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Indications & Contraindications
Injury grading, patient selection, TEVAR candidacy
Indications
- Blunt thoracic aortic injury (BTAI) — deceleration mechanism (high-speed MVC, fall from height, auto-pedestrian)
- SVS Grade II — intramural hematoma: TEVAR indicated
- SVS Grade III — pseudoaneurysm: TEVAR indicated (semi-elective within 24–72h after stabilizing concomitant injuries)
- SVS Grade IV — free rupture / active extravasation: emergent TEVAR
- Most common location: aortic isthmus (just distal to left subclavian artery origin)
- ~80% of BTAI patients die before hospital arrival; TEVAR has reduced in-hospital mortality from ~14.6% to ~4.8%
Contraindications
- Inadequate landing zone — <2 cm of healthy aorta proximal/distal to injury for endograft seal
- Access vessels too small for delivery system (up to 25 Fr sheath); iliac/femoral diameter insufficient
- Severe aortic tortuosity or aneurysmal disease preventing safe device delivery
- Known connective tissue disorder (Marfan, Ehlers-Danlos) — relative contraindication
- Grade I (intimal tear) — typically managed with observation and serial imaging, not TEVAR
SVS Injury Grading (Azizzadeh et al. 2009)
| Grade | Injury Pattern | Management |
|---|---|---|
| I | Intimal tear (<10 mm, no contour abnormality) | Observation with serial CTA; most heal spontaneously |
| II | Intramural hematoma (intimal disruption with mural involvement) | TEVAR — semi-elective after stabilization |
| III | Pseudoaneurysm (external contour abnormality) | TEVAR — semi-elective within 24–72h |
| IV | Free rupture / active extravasation | Emergent TEVAR — mortality >50% without intervention |
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Pre-Procedure Planning
Imaging, hemodynamic control, team coordination
Imaging & Measurements
- CTA chest with 3D reconstruction — diagnostic test of choice (sensitivity >98%)
- Measure aortic diameter at proximal and distal landing zones (2 cm healthy aorta required each side)
- Distance from injury to left subclavian artery (LSA) origin — determines need for LSA coverage
- Measure access vessel diameter (iliac and femoral arteries) — must accommodate up to 25 Fr sheath
- Identify injury grade, concomitant injuries, and vascular anatomy
- IVUS at time of procedure to confirm measurements (aorta may be smaller on CTA if patient hypotensive at imaging)
Hemodynamic Control & Preparation
- Anti-impulse therapy (CRITICAL) — IV beta-blocker (esmolol) or nicardipine infusion
- Target: SBP <120 mmHg, HR <80 bpm — reduces shear stress on injured aorta
- Blood products available: type & cross-match, MTP activation if hemodynamically unstable
- ICU bed reserved for post-procedure monitoring
- Anesthesia for general anesthesia with endotracheal intubation
- Bilateral femoral access planned (right = primary device access, left = angiography)
CTA reviewed with 3D reconstruction. Injury grade assigned, landing zone diameters measured, LSA distance assessed, access vessel caliber confirmed adequate for device.
Anti-impulse therapy initiated. SBP <120, HR <80 confirmed. Esmolol or nicardipine infusion running.
Blood products available. Type & cross-matched, MTP on standby for hemodynamically unstable patients.
Device selected and available. Endograft sized appropriately (10–15% oversize from true aortic diameter). Young patients = small aortas — avoid excessive oversizing.
Anesthesia and ICU notified. GA planned, right radial arterial line for BP monitoring, ICU bed secured.
LSA coverage plan determined. If LSA will be covered: revascularization plan (carotid-subclavian bypass) discussed with vascular surgery, especially if dominant left vertebral artery.
