J ournal of Medical Care Research and Review JMCRR 3 (5), 359–364 (2020) ISSN (O) 2589-8949 | (P) 2589-8930 Left Subclavian Artery - Does it need attention during TEVAR for Blunt Traumatic Aortic Injury Sivakumar Krishnasamy?1, Ong Hao Siang2, Ahmad Rafizi Hariz Ramli3, Nur Adura Yaakup4, Norshazriman Sulaiman4, Ramesh Singh5, Raja Amin Raja Mokhtar1 11Division of Cardiothoracic Surgery , Department of Surgery , Faculty of Medicine , University Malaya 2Faculty of Medicine , University Malaya 3Vascular Unit , Department of Surgery, Faculty of Medicine, University Malaya 4Interventional Radiology , Department of Radiology, University Malaya 5Division of Cardiology, Department of Medicine, Faculty of Medicine , University of Malaya DOI: https://doi.org/10.15520/mcrr.v3i5.96 Accepted 2/5/2020; Received 2/4/2020; Publish Online 7/5/2020 Reviewed By: K. ABSTRACT Ahmed Ismail ElTris Introduction: Endovascular treatment for Blunt Thoracic Aortic Injury is currently an emerging alternative as compared to traditional open repair due to superior out- comes in terms of mortality and morbidity. However, the decision to revascularize the left subclavian artery remains controversial in cases requiring the coverage of the left subclavian artery. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury. Methods: Medical records from 11 patients who underwent Thoracic Endovascular Aortic Repair (TEVAR) for Blunt Thoracic Aortic Injury (BTAI) between January 2017 to April 2019 were analysed Results: Among the 11 patients who sustained BTAI, 10 of them have been caused by motor vehicle accidents with the exception of 1 patient who sustained a fall from height. The mean Injury Severity Score is 32.72. Time elapsed between injury and TEVAR ranged between 13 hours and 321.17 hours with a mean of 73.47 hours and a median of 31.5 hours. Technical success rate was 100%. The left subclavian artery (LSA) was covered in 6 patients while the rest had partially covered LSA to achieve adequate proximal landing zone. None of our patients had experience upper limb ischaemia. Two patients developed a cerebrovascular accident, while a Type 1a endo- leak was seen in 1 patient. One patient underwent revascularization of the LSA due to atretic right vertebral artery. The mortality rate was (2/11) however the deaths were unrelated to TEVAR. Mean follow up was 8.88 months with a range of 1 to 23 months. Conclusions: We concluded that TEVAR is a safe and viable option to treat blunt thoracic aortic repair within our inherently young patient sample. LSA could be safely covered in TEVAR without preoperative revascularization as long as of contraindica- tions such as atretic right vertebral artery or aberrations of the left vertebral artery anatomy are ruled out in preoperative CT angiogram. Key words: Endovascular Repair–TEVAR–Aortic Transection–Blunt Thoracic Aor- tic Injury–Left subclavian artery–Revascularization. 1 INTRODUCTION: Aortic transection is a surgical emergency with up to 85% ? Corresponding author. mortality rate typically seen in patients who sustained de- 360 Sivakumar Krishnasamy et al. celeration injury or blunt trauma. [1] As result from the Inc., Santa Rosa, CA, USA) for all patients treated for blunt mechanical strain generated by the differential forces acting thoracic aortic injury. Patients were placed in a supine po- on the isthmus, of which the fixed aortic arch is connected sition under general anaesthesia in the angiography suite as to the relatively mobile descending aorta, aortic transec- prophylactic antibiotics were administered. Subsequently, tion commonly occur within the proximity of the ostium both left and right groin were prepared. The device de- of the left subclavian artery. Recent guidelines favour the ployment artery which is the right femoral artery for all use of Thoracic Endovascular Repair (TEVAR) over tradi- our cases, we used the percutaneous access under ultra- rcledR; tional open surgical repair due to significantly lower risk of sound guidance with Perclose Proglide (Abbott Vas- death, end stage renal disease and spinal cord ischaemia [2– cular Devices, Redwood City, CA, USA) device for most 5] Yet the prospect of occluding the left subclavian artery of our cases . We did use open access to the right femoral to achieve adequate proximal landing zone projects upon artery for 3 cases where the femoral artery size was only the risk of posterior circulation stroke as well as other con- 6 mm. A 9Fr sheath is then used for the right common cerns regarding timing to operation, intra-operative antico- femoral artery. A 6Fr sheath is then placed over the left agulation and future stent graft related complications par- common femoral artery under ultrasound guidance. Antico- ticularly associated with the uncertain natural history of agulation was administered with low dose of heparin with a the repair in younger trauma victims and the morphologic range of 2500-5000 IU depending on the risk of bleeding. A changes of the aorta