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Limitation of Imaging in Identifying Iatrogenic Aortic Coarctation following Thoracic Endovascular Aortic Repair
Limitation of Imaging in Identifying Iatrogenic Aortic Coarctation following Thoracic Endovascular Aortic Repair Rajiv N. Thakkar,1 Lauren Thomaier,2 Umair Qazi,2 Franco Verde,3 and Mahmoud B. Malas,2 Baltimore, Maryland
A 21-year-old male suffered blunt trauma from a motor vehicle accident causing thoracic aorta tear. The smallest available stent graft was deployed. Definitive repair was later performed using a 22 22 116 mm Talent Thoracic Stent Graft. The postoperative course was uneventful. Seventeen months later, he presented with dizziness, chest pain, acute renal failure, malignant hypertension, and troponin elevation. Computed tomography (CT) angiogram and transesophageal echocardiogram did not reveal any dissection, stent stenosis or collapse. Cardiac catheterization showed normal coronary arteries but a 117 mm Hg gradient across the stent graft. Iatrogenic coarctation of the aorta was confirmed with a second measurement during arch angiogram. A Palmaz stent was deployed over the distal end of the previous stent graft with complete resolution of symptoms and gradual normalization of kidney function. This case report demonstrates a need for wider availability and selecting appropriate stent graft in treating traumatic aortic injuries in young patients. It is the first case report of the inability of current imaging modalities in confirming stent collapse. Pressure gradient is a useful tool in confirming stent collapse when clinical scenario does not match CT findings.
A 21-year-old male was brought to the emergency room after he sustained a deceleration blunt trauma as a restrained driver in a motor vehicle accident. The patient was hemodynamically stable. Chest radiograph demonstrates enlarged mediastinum. Contrast-enhanced computed tomography (CT) scan axial image at the level of the aortic arch demonstrated hemomediastinum and sagittal reconstruction images demonstrated a 3-cm saccular pseudoaneurysm arising from the proximal
1 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 2 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. 3 Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD.
Correspondence to: Mahmoud B. Malas, MD, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Building A/5, Surgical Admin, Baltimore, MD 21224, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 594.e11e594.e16 http://dx.doi.org/10.1016/j.avsg.2014.10.044 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: June 18, 2014; manuscript accepted: October 4, 2014; published online: January 28, 2015.
descending aorta at the level of ligamentum arteriosum (Fig. 1). The patient was taken to the operating room for stent-graft placement. The diameter of his thoracic aorta was 17e19 mm. The smallest stent available was a 26 mm 33 mm aortic cuff extension for Gore Excluder (W. L. Gore & Associates, Inc., Flagstaff, AZ). Because this stent was designed for abdominal aneurysm repair, the delivery system was short of reaching the thoracic injury. Hence, the cuff was deployed through an axillary approach. As one cuff was unable to cover the entire 3-cm aortic tear and pseudoaneurysm (Fig. 2 showing type 1 endoleak), a second cuff was introduced but failed to deploy at the lesion. As the delivery system was withdrawn, the cuff was spontaneously deployed in the subclavian artery. An immediate occlusion balloon was introduced through femoral approach to the proximal subclavian artery to control any potential bleeding. Open repair required removal of the cuff and a subclavianeaxillary artery bypass using ringed polytetrafluoroethylene graft. The patient was stable postoperatively. The next day a Talent Thoracic Stent Graft (22 22 116 mm) (Medtronic, Minneapolis, MN) became available, 594.e11
594.e12 Case reports
Fig. 1. Sagittal reconstruction CT of the chest demonstrates a 3-cm saccular pseudoaneurysm arising from the proximal descending at the level of ligamentum arteriosum (arrows).
Fig. 2. Angiogram after first gore cuff placement demonstrates near complete exclusion of pseudoaneurysm with residual extravasation of contrast (arrows) at the proximal medial margin of the stent (type Ia endoleak).
so he underwent definitive endovascular repair. This was deployed over the existing Gore Cuff stent graft to completely cover the tear (Fig. 3). We did not perform an angioplasty with a coda balloon after the deployment of the Talent Thoracic Stent Graft to avoid any further potential damage to the aorta. The patient recovered well postoperatively. Contrastenhanced chest CT in sagittal plane (Fig. 4), performed 2 months after endovascular repair,
Annals of Vascular Surgery
Fig. 3. Follow-up digital subtraction angiogram after definitive stent deployment (Talent) demonstrates complete coverage of prior stent (short arrows) with resolution of endoleak.
