J. L. Velazquez1, P. Rodriguez1, F. Joglar1 1University Of Puerto Rico School Of Medicine,Department Of Surgery,San Juan, Puerto Rico, Puerto Rico
Introduction: The use of endovascular stentgrafts in blunt thoracic aortic injuries (TAI) has become widespread, and it has changed the treatment paradigm for blunt TAI patients due to its lower morbidity and mortality. Penetrating arterial injury to the aorta, the subclavian artery, and other vessels such as the renal arteries can be difficult to manage with open repair in the acute setting requiring extensive exposure procedures. For contained penetrating arterial injuries were traditional exposure is associated with higher morbidity and mortality, endovascular management is an option to be considered if the necessary equipment and expertise is available.
Methods: We studied all adult patients admitted with penetrating arterial injury at the Pueto Rico Trauma Center (PRTC), a state-designated level 1 trauma center. All patients with thoracic or abdominal large vessel arterial injury due to penetrating trauma consulted to the Vascular Surgery service were included in the study. Patient that had active bleeding or were hemodynamically unstable underwent emergent open repair. Patients considered for endovascular repair were those that had contained arterial injuries in the aorta, axillosubclavian, or visceral arteries. Analyses of demographics, injury severity scores, type of injury, procedure-related complications, and outcomes were performed.
Results: From January 1, 2011 to September 30, 2013 a total of 4,095 patients were admitted to the PRTC. A total of 218 (5.3%) penetrating arterial injuries were identified. A total of 8 patients underwent endovascular repair for penetrating arterial injury. The mean age was 22± years (range, 16-26) and the mean Injury Severity Score was 23.6 ± (range, 11-41). A total of 4 (50%) subclavian vessel injuries, 3 (38%) aortic injuries and 1 (12%) renal artery injury. All injuries were repaired by endovascular approach with covered stent grafts. Of the aortic injuries 2 were abdominal posterior aortic pseudoaneurysms (PSAs) and 1 descending thoracic aortic PSA. All 4 cases of subclavian injury were repaired stentgrafts due to PSAs. One patient with a right renal artery PSA underwent successful repair with a stentgraft. There were no access site, renal, or procedure-related complications. Three patients required video assisted thoracoscopic surgery due to retained hemothorax. All patients were discharged home without major postoperative complications. Three patients were lost to follow up. There is a mean follow up of 9.6± months (range,1-13).
Conclusion: Hemodynamically stable trauma patients with penetrating arterial injury in locations where open exposure may be associated with high morbidity and mortality can be successfully treated with an endovascular approach. Whether these techniques can be applied in unstable patients depends on the availability of the necessary equipment and the expertise of the operating surgeon.