Intragraft Obstructive Thrombus Two Years After Endovascular Repair of Traumatic Aortic Injury: A Case Report and Review of the Literature.
EJVES Vasc Forum 2021;
53:36-41. [PMID:
34927115 PMCID:
PMC8652008 DOI:
10.1016/j.ejvsvf.2021.10.018]
[Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 08/07/2021] [Accepted: 10/20/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction
Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for blunt thoracic aortic injury (BTAI) and has proven to be a good alternative to open surgery. TEVAR requires less operation time, has fewer complications, can be used for relatively unstable patients, and is associated with a significantly lower mortality rate. Moreover, long term follow up data demonstrate low re-intervention rates and stentgraft failure.
Report
The case of a 21 year old man who sustained severe trauma, including a traumatic pseudoaneurysm of the descending thoracic aorta distal to the left subclavian artery in 2016, is presented. The patient was treated by TEVAR. Two years later, he presented with progressive paraplegia due to stentgraft occlusion occurring four days after a new high velocity motor vehicle accident. An axillofemoral bypass was performed to assure blood flow to the lower body. Two days later the stentgraft was removed via left thoracotomy and replaced by a Dacron graft. Gross examination showed severe thrombus formation at the proximal edge, and a thrombotic occlusion in the middle and distal third of the stent. After three months of hospitalisation the patient was discharged to a rehabilitation clinic with partial recovery of his paraplegia. As of June 2020, the patient was able to walk without assistance and his paraplegia improved with only loss of sensation of his lower legs.
Conclusion
A serious thrombotic complication two years after TEVAR is described. Although TEVAR is the currently preferred treatment for BTAI, more research is needed to examine the mechanisms behind this thrombotic complication and to elucidate whether TEVAR is definitive treatment or a “bridge to further surgery”. Smaller diameter stentgrafts, anticoagulation, regular (lifelong) follow up imaging, and prophylactic surgical conversion in (selected) patients might help to prevent this serious complication.
Although thoracic endovascular aortic repair is the first choice treatment for blunt thoracic aortic injury, the cause of intragraft thrombus is unknown.
Nine cases have been reported with thrombotic (near) occlusions of thoracic stentgrafts. This is the first reported total occlusion following a second trauma.
Oversizing and trauma can potentially play a role in the formation and progression of obstructive thrombus in thoracic stentgrafts.
Follow up is important to detect intragraft thrombus deposition and to prevent major complications by adjusting anticoagulation or performing prophylactic removal of thrombotic stentgrafts.
Collapse