1. Scott Stevens The University of Tennessee Medical Center

2. TRAUMA TEVAR SAVS 07 Puerto Rico Scott Stevens

3. TEVAR - The New Benchmark For Thoracic Aortic Injuries

4. OBJECTIVES Spectrum of problem Spectrum of problem Endovascular strategies Endovascular strategies Review outcomes data Review outcomes data Tips, tricks and trouble shooting Tips, tricks and trouble shooting

5. Blunt Thoracic Aortic Injuries

6. Mechanism of Injury

8. Diagnosing Thoracic Aortic Injuries

12. Open Repair

13. Thoracic Aorta Trauma - 1997 Fabian – North American Study Fabian – North American Study Semba and Dake Semba and Dake

14. Open Repair Percutaneous

15. TEVAR for Trauma Clinical Data Technical success Technical success Less invasive Less invasive Decreased operative time Decreased operative time Low morbidity Low morbidity Less mortality Less mortality

16. Clinical Series - Starnes All existing literature All existing literature 235 patients 235 patients Mortality – 6.8% Mortality – 6.8% No reported paraplegia No reported paraplegia Beware of case series Beware of case series

17. Ott Journal of Trauma 04 Open (12) Endovascular (6) MORTALITY17%0% PARAPLEGIA16%0% LARYNGEAL NERVE 8.3%0%

18. Kasirajan Annals of Vascular Surgery 04 Mortality Mortality O. R. time O. R. time Length of stay Length of stay

19. Wellons: Journal of Vascular Surgery Nine patients Nine patients Infra-renal aortic cuffs Infra-renal aortic cuffs No procedural deaths No procedural deaths 100% technical success 100% technical success No paraplegia No paraplegia

20. Limitations Endoleaks Endoleaks Migration Migration Fistula Fistula Infection Infection No long-term data No long-term data

21. Technical Considerations Passive hypotension Passive hypotension Address life threatening injuries Address life threatening injuries Study access vessels Study access vessels Position patient for arch images Position patient for arch images Measure distance from access to proximal landing zone Measure distance from access to proximal landing zone

22. Anatomic Considerations Proximal landing zones – critical Distal landing zones – forgiving Assess arch angulations Watch for pseudo-coarctation

23. What about the left subclavian? Covered intentionally Covered intentionally Extremity ischemia-rare Extremity ischemia-rare Posterior strokes-rare Posterior strokes-rare Subclavian-carotid, if dominant left vertebral or LIMA graft Subclavian-carotid, if dominant left vertebral or LIMA graft

24. Tips and Tricks Body floss Stiff wire to pin graft along greater curvature Keep buddy-wire alongside of graft as bailout for carotid Endo “wedgie” Drop MAP 50-60 mm Hg Adenosine pause

25. Trouble Shooting Poor apposition along lesser curvature Graft in folding Graft collapse Avoid landing in transition zone Extend proximally Support with second graft or Palmaz stent

27. Trauma TEVAR -Limitations Graft over sizing Graft over sizing Steep arch transition Steep arch transition In folding of graft In folding of graft Durability – young patients Durability – young patients

28. Available Devices

29. Available Devices - Cuffs Brand Working length Graft diameter Graft length AneuRx 55 cm 28 mm 4.O cm Excluder 61 cm 28.5 mm 3.3 cm Zenith 55 cm 32 mm 3.6 cm Endologix 63 cm 28 mm 7.5 cm

30. High Rent District + Off Label Highly litigious Broad specialty support Prospective institutional support Consider IRB approval

31. Trauma TEVAR The New Benchmark ? Demanding Compelling data Dramatic shift in therapy Limited devices - judgment

32. Scott Stevens The University of Tennessee Medical Center

33. “A Good Retreat is Better Than a Bad Stand” – my brother