Fig. 4. Intravenous contrast-enhanced chest CT in sagittal plane, performed 2 months after endovascular repair, demonstrates resolution of mediastinal hematoma and no residual endoleak.
demonstrated resolution of the mediastinal hematoma and no residual endoleak. He presented to the emergency department 17 months later with acute onset chest and abdominal pain with dizziness while playing basketball. His initial vitals were blood pressure 154/80 mm Hg,
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Case reports 594.e13
Fig. 5. Intravenous contrast-enhanced chest CT scan (thick slab, 20 mm) of sagittal maximal intensity projection image (A) demonstrated descending aortic stents with intact metallic structure. Axial 3-mm section within
the distal portion of stent (long arrow) demonstrated an intraluminal graft material flap (short arrow) causing minimal luminal stenosis (B).
heart rate 42 beats/min, respiratory rate 16 breaths/ min, and oxygen saturation 98% on room air. Physical examination was notable for a grade III/VI harsh mid-systolic murmur at the right upper sternal border radiating to the carotid arteries bilaterally. His creatinine level was 1.8 mg/dL and troponin I was 0.34 mg/dL. Electrocardiogram showed sinus bradycardia, and a carotid duplex study showed velocities of 300e400 cm/sec bilaterally indicating hyperdynamic flow. Intravenous contrast-enhanced chest CT scan (thick slab, 20 mm) of sagittal maximal intensity projection image (Fig. 5A) demonstrated descending aortic stents with intact metallic structure. Axial 3-mm section within the distal portion of the stent (long arrow) demonstrated an intraluminal graft material flap (short arrow) causing minimal luminal stenosis (Fig. 5B). A transesophageal echocardiogram revealed a normal aortic root, moderate mitral regurgitation with no evidence of aortic dissection. Over the next 4 days, the patient developed worsening headache, pulmonary edema, hypertension (210/80 mm Hg), with worsening renal failure, and troponemia (creatinine 2.2 mg/dL and troponin 2.1 ng/dL). Intravascular ultrasound was not available at our institute. Left heart catheterization showed normal coronary arteries, but there was difficulty advancing the wire and catheter through the distal end of the endograft. There was a 117 mm Hg pressure gradient across the endograft (187/70 mm Hg proximal vs.
70/63 mm Hg distal to endograft). Digital subtraction angiogram (Fig. 6) demonstrated poor flow across the distal portion of the stent with a pressure gradient of over 100 mm Hg in real time. Despite the lack of radiological evidence of stent-graft collapse or filling defect on angiography, we decided to place a Palmaz XL stent (10 56 mm) (Cordis Corporation, Bridgewater, NJ) at the distal end of the previous endograft based on pressure gradient. The stent was mounted on a Coda balloon (32 mm) (Cook Medical, Inc., Bloomington, IN). Immediately after stent deployment, the pressure gradient across the stent decreased to 40 mm Hg (Fig. 7) in real time with marked improvement in his blood pressure and headache. Postoperatively, his creatinine returned to 1.1 mg/dL and 3 days later he was discharged in stable condition. A repeat carotid duplex study at his 1-month follow-up visit showed normal flow with less than 50% bilateral carotid stenosis. He continues to do well with yearly CT scan 4 years after the initial repair and has started playing basketball again. Traumatic thoracic aortic transection or dissection is a highly lethal injury.1 Thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to traditional open repair for treatment of traumatic aortic injuries with improved perioperative mortality, morbidity, and postoperative outcomes.1e3 Complications from TEVAR are most often encountered within 3 months4 with the greatest
594.e14 Case reports
Fig. 6. Initial digital subtraction angiogram demonstrated poor flow across distal portion of the stent with pressure gradient of over 100mm Hg in real time.