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Relevant Anatomy
Aortic arch zones, isthmus, left subclavian artery coverage
Aortic Arch Zones
- Zone 0: ascending aorta to innominate artery origin
- Zone 1: innominate artery to left common carotid artery
- Zone 2: left common carotid artery to left subclavian artery
- Zone 3: left subclavian artery to proximal descending aorta (most TEVAR landing zones)
- Zone 4: proximal descending thoracic aorta (distal to isthmus)
- Aortic isthmus: segment between LSA origin and ligamentum arteriosum — most common site of traumatic injury due to tethering
LSA Coverage Considerations
- Proximal landing zone often requires covering the LSA origin to achieve adequate seal
- LSA revascularization recommended if: >20 mm of LSA coverage required, dominant left vertebral artery, left internal mammary artery graft (prior CABG), or planned future aortic coverage
- Carotid-subclavian bypass is the standard revascularization technique
- Coverage without revascularization: ~2–3% stroke risk, potential left arm ischemia, vertebrobasilar insufficiency
- In emergent situations, LSA coverage without revascularization is acceptable — plan delayed revascularization
Young Trauma Patient Aortic Considerations
Trauma patients are typically young with small, compliant aortas (often <25 mm diameter). Available thoracic endografts were designed for older patients with aneurysmal disease (larger, stiffer aortas). Excessive oversizing (>15%) in small aortas risks device infolding, proximal collapse, bird-beak configuration, and retrograde type A dissection. Hypotensive patients may have even smaller aortic diameters on initial CTA — IVUS at time of procedure provides true measurements after resuscitation.
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Technique
Percutaneous or cutdown access, device deployment, completion imaging
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General Anesthesia & Positioning
Patient supine under general anesthesia with endotracheal intubation. Right radial arterial line for continuous BP monitoring. Prep from base of neck to mid-thighs. Sterile drape including groin access sites bilaterally.
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Bilateral CFA Access
Ultrasound-guided micropuncture access to bilateral common femoral arteries. Primary access (usually right) for device delivery. Contralateral access for angiographic runs. Choice: percutaneous with Perclose ProGlide pre-close (deploy 2 ProGlide devices at 10 and 2 o'clock positions before upsizing) or surgical cutdown (preferred if access vessel calcified, small, or patient hemodynamically unstable).
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Wire & Sheath Advancement
Exchange to stiff guidewire (Lunderquist extra-stiff 260 cm) and advance to ascending aorta, just above aortic valve. IVUS advanced over wire to evaluate injury, confirm landing zone measurements, and mark coverage zone. Large-bore sheath (up to 25 Fr, e.g., Gore DrySeal) advanced over wire to infrarenal abdominal aorta.
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Device Positioning
Advance endograft (Gore Conformable TAG, Medtronic Valiant, or Cook Zenith Alpha) through sheath to desired position in the arch/proximal descending aorta. Flush catheter advanced alongside device to ascending aorta. Thoracic aortogram performed in steep LAO (calculated from CTA) with respirations held. Align leading edge of endograft with base of LSA using bony landmarks and aortography.
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Device Deployment
Deploy under rapid ventricular pacing or adenosine-induced transient hypotension to minimize aortic pulsatility and device migration during deployment. Requires coordination between two operators: one deploying the device with the releasing mechanism, the other micro-adjusting the delivery catheter position. Retract flush catheter below landing zone before deployment. Hold respirations.
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Completion Imaging
Remove delivery catheter. Advance IVUS to ascending aorta to rule out retrograde type A dissection. Completion aortogram to confirm: exclusion of traumatic injury, no endoleak (especially type I), patent arch branch vessels, and appropriate device position. Balloon molding of proximal/distal seal zones only if necessary.
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Access Site Closure
Carefully remove sheath (inspect for access vessel injury during withdrawal). Close primary access site with pre-deployed Perclose ProGlide devices. Manual compression on contralateral access site or Perclose closure. Completion angiogram of access vessels to confirm hemostasis and vessel patency.
