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Aortic Healing Appears to Occur Rapidly after Successful Endovascular Sealing of Blunt Thoracic Aortic Injury

  • Edvard Skripochnik
    Correspondence
    Correspondence to: Edvard Skripochnik, MD, Columbia University Irving Medical Center, Vascular Surgery, 3219 East Tremont Avenue, Bronx, NY 10461
    Affiliations
    Divison of Vascular and Endovascular Interventions, Department of Surgery, New York Presbyterian/Columbia University College of Physicians and Surgeons, New York, NY
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  • Thomas V. Bilfinger
    Affiliations
    Division of Cardiothoracic Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY
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  • Shang A. Loh
    Correspondence
    Correspondence to: Shang Loh, MD, FACS, Professor Clinical Surgery, Chief of Vascular Surgery, Penn Presbyterian Medical Center, University of Pennsylvania Health System, Division of Vascular and Endovascular Therapy, Philadelphia, PA
    Affiliations
    Division of Vascular and Endovascular Therapy, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
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Published:March 24, 2022DOI:https://doi.org/10.1016/j.avsg.2022.03.017

      Background

      The traumatic nature of blunt thoracic aortic injury (BTAI) would suggest that healing of the aorta would occur once the injured area is shielded from aortic pressure. This would be in contrast to degenerative aortic diseases which often continue to degenerate despite coverage. We hypothesize that after successful thoracic aortic endografting (TEVAR) that the aorta rapidly heals itself leaving minimal to no trace of the residual injury.

      Methods

      BTAI that were successfully covered with TEVAR from 2006 to 2019 were collected. Those with failed sealing or a lack of follow-up scans were excluded. Centerline aortic diameters were measured at healthy aorta 1 cm above (D1) and below the injury (D3) and at the widest point of injury (D2) on preoperative and initial postoperative computed tomography (CT) scans. Postoperative CTs were examined for residual signs of aortic injury including residual periaortic hematoma, persistent thrombosed pseudoaneurysm, or thickened aortic wall. Diameter changes in the healthy and injured aortic segments were compared pre and post TEVAR. Aortic diameter changes were analyzed with the Student's t-test.

      Results

      Twenty four patients were identified with sealed BTAI. The mean graft diameter was 24.2 ± 3.2 mm with oversizing of 10.74 ± 6.1 % at D1 and 19.52 ± 10.22 % at D3. Postoperative CTs occurred at 61.25 ± 123.6 days with one outlier at 602 days. Injured aortic segments (D2) had significantly larger diameters compared to D1 (28.94 ± 5.08 mm vs. 22.14 ± 3.08 mm, P < 0.001). After TEVAR, 23/24 (95.8%) had no residual radiographic evidence of aortic injury by 2 months. One patient had a persistent thrombosed pseudoaneurysm likely due to more than 50% disruption of the aortic wall. Post TEVAR, there was a significant diameter reduction at D2 by 13.8% (29.10 ± 5.27 mm vs. 24.8 ± 4.2 mm, P < 0.001) which was within 2.45% of the mean stent graft diameter. The healthy aorta dilated to accommodate the graft by 9% at D1 (21.9 ± 3.0 vs. 23.7 ± 2.5 mm, P < 0.001) and 17% at D3 (20.6 ± 3.4 mm vs. 23.6 ± 3.2 mm, P < 0.001).

      Conclusions

      TEVAR promotes rapid aortic healing in BTAI with no evidence of residual aortic injury suggesting that a long-term seal is not necessary. The healthy aorta dilates to the stent graft size, as expected, whereas the injured aortic segment heals around the stent graft and assumes its diameter as well. Massive disruption of the aortic wall may preclude early healing.
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