risk in the immediate month following repair.5 They include aortic dissection, graft infection, collapse, stenosis, migration distal embolization and paraplegia.1,6,7,9 Symptomatic late (>3 months) endograft collapse like the one noted in our patient is rare. Literature review shows few reported cases like the one published by Shukla et al.4 The risk of endograft collapse is higher in young patients undergoing TEVAR for trauma.5,8 Excessive stent graft over sizing is reported as an important cause of endograft collapse in younger patients.1,8 There are anatomical differences in the aorta of younger patients compared with older patients that make them more susceptible to endograft collapse including the following: smaller diameters with more straight course, a more acute angle at the level of the arch, and a more elastic compliant wall.10 Many currently available endografts are not designed for young patients with traumatic nonatherosclerotic aortic injury.8 Unfortunately, there was no Food and Drug Administration (FDA)-approved device available for aortic trauma and/or dissection at the time of this case. Several companies have recently recognized the need for smaller stent graft designed specifically for use in patients with traumatic aortic injury or type B dissection to avoid over sizing and endograft collapse.9
Annals of Vascular Surgery
Using the company-sponsored registry database, 91 patients who underwent TEVAR with Relay stent graft (Bolton Medical, Barcelona, Spain) for aortic dissection were followed for 2 years. Data showed technical success rate of 95%, mortality of 8% at 30 days with 2-year survival rate of 82%. Zipfel et al.11 concluded that Relay sent graft is safe for the treatment of acute and chronic type B aortic dissection. Relay stent graft is not approved by FDA for aortic dissection or traumatic aortic injury. Gore Medical conducted 2 pivotal, prospective, nonrandomized, multicenter, single-arm clinical studies designed to evaluate safety and effectiveness of using Conformable Gore TAG Thoracic Endoprosthesis (W. L. Gore & Associates, Inc.) for patients with aortic trauma or dissection. TAG 08-01 trial enrolled 50 patients who underwent TEVAR using Gore Tag Thoracic Endoprosthesis for the treatment of acute complicated type B dissections.12 It showed procedural and hospital survival rates of 100% and 92%, respectively, with a 30-day all-cause mortality rate of 8%. TAG 08-02 enrolled 51 patients for the treatment of traumatic aortic transection of descending thoracic aorta using Gore Tag Thoracic Endoprosthesis.12 This study showed procedural and hospital survival rates of 100% and 92.2%, respectively, with a 30-day all-cause mortality rate of 7.8%. Based on this safety and effectiveness data, Conformable Gore Tag Thoracic Endoprosthesis was the first device approved by the FDA in September 2013 for use in type B aortic dissection and/or aortic trauma patients. Medtronic Dissection Trial was also a prospective, nonrandomized, multicenter trial. They enrolled 50 patients with TEVAR using Valiant Captivia Thoracic Stent Graft System (Medtronic), with acute, complicated (malperfusion, rupture) type B aortic dissection from 16 US centers during 2010e 2012. These yet unpublished data showed 100% technical success and an 8% all-cause mortality rate at 30 days with no aortic rupture in 12 months.13 This is 3- to 4-fold mortality improvement over open surgical repair. FDA approved this device in January 2014 for type B aortic dissection and for traumatic aortic injury patients. Our case demonstrates a late complication (>3 months) after TEVAR in a young nonatherosclerotic patient with traumatic thoracic aortic injury presenting as iatrogenic coarctation of the aorta. This case supports extended imaging surveillance after TEVAR in younger patients to detect any complications. This case also showed a striking ‘‘disconnect’’ between the CT scan finding and pressure gradient on
Vol. 29, No. 3, April 2015
Case reports 594.e15
Fig. 7. Additional stenting (arrows) across the distal portion of the stent and aorta improves pressure gradient to 40 mm Hg in real time.
angiogram. It highlights the importance of high index of suspicion in younger patient presenting with signs and symptoms of stent-graft collapse and that if need be to have low threshold in using multiple imaging modalities to identify any complication(s) after TEVAR. REFERENCES 1. Jonker FH, Giacovelli JK, Muhs BE, et al. Trends and outcomes of endovascular and open treatment for traumatic thoracic aortic injury. J Vasc Surg 2010;51:565e71. 2. Piffaretti G, Benedetto F, Menegolo M, et al. Outcomes of endovascular repair for blunt thoracic aortic injury. J Vasc Surg 2013;58:1483e9.