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Landmarks & Measurements
Critical anatomic landmarks and sizing parameters
Key Landmarks
- Aortic isthmus — between LSA origin and ligamentum arteriosum; most common injury site (~90%)
- Left subclavian artery origin — critical reference for proximal landing zone positioning
- Celiac trunk origin — distal reference for thoracic aortic coverage length
- Ligamentum arteriosum — fibrous remnant of ductus arteriosus; tethering point that creates shear forces during deceleration
- Left common carotid artery — defines Zone 2 boundary; if landing in Zone 2, carotid-carotid bypass may be needed
Sizing Parameters
- Proximal landing zone diameter: measure at inner-wall-to-inner-wall on CTA; confirm with IVUS after resuscitation
- Distal landing zone diameter: at least 2 cm distal to injury
- Oversize 10–15% from true aortic diameter — excessive oversizing (>20%) risks infolding and collapse
- Coverage length: minimum 2 cm seal zone proximal and distal to injury
- Access vessel diameter: minimum 7–8 mm for most delivery systems; consider iliac conduit if inadequate
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Troubleshooting
Intraoperative problems and solutions
Small Aorta
Aortic Diameter <20 mm
Young trauma patients frequently have aortas <20 mm. Available thoracic devices have minimum diameters of 21–26 mm, leading to excessive oversizing. Options: consider delayed repair with anti-impulse therapy and serial imaging (if hemodynamically stable), use the smallest available device and accept some oversizing (keep <15%), or consider investigational or custom devices. IVUS is essential to measure true post-resuscitation diameter.
LSA Coverage
Landing Zone Requires Covering the Left Subclavian Artery
Common scenario when injury is close to the LSA origin. In emergent setting: cover the LSA and plan staged revascularization. If pre-operative planning time allows: carotid-subclavian bypass before or concurrent with TEVAR. Always check vertebral artery dominance — if dominant left vertebral, revascularization is strongly recommended. Monitor for left arm ischemia and posterior circulation symptoms post-operatively.
Bird-Beak Configuration
Graft Malapposition at Proximal Landing Zone
Occurs when the endograft does not fully conform to the inner curvature of the aortic arch, leaving a gap between the device and lesser curvature. More common in angulated arches and small aortas. Increases risk of type Ia endoleak and device migration. Management: gentle balloon molding of the proximal landing zone. If persistent, consider extension with a second endograft. Avoid aggressive ballooning near the injury site.
Critical
Type I Endoleak on Completion Aortogram
Type I endoleak (proximal or distal seal failure) is the most critical endoleak type — persistent pressurization of the aneurysm sac. Must be addressed before leaving the procedure room. Options: balloon molding of the seal zone, placement of an extension cuff, or use of an aortic cuff/Palmaz stent to improve seal. If not correctable endovascularly, consult vascular surgery for potential open conversion.
Access Vessel Injury
Iliac or Femoral Artery Injury During Device Delivery/Removal
Large-bore delivery systems (up to 25 Fr) can cause iliac dissection, rupture, or perforation. Suspect if: increasing resistance during sheath advancement, new retroperitoneal fluid on imaging, or unexplained hypotension. Management: occlusion balloon proximal to injury, covered stent placement, or surgical repair. Pre-procedure iliofemoral angiogram helps identify high-risk anatomy. Consider iliac conduit for patients with small or calcified iliac arteries.
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Complications
Device, neurologic, and access-site complications
Device-Related
- Endoleak — type I (seal failure, most critical); type II (branch vessel backflow); most endoleaks occur within 30 days
- Device migration — even millimeters can cause endoleak or branch vessel occlusion; reported up to 2–3 years post-deployment
- Device infolding/collapse — from oversizing in small aortas; managed with additional endograft placement
- Post-implantation syndrome — fever, leukocytosis, elevated CRP without infection; self-limited, treat supportively
Neurologic
- Stroke (2–3%) — associated with LSA coverage without revascularization, prolonged procedure time, female gender
- Spinal cord ischemia (2.5–10%) — risk factors: coverage of ≥3 endografts, prior abdominal aortic repair, LSA coverage without revascularization, renal failure
- Retrograde type A dissection — rare but catastrophic; detected on IVUS or completion aortogram; requires emergent open surgical repair
Access-Site
- Incidence ~12.8% (VALOR trial data)
- Groin hematoma / pseudoaneurysm
- AV fistula
- Retroperitoneal hemorrhage
- Access vessel rupture, dissection, or occlusion
- Iliac conduit may be required in ~21% of cases
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Pearls & Pitfalls
Critical tips for successful TEVAR in trauma
✦
Anti-impulse therapy is CRITICAL. Begin immediately upon diagnosis and continue post-repair. Target SBP <120 mmHg and HR <80 bpm. Reduces shear stress on the injured aorta and decreases risk of rupture before and after endograft placement.
