascular Surgeon
Auckland City Hospital

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Outline

Is there a role for endoluminal stenting in the treatment of the ruptured thoracic aorta?
Andrew Hill
Vascular Surgeon
Auckland Hospital

Rigid intraluminal prosthesis for replacement of thoracic aorta Lemole et al JEVS 1984:1;1

Ruptured thoracic aorta
    Most die at roadside
    Most (75%) have other organ system injury
    Cerebral, lung, abdominal viscera, orthopedic
    Trend towards later treatment

Off the shelf grafts - 2 piece

2 piece grafts fitted together using the “trombone” technique

Deployment sequence

Requirement for flexibility in the thoracic aorta up to 50mm radius

A curved aorta requires a flexible graft and a curved introducer

Thoracic aortic aneurysm

Thoracic aneurysm - endoluminal repair

Ruptured thoracic aorta - pre CT

Ruptured thoracic aorta - pre angio

Ruptured thoracic aorta - completion angio

Ruptured thoracic aorta - completion CT

Ruptured thoracic aorta - 6 month CT

Ruptured thoracic aorta - pre angio

Ruptured thoracic aorta - IVUS

Ruptured thoracic aorta - completion angio

Ruptured thoracic aorta - advantages
    Less invasive
    avoids thoracotomy
    Avoids requirement for one lung anaesthesia and reduces post-op respiratory failure/complications
    Avoids heparin by doing away with systemic heparin, bypass or shunts
    Avoids aortic clamp
    preventing swings in upper body and particularly cerebral perfusion pressure in head injured patients
    ?Reduces renal dysfunction
    Avoids transfer of patient (local)

Ruptured thoracic aorta - disadvantages
    Potential delays while assessing suitability and graft availability
    Long-term durability unknown
    Some L subclavian cover
    Requires guidewire manipulation in injured artery especially if “pseudo-coarctation”
    ?urgent conversion to thoracotomy or bypass

Ruptured thoracic aorta
    Feasible
    Can delay until graft available but some graft systems are now available off the shelf
    The sicker the patient the more the advantage