3. Azizzadeh A, Charlton-Ouw KM, Chen Z, et al. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. J Vasc Surg 2013;57:108e14. 4. Shukla AJ, Jeyabalan G, Cho JS. Late collapse of a thoracic endoprosthesis. J Vasc Surg 2011;53:798e801. 5. Jonker FH, Schlosser FJ, Geirsson A, et al. Endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther 2010;17:725e34. 6. Canaud L, Alric P, Gandet T, et al. Open surgical secondary procedures after thoracic endovascular aortic repair. Eur J Vasc Endovasc Surg 2013;46:667e74. 7. Desai ND. Techniques for repair of retrograde aortic dissection following thoracic endovascular aortic repair. Ann Cardiothorac Surg 2013;2:369e71. 8. Annamalai G, Cook R, Martin M. Endograft collapse following endovascular repair of traumatic aortic injury. Diagn Interv Radiol 2011;17:84e7.
594.e16 Case reports
9. Goncalves FB, van Herwaarden JA, Verhagen HJ. Insights on the prevention of endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther 2010;17: 735e7. 10. Melissano G, Civilini E, Rinaldi E, et al. Toward a better understanding of endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther 2010;17:738e43. 11. Zipfel B, Czerny M, Funovics M, et al. Endovascular treatment of patients with types A and B thoracic aortic dissection using relay thoracic stent-grafts: results from the RESTORE patient registry. J Endovasc Ther 2011;18: 131e43.
Annals of Vascular Surgery
12. W. L. Gore & Associates, Inc. Comfortable Gore Tag Thoracic Endoprosthesis. Instruction for use. Summary of US clinical studies. Available at http://www.goremedical.com/resources/ dam/assets/20010613_MD117851.pdf. Last accessed: February 2015. 13. Medtronic Inc. U.S. Medtronic Dissection Trial: A prospective, non-randomized, multi-center trial. Outcomes of Tevar in acute, type b aortic dissection: Results from the Valiant US Ide trial. Available at http://www.aortic. medtronicendovascular.com/wcm/groups/mdtcom_sg/@mdt/ @endov/documents/documents/uc201405090en_vc_dissection_ us.pdf. Last accessed: February 2015.
A 21-year-old male suffered blunt trauma from a motor vehicle accident causing thoracic aorta tear. The smallest available stent graft was deployed. Definitive repair was later performed using a 22 22 116 mm Talent Thoracic Stent Graft. The postoperative course was uneventful. Seventeen months later, he presented with dizziness, chest pain, acute renal failure, malignant hypertension, and troponin elevation. Computed tomography (CT) angiogram and transesophageal echocardiogram did not reveal any dissection, stent stenosis or collapse. Cardiac catheterization showed normal coronary arteries but a 117 mm Hg gradient across the stent graft. Iatrogenic coarctation of the aorta was confirmed with a second measurement during arch angiogram. A Palmaz stent was deployed over the distal end of the previous stent graft with complete resolution of symptoms and gradual normalization of kidney function. This case report demonstrates a need for wider availability and selecting appropriate stent graft in treating traumatic aortic injuries in young patients. It is the first case report of the inability of current imaging modalities in confirming stent collapse. Pressure gradient is a useful tool in confirming stent collapse when clinical scenario does not match CT findings.
A 21-year-old male was brought to the emergency room after he sustained a deceleration blunt trauma as a restrained driver in a motor vehicle accident. The patient was hemodynamically stable. Chest radiograph demonstrates enlarged mediastinum. Contrast-enhanced computed tomography (CT) scan axial image at the level of the aortic arch demonstrated hemomediastinum and sagittal reconstruction images demonstrated a 3-cm saccular pseudoaneurysm arising from the proximal
1 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 2 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. 3 Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD.