✦
Most injuries occur at the isthmus. The ligamentum arteriosum tethers the aorta at the junction of the mobile arch and fixed descending aorta, creating a shear point during rapid deceleration. This predictable location simplifies endograft planning.
✦
Young patients = small, compliant aortas. Do NOT oversize more than 10–15%. Excessive oversizing risks infolding, collapse, and type I endoleak. Use IVUS after resuscitation to get true diameter measurements.
✦
Perclose pre-close technique is mandatory for percutaneous large-bore access. Deploy two ProGlide devices at 10 and 2 o'clock positions BEFORE upsizing to the large-bore sheath. Confirm adequate access with ipsilateral oblique iliofemoral angiogram before committing to percutaneous approach.
✦
Grade I injuries can often be observed. Intimal tears without contour abnormality typically heal with anti-impulse therapy and serial imaging alone. Do not rush to TEVAR for grade I injuries.
✦
IVUS is superior to angiography alone for evaluating injury, confirming landing zone measurements, and detecting retrograde type A dissection. Hypotensive patients may have falsely small aortic measurements on initial CTA.
⚠
Do NOT rely solely on CTA measurements in hypotensive patients. The aorta may be significantly smaller on initial imaging. Always confirm with IVUS after resuscitation before final device sizing.
⚠
Covering the LSA without a plan is dangerous. Always assess vertebral artery dominance pre-procedure. If dominant left vertebral and LSA must be covered, arrange carotid-subclavian bypass either concurrently or staged.
⚠
Watch for post-implantation syndrome. Fever and leukocytosis after TEVAR can mimic infection. Do not reflexively start antibiotics — check inflammatory markers and cultures, and treat supportively if consistent with post-implantation syndrome.
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References & Resources
Primary sources and classification systems
SVS Guidelines & Classification
- Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187–192.
- Azizzadeh A, Keyhani K, Miller CC 3rd, et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg. 2009;49:1403–1408.
- Heneghan RE, Aarabi S, Quiroga E, et al. Call for a new classification system and treatment strategy in blunt aortic injury. J Vasc Surg. 2016;64:171–176.
DeBakey / Stanford Classifications (Reference)
- DeBakey Type I: dissection originates in ascending aorta, propagates distally through arch and descending aorta
- DeBakey Type II: dissection confined to ascending aorta
- DeBakey Type III: dissection originates in descending aorta (IIIa = thoracic only, IIIb = extends to abdomen)
- Stanford Type A: involves ascending aorta (regardless of origin) — surgical emergency
- Stanford Type B: involves descending aorta only (distal to LSA) — medical management or TEVAR if complicated
Additional References
- Cline M, Cooper KJ, Khaja MS, et al. Endovascular management of acute traumatic aortic injury. Tech Vasc Interventional Rad. 2018;21:131–136.
- Takagi H, Kawai N, Umemoto T. A meta-analysis of comparative studies of endovascular versus open repair for blunt thoracic aortic injury. J Thorac Cardiovasc Surg. 2008;135:1392–1394.
- Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors (EUROSTAR registry). J Vasc Surg. 2007;46:1103–1110.
- Fairman RM, Criado F, Farber M, et al. Pivotal results of the Medtronic Vascular Talent Thoracic Stent Graft System: the VALOR trial. J Vasc Surg. 2008;48:546–554.
- Nagpal P, Mullan BF, Sen I, et al. Advances in imaging and management trends of traumatic aortic injuries. Cardiovasc Interv Radiol. 2017;40:643–654.