Endovascular Repair Of A Gunshot Wound To The Descending Thoracic Aorta
Sitaram V. Chivukula, MD, Erin Farlow, MD, Richard Keen, MD, Neha Sheng, MD.
Cook County Health and Hospital Systems, Chicago, IL, USA.
A 22-year old male presented to the trauma bay after sustaining a gunshot wound (GSW) to the back. On primary survey, his airway and breathing were intact, and he was tachycardic and hypotensive. His secondary survey was notable for a GSW to the left back. His lower extremity pulses were intact but he had no sensorimotor function below T8-9. The patient stabilized with blood product resuscitation. A chest x-ray showed a retained missile in the posterior mediastinum at the level of T8, and an echocardiogram was negative. CT angiogram demonstrated the retained missile in the fractured T8 vertebral body and a traumatic descending thoracic aortic injury with contrast extravasation, an associated pseudoaneurysm, and periaortic and mediastinal hematoma. Vascular and Cardiothoracic surgery were consulted and the patient was taken emergently to the operating room. The patient underwent thoracic aortic repair with endovascular technique (TEVAR), with successful exclusion of the aortic pseudoaneurysm without endoleak. Concurrent endoscopy ruled out esophageal or tracheal injuries. Postoperatively, the patient's sensorimotor deficit persisted. Neurosurgery was consulted and determined that the deficit was related to transection injury secondary to the GSW rather than ischemic injury. On postoperative day 10, a CT was performed for an infectious workup which showed appropriate and stable positioning of the aortic stent graft, and interval decrease in the hematoma. The patient recovered uneventfully and was discharged to a rehabilitation facility. Repeat imaging for graft surveillance was planned at 6 months, however the patient did not return for follow-up.
This is the rare case of a survivable penetrating aortic injury. In the stable patient, endovascular therapy can be attempted. A multidisciplinary approach, including vascular surgery, cardiothoracic surgery, and cardiac anesthesia is optimal. A transesophageal echo is useful to confirm access to the true lumen. When deploying the graft, locations of the left subclavian artery and the visceral arteries must be determined in relation to the graft landing zones. Aortic branch vessel revascularization may be required. Other risks of the procedure include retrograde aortic dissection and spinal cord ischemia.
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