Correspondence to: Mahmoud B. Malas, MD, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Building A/5, Surgical Admin, Baltimore, MD 21224, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 594.e11e594.e16 http://dx.doi.org/10.1016/j.avsg.2014.10.044 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: June 18, 2014; manuscript accepted: October 4, 2014; published online: January 28, 2015.
descending aorta at the level of ligamentum arteriosum (Fig. 1). The patient was taken to the operating room for stent-graft placement. The diameter of his thoracic aorta was 17e19 mm. The smallest stent available was a 26 mm 33 mm aortic cuff extension for Gore Excluder (W. L. Gore & Associates, Inc., Flagstaff, AZ). Because this stent was designed for abdominal aneurysm repair, the delivery system was short of reaching the thoracic injury. Hence, the cuff was deployed through an axillary approach. As one cuff was unable to cover the entire 3-cm aortic tear and pseudoaneurysm (Fig. 2 showing type 1 endoleak), a second cuff was introduced but failed to deploy at the lesion. As the delivery system was withdrawn, the cuff was spontaneously deployed in the subclavian artery. An immediate occlusion balloon was introduced through femoral approach to the proximal subclavian artery to control any potential bleeding. Open repair required removal of the cuff and a subclavianeaxillary artery bypass using ringed polytetrafluoroethylene graft. The patient was stable postoperatively. The next day a Talent Thoracic Stent Graft (22 22 116 mm) (Medtronic, Minneapolis, MN) became available, 594.e11
594.e12 Case reports
Fig. 1. Sagittal reconstruction CT of the chest demonstrates a 3-cm saccular pseudoaneurysm arising from the proximal descending at the level of ligamentum arteriosum (arrows).
Fig. 2. Angiogram after first gore cuff placement demonstrates near complete exclusion of pseudoaneurysm with residual extravasation of contrast (arrows) at the proximal medial margin of the stent (type Ia endoleak).
so he underwent definitive endovascular repair. This was deployed over the existing Gore Cuff stent graft to completely cover the tear (Fig. 3). We did not perform an angioplasty with a coda balloon after the deployment of the Talent Thoracic Stent Graft to avoid any further potential damage to the aorta. The patient recovered well postoperatively. Contrastenhanced chest CT in sagittal plane (Fig. 4), performed 2 months after endovascular repair,
Annals of Vascular Surgery
Fig. 3. Follow-up digital subtraction angiogram after definitive stent deployment (Talent) demonstrates complete coverage of prior stent (short arrows) with resolution of endoleak.
Fig. 4. Intravenous contrast-enhanced chest CT in sagittal plane, performed 2 months after endovascular repair, demonstrates resolution of mediastinal hematoma and no residual endoleak.
demonstrated resolution of the mediastinal hematoma and no residual endoleak. He presented to the emergency department 17 months later with acute onset chest and abdominal pain with dizziness while playing basketball. His initial vitals were blood pressure 154/80 mm Hg,
Vol. 29, No. 3, April 2015
Case reports 594.e13
Fig. 5. Intravenous contrast-enhanced chest CT scan (thick slab, 20 mm) of sagittal maximal intensity projection image (A) demonstrated descending aortic stents with intact metallic structure. Axial 3-mm section within
the distal portion of stent (long arrow) demonstrated an intraluminal graft material flap (short arrow) causing minimal luminal stenosis (B).
heart rate 42 beats/min, respiratory rate 16 breaths/ min, and oxygen saturation 98% on room air. Physical examination was notable for a grade III/VI harsh mid-systolic murmur at the right upper sternal border radiating to the carotid arteries bilaterally. His creatinine level was 1.8 mg/dL and troponin I was 0.34 mg/dL. Electrocardiogram showed sinus bradycardia, and a carotid duplex study showed velocities of 300e400 cm/sec bilaterally indicating hyperdynamic flow. Intravenous contrast-enhanced chest CT scan (thick slab, 20 mm) of sagittal maximal intensity projection image (Fig. 5A) demonstrated descending aortic stents with intact metallic structure. Axial 3-mm section within the distal portion of the stent (long arrow) demonstrated an intraluminal graft material flap (short arrow) causing minimal luminal stenosis (Fig. 5B). A transesophageal echocardiogram revealed a normal aortic root, moderate mitral regurgitation with no evidence of aortic dissection. Over the next 4 days, the patient developed worsening headache, pulmonary edema, hypertension (210/80 mm Hg), with worsening renal failure, and troponemia (creatinine 2.2 mg/dL and troponin 2.1 ng/dL). Intravascular ultrasound was not available at our institute. Left heart catheterization showed normal coronary arteries, but there was difficulty advancing the wire and catheter through the distal end of the endograft. There was a 117 mm Hg pressure gradient across the endograft (187/70 mm Hg proximal vs.
