Fig. 1. Arch aortogram shows thoracic aortic tear beyond the origin of the left subclavian artery (see arrow). Note the sharp curve of the thoracic aorta beyond the tear.

Fig. 2. More detailed view of the injury with cranio-caudad angulation (see arrow).

A 79-year-old man fell off a ladder and ruptured his thoracic aorta. In addition, he had a T10-T11 spinal fracture-dislocation resulting in spinal injury and paraplegia. He was considered a poor operative candidate and the surgical team requested placement of a stentgraft to exclude the tear. Diagnostic arch aortogram (figures 1 and 2) showed a tear approximately 1.5 cm distal to the left subclavian artery. Beyond the tear there was a fairly sharp curve of the thoracic aorta, making endovascular intervention problematic. The two devices that were considered because of their known relative flexibility were the Thoracic Excluder (W.L. Gore) and the Talent device (World Medical Manufacturing Corporation). The Talent device was obtained for compassionate use and IRB approval was granted. The diagnostic and contrast-monitoring portion of this study was done through a 5F left femoral access. The right femoral artery was exposed surgically and a shortened 22 French Keller-Timmermans sheath (Cook) was introduced and positioned with the tip in the abdominal aorta. Subsequently, a 22 French Talent delivery system was introduced and advanced over the superstiff wire and positioned in the thoracic aorta just beyond the left subclavian artery origin. The Talent device was deployed with the bare portion (approximately 1.5 cm) over the left subclavian artery and the covered portion starting just proximal to the aortic tear. The length of the device was 10.5 cm. The diameter at the upper end was 2.8 cm and at the lower end it was 3 cm. A balloon was inflated (part of the delivery system) to fix the device and seal its upper end (figure 3). Aortography following the main device deployment demonstrated a continued leak from the upper end with visualization of the tear (figure 4). Subsequently, a 6 cm long (bare portion 14 mm) by 3.2 cm wide extension cuff was introduced at the upper end of the previously placed stentgraft (figure 5) to try and eliminate the leak. Two additional extension cuffs were added at the lower end for apparent lower end leaks. Aortography following deployment of the cuffs showed complete exclusion of the aortic tear (figure 6). Subsequently, the 22 French access sheath was removed from the right groin and the artery was repaired surgically. The patient has done quite well after the procedure except for a transient elevation of his creatinine. He underwent successful spinal fusion and currently recovering in the hospital.

Questions:

1) Will the stentgraft technology expand to include treatment of aortic injuries?

2) Currently the stentgraft manufacturers focus on true aneurysms trials (abdominal and thoracic). Should there be more focus on trauma applications?

3) Given that these type of procedures will become more popular, should the standard Interventional room be OR compatible?

4) Should interventional radiologists be trained in femoral cutdowns?

Related Cases:

Case 1099_02 -- Endograft Placement for Thoracic Aortic Transection

Case 0399_03 --Traumatic Aortic Transection

Fig. 3. Single view of the Talent device in place following deployment. The fixation balloon is inflated at the upper end (see arrow).

Fig. 4. Arch aortogram following stentgraft deployment and balloon fixation demonstrates a leak with visualization of the pseudoaneurysm (see arrow). The leak was thought to originate from the proximal portion of the stentgraft.

Fig. 5. An extension cuff (see arrow) is ready to be deployed through a 22F Keller-Timmermans sheath (Cook) to try and seal the leak.

Fig. 6. Final thoracic aortogram showing complete exclusion of the aortic tear.