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Intravascular Ultrasound During Endovascular Repair of Blunt Traumatic Aortic Injury: Impact on Operative Results and Postoperative Complications
James Etheridge, MHS, Sadie Ahanchi, MD, David Dexter, MD, Brandon Cain, MD, Jay Collins, MD, Jean Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
OBJECTIVES: Endovascular repair has become first line therapy for blunt traumatic aortic injury (BTAI). We assessed the impact of intravascular ultrasound (IVUS) on complications and aortic remodeling.
METHODS: Procedural data and outcomes of endovascular repair with and without intraoperative IVUS were compared for all BTAI patients from 2005-2015. Primary endpoints were device-related complications (collapse, migration, endoleak, and reintervention) and aortic-related complications (aortic-related mortality, stroke, and spinal cord ischemia). Aortic measurements were calculated from 3D reconstructed CT scans and IVUS images. Remodeling was quantified by volume change over time from initial to first follow-up CT scan.
RESULTS: 25 patients underwent endovascular BTAI repair. 14 patients received intraoperative IVUS and 11 did not. Mean age was 41 years, and 72% were male. No significant differences in demographics or injury characteristics were observed between IVUS and non-IVUS patients. Average proximal neck diameter on intraoperative IVUS was 1.2 mm greater than that measured on initial CT scan. Based on initial CT measurements, proximal neck oversizing was 25% vs 9% in IVUS vs non-IVUS patients (p=.001).
Technical success was achieved in all patients except one non-IVUS patient who required reintervention for graft collapse within 24 hours. Non-IVUS patients had increased complete or partial branch vessel coverage (81.8% vs 42.9%, p=.048) and bird-beaking (27.3% vs 0%, p=.037) compared to IVUS patients.
All-cause mortality was 20% and did not significantly differ between groups. One non-IVUS patient suffered a major stroke within 30 days; no additional aortic-related complications occurred.
At a mean follow-up of 13 months (range: 1-68 months), device-related complications occurred in 36.4% of non-IVUS patients vs 0% of IVUS patients (p=.026). One patient had device collapse with migration and reintervention, one patient had asymptomatic collapse, and two patients had asymptomatic graft migration. No endoleaks were noted in either group. 16 patients had follow-up CTs available at a mean of 31 days (range: 7-77 days). Reduction in aortic volume was 4.41 cm3/day in IVUS patients vs 2.34 cm3/day in non-IVUS patients (p=.255) demonstrating a trend towards more rapid remodeling in the IVUS group.
CONCLUSIONS: Adjunctive use of intraoperative IVUS in endovascular BTAI repair can alter operative outcomes such as branch vessel coverage and bird-beaking and may reduce device-related complications. IVUS-based endograft sizing also appears to contribute to enhanced aortic remodeling.
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