70/63 mm Hg distal to endograft). Digital subtraction angiogram (Fig. 6) demonstrated poor flow across the distal portion of the stent with a pressure gradient of over 100 mm Hg in real time. Despite the lack of radiological evidence of stent-graft collapse or filling defect on angiography, we decided to place a Palmaz XL stent (10 56 mm) (Cordis Corporation, Bridgewater, NJ) at the distal end of the previous endograft based on pressure gradient. The stent was mounted on a Coda balloon (32 mm) (Cook Medical, Inc., Bloomington, IN). Immediately after stent deployment, the pressure gradient across the stent decreased to 40 mm Hg (Fig. 7) in real time with marked improvement in his blood pressure and headache. Postoperatively, his creatinine returned to 1.1 mg/dL and 3 days later he was discharged in stable condition. A repeat carotid duplex study at his 1-month follow-up visit showed normal flow with less than 50% bilateral carotid stenosis. He continues to do well with yearly CT scan 4 years after the initial repair and has started playing basketball again. Traumatic thoracic aortic transection or dissection is a highly lethal injury.1 Thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to traditional open repair for treatment of traumatic aortic injuries with improved perioperative mortality, morbidity, and postoperative outcomes.1e3 Complications from TEVAR are most often encountered within 3 months4 with the greatest
594.e14 Case reports
Fig. 6. Initial digital subtraction angiogram demonstrated poor flow across distal portion of the stent with pressure gradient of over 100mm Hg in real time.
risk in the immediate month following repair.5 They include aortic dissection, graft infection, collapse, stenosis, migration distal embolization and paraplegia.1,6,7,9 Symptomatic late (>3 months) endograft collapse like the one noted in our patient is rare. Literature review shows few reported cases like the one published by Shukla et al.4 The risk of endograft collapse is higher in young patients undergoing TEVAR for trauma.5,8 Excessive stent graft over sizing is reported as an important cause of endograft collapse in younger patients.1,8 There are anatomical differences in the aorta of younger patients compared with older patients that make them more susceptible to endograft collapse including the following: smaller diameters with more straight course, a more acute angle at the level of the arch, and a more elastic compliant wall.10 Many currently available endografts are not designed for young patients with traumatic nonatherosclerotic aortic injury.8 Unfortunately, there was no Food and Drug Administration (FDA)-approved device available for aortic trauma and/or dissection at the time of this case. Several companies have recently recognized the need for smaller stent graft designed specifically for use in patients with traumatic aortic injury or type B dissection to avoid over sizing and endograft collapse.9
Annals of Vascular Surgery
Using the company-sponsored registry database, 91 patients who underwent TEVAR with Relay stent graft (Bolton Medical, Barcelona, Spain) for aortic dissection were followed for 2 years. Data showed technical success rate of 95%, mortality of 8% at 30 days with 2-year survival rate of 82%. Zipfel et al.11 concluded that Relay sent graft is safe for the treatment of acute and chronic type B aortic dissection. Relay stent graft is not approved by FDA for aortic dissection or traumatic aortic injury. Gore Medical conducted 2 pivotal, prospective, nonrandomized, multicenter, single-arm clinical studies designed to evaluate safety and effectiveness of using Conformable Gore TAG Thoracic Endoprosthesis (W. L. Gore & Associates, Inc.) for patients with aortic trauma or dissection. TAG 08-01 trial enrolled 50 patients who underwent TEVAR using Gore Tag Thoracic Endoprosthesis for the treatment of acute complicated type B dissections.12 It showed procedural and hospital survival rates of 100% and 92%, respectively, with a 30-day all-cause mortality rate of 8%. TAG 08-02 enrolled 51 patients for the treatment of traumatic aortic transection of descending thoracic aorta using Gore Tag Thoracic