that come with age. [2] Hence, this soft tip wire with pigtail was then introduced via the right study aims to report our experience with TEVAR in Aortic femoral access. This soft tip wire was then exchanged for transection in a tertiary hospital with particular emphasis a stiff wire and the pigtail was then removed. The pigtail and soft tip wire was then introduced to the left common on the management of the left subclavian artery (LSA). femoral artery and advanced under fluoroscopic guidance into ascending aorta. The pigtail catheter is positioned in the ascending aorta via the left femoral artery cannula as 2 MATERIALS AND METHODS: dye introducer. The measured thoracic stent graft will be Patient selection. inserted under fluoroscopy guidance after serial dilatation This is a retrospective study from January 2017 to April of the right common femoral artery. An aortogram will be 2019. A total of 11 patients with aortic transection were done at this stage and the junction between the left common managed by a multidisciplinary team at our centre con- carotid artery and left subclavian artery will be marked as sisting of surgeons and physicians from the cardiothoracic the no landing area for the covered part of the stent graft. Prior to stent deployment, the systolic blood pressure is surgery, vascular surgery and the interventional radiology brought down to 80 mmHg, and the ventilation is stopped team. We define our inclusion criteria to include allpa- for the stent deployment. Due to the focal nature of BTAI, tients in who sustained any aortic injury (Grade 1-4) as we did not observe any issues with achieving distal seal. direct result of a blunt trauma and received subsequent However, to achieve at least 20mm landing zone for ade- TEVAR as treatment. These patients were recruited based quate proximal seal we have had to partial or total cover on a retrospective search through existing electronic med- the left subclavian artery ostium. Upon completion of de- ical records from the University of Malaya Medical Centre ployment, contrast dye is injected to confirm the patency of (UMMC), Kuala Lumpur. All trauma patients admitted to the aortic arch vessels as also to rule out signs of endo-leak. our Emergency & Trauma department were managed by After the completion angiogram, the introducer sheath emergency staff according to the Advanced Trauma and Life was removed carefully leaving the wire in the aorta. Af- Support protocols. Following the suspicion of BTAI seen by ter that the guide wire was removed and the right femoral widened mediastinum on chest X-ray, a computed tomog- artery was sealed using the Perclose ProglidercledR; (Ab- raphy arch aortogram (CT AoA) was done to visualise the bott Vascular Devices, Redwood City, CA, USA) system aortic pathology and the anatomy of the vertebral arteries. followed by direct compression for the left femoral artery As of 2017, all patients who were diagnosed at our cen- after the sheath was removed. We define technical success tre with BTAI requiring intervention were offered TEVAR as deployment of the endograft in the correct position to ex- rather than open repair. Aortic diameters were measured, clude the aortic pathology without the presence of endo-leak and a strict endograft oversizing factor of 10% was opted on completion aortogram. [6] The presence of distal pulses for our study group. Spinal drain was not performed in all was checked to rule out possibility of limb ischaemia. patients due to the emergent basis of the procedure and low LSA revascularization and LCCA chimney graft risk of spinal cord ischaemia. The proximal landing zone LSA revascularisation was employed with left common of at least 20 mm was considered prior graft deployment. carotid artery-left subclavian artery (LCCA-LSA) bypass Should the need for LSA coverage to achieve adequate prox- method. This procedure was done with an end-to-side anas- imal landing zone arises, we employ the practice of selective tomosis of the LCCA and LSA using a Dacron Graft which revascularisation based on the presence of aberrations in sutured by 5/0 prolene sutures. In cases where the aortic vascular anatomy. stent graft migrated proximally to affect the LCCA circula- TEVAR procedure tion, A chimney graft method was chosen for revascularize Our centre utilised the ValiantTM endoluminal stent- the LCCA. In which case a BeGraftTM peripheral endo- graft with the CaptiviaTM Delivery System (Medtronic graft (Bentley InnoMed, Hechingen, Germany) was used Journal of Medical Care Research and Review, Vol 3 Iss 5, 359–364 (2020) Left Subclavian Artery - Does it need attention during TEVAR for Blunt Traumatic Aortic Injury 361 as a chimney graft to revascularize the left common sub- mitral valve replacement 21 years ago. The mean length of clavian artery by left common carotid access to restore hospital stay and Intensive Care Unit (ICU) stay were 20.64 sufficient cerebral perfusion. In both the above cases, An and 9.55 days respectively.