Endoprosthesis.12 This study showed procedural and hospital survival rates of 100% and 92.2%, respectively, with a 30-day all-cause mortality rate of 7.8%. Based on this safety and effectiveness data, Conformable Gore Tag Thoracic Endoprosthesis was the first device approved by the FDA in September 2013 for use in type B aortic dissection and/or aortic trauma patients. Medtronic Dissection Trial was also a prospective, nonrandomized, multicenter trial. They enrolled 50 patients with TEVAR using Valiant Captivia Thoracic Stent Graft System (Medtronic), with acute, complicated (malperfusion, rupture) type B aortic dissection from 16 US centers during 2010e 2012. These yet unpublished data showed 100% technical success and an 8% all-cause mortality rate at 30 days with no aortic rupture in 12 months.13 This is 3- to 4-fold mortality improvement over open surgical repair. FDA approved this device in January 2014 for type B aortic dissection and for traumatic aortic injury patients. Our case demonstrates a late complication (>3 months) after TEVAR in a young nonatherosclerotic patient with traumatic thoracic aortic injury presenting as iatrogenic coarctation of the aorta. This case supports extended imaging surveillance after TEVAR in younger patients to detect any complications. This case also showed a striking ‘‘disconnect’’ between the CT scan finding and pressure gradient on
Vol. 29, No. 3, April 2015
Case reports 594.e15
Fig. 7. Additional stenting (arrows) across the distal portion of the stent and aorta improves pressure gradient to 40 mm Hg in real time.
angiogram. It highlights the importance of high index of suspicion in younger patient presenting with signs and symptoms of stent-graft collapse and that if need be to have low threshold in using multiple imaging modalities to identify any complication(s) after TEVAR. REFERENCES 1. Jonker FH, Giacovelli JK, Muhs BE, et al. Trends and outcomes of endovascular and open treatment for traumatic thoracic aortic injury. J Vasc Surg 2010;51:565e71. 2. Piffaretti G, Benedetto F, Menegolo M, et al. Outcomes of endovascular repair for blunt thoracic aortic injury. J Vasc Surg 2013;58:1483e9.
3. Azizzadeh A, Charlton-Ouw KM, Chen Z, et al. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. J Vasc Surg 2013;57:108e14. 4. Shukla AJ, Jeyabalan G, Cho JS. Late collapse of a thoracic endoprosthesis. J Vasc Surg 2011;53:798e801. 5. Jonker FH, Schlosser FJ, Geirsson A, et al. Endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther 2010;17:725e34. 6. Canaud L, Alric P, Gandet T, et al. Open surgical secondary procedures after thoracic endovascular aortic repair. Eur J Vasc Endovasc Surg 2013;46:667e74. 7. Desai ND. Techniques for repair of retrograde aortic dissection following thoracic endovascular aortic repair. Ann Cardiothorac Surg 2013;2:369e71. 8. Annamalai G, Cook R, Martin M. Endograft collapse following endovascular repair of traumatic aortic injury. Diagn Interv Radiol 2011;17:84e7.
594.e16 Case reports
9. Goncalves FB, van Herwaarden JA, Verhagen HJ. Insights on the prevention of endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther 2010;17: 735e7. 10. Melissano G, Civilini E, Rinaldi E, et al. Toward a better understanding of endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther 2010;17:738e43. 11. Zipfel B, Czerny M, Funovics M, et al. Endovascular treatment of patients with types A and B thoracic aortic dissection using relay thoracic stent-grafts: results from the RESTORE patient registry. J Endovasc Ther 2011;18: 131e43.
Annals of Vascular Surgery
12. W. L. Gore & Associates, Inc. Comfortable Gore Tag Thoracic Endoprosthesis. Instruction for use. Summary of US clinical studies. Available at http://www.goremedical.com/resources/ dam/assets/20010613_MD117851.pdf. Last accessed: February 2015. 13. Medtronic Inc. U.S. Medtronic Dissection Trial: A prospective, non-randomized, multi-center trial. Outcomes of Tevar in acute, type b aortic dissection: Results from the Valiant US Ide trial. Available at http://www.aortic. medtronicendovascular.com/wcm/groups/mdtcom_sg/@mdt/ @endov/documents/documents/uc201405090en_vc_dissection_ us.pdf. Last accessed: February 2015.