# Acute Thoracic Endograft Stenosis after Blunt Thoracic Aortic Injury: Use of a Large Self Expanding Stent Graft as a Low Risk Effective and Potentially Durable Treatment

Aurelien Hostalrich, Thibaut Boisroux, Benoit Lebas, Jean Segal, Jean-Baptiste Ricco, Xavier Chaufour

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Aurelien Hostalrich, Thibaut Boisroux, Benoit Lebas, Jean Segal, Jean-Baptiste Ricco, et al.. Acute Thoracic Endograft Stenosis after Blunt Thoracic Aortic Injury: Use of a Large Self Expanding Stent Graft as a Low Risk Effective and Potentially Durable Treatment. European Journal of Vascular and Endovascular Surgery, 2024, 68 (1), pp.135-136. 10.1016/j.ejvs.2024.03.001. hal-04642365

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RESEARCH LETTER

# Acute Thoracic Endograft Stenosis after Blunt Thoracic Aortic Injury: Use of a Large Self Expanding Stent Graft as a Low Risk Effective and Potentially Durable Treatment

Aurelien Hostalrich<sup>a</sup>, Thibaut Boisroux<sup>a</sup>, Benoit Lebas<sup>a</sup>, Jean Segal<sup>a</sup>, Jean-Baptiste Ricco<sup>a,b,*</sup>, Xavier Chaufour<sup>a</sup>

The revolution in thoracic endovascular aortic repair (TEVAR) for patients with blunt thoracic aortic injury (BTAI) has led to spectacular improvement in the prognosis of this major aortic trauma.¹

Even if the literature on the immediate outcome of TEVAR for BTAI in young patients is reassuring, hyper-plastic stenosis at the boundary between the distal end of the thoracic aortic endograft and the descending thoracic aorta is a delayed complication with dramatic consequences that may be attributed to excessive oversizing in patients with a small aorta (Fig. 1A).²

Treatment of this lesion is not yet the subject of guideline recommendations. Only a few clinical cases have suggested varied solutions: (1) open conversion with implantation of an aortic prosthesis under extracorporeal circulation and removal of the stent graft, leading to a significant risk of paraplegia;³ (2) insertion of another thoracic aortic endo-graft, entailing considerable risk of recurrence; and (3) an axillobifemoral bypass, a low risk procedure that improves vascularisation of the lower limbs but has poor midterm patency, rendering it inappropriate for young patients. Nieuwstraten et al. recently reported the case of a patient treated with a Palmaz stent leading to positive post-operative evolution.⁴

In this clinical situation, use of a Sinus-XL self expanding nitinol stent (OptiMed, Ettlingen, Germany) was reported for the first time in 2019.⁵ Here the results of application of this technique in five consecutive pa-tients operated on between January 2019 and December 2023 at a mean ± standard deviation age of 18 ± 4 years is described. At the time of re-operation, all five patients had severe arterial hypertension with pulmo-nary oedema (three patients), weakness of the lower extremities (three patients), or renal ischaemia (two patients). In this cohort, monitoring following re-intervention consisted of computed tomography angi-ography (CTA) at 1, 3, 6 months and 1 year, followed by

annual duplex ultrasonography. Two patients presented with moderate and asymptomatic hyperplasia on CTA, 6 months following TEVAR. As the evolution of mild aortic hyperplasia is unknown, and since CTA is an effective means of surveillance, the decision was taken not to intervene earlier in these asymptomatic patients.

The five patients initially had a grade II or III BTAI and received the smallest thoracic endovascular graft avail-able (Zenith Alpha thoracic endovascular graft ZTA-P-24- 100; Cook Medical, Bloomington, IN, USA) with median oversizing of 18% (interquartile range [IQR] 15, 21). Despite only moderate oversizing of the endograft, they presented with post-TEVAR hyperplastic stenosis and were re-operated on a mean of 13.6 ± 5.1 months after TEVAR (median 12 months, IQR 9, 18 months) with insertion of an OptiMed Sinus-XL self expanding nitinol stent.

The mean follow up after re-intervention was 18.6 ± 5.7 months. No patient was lost to follow up. Immediate disappearance of ischaemic symptoms was observed, and there was no clinical recurrence or abnormality on imaging.

The diameter of the self expanding nitinol stent was empirically chosen as the average between the diameter of the aortic endograft and that of the underlying aorta. Typically, a bare stent of 20 mm diameter was used (Fig. 1B). Pre-dilatation was required in one patient. No distal emboli were observed either during or after stent insertion. During the first post-operative month, direct oral anticoagulants were combined with long term treatment with aspirin or clopidogrel.

The results of this retrospective cohort suggest that use of a large, self expanding stent for thoracic endograft stenosis after BTAI provides medium term stable aortic revascularisation at 2 years, without resorting to major open conversion surgery that entails significant risks.

CONFLICTS OF INTEREST STATEMENT AND FUNDING

None declared.

<footnote><sup>a</sup>Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France</footnote>

<footnote><sup>b</sup>University of Poitiers, School of Medicine, Poitiers, France</footnote>

<footnote>* Corresponding author. Department of Vascular Surgery, University Hospital Rangueil, 1 avenue Jean Poulhes, 31059 Toulouse, Cedex 09, France. Tel.: +33 5 61 32 26 20.</footnote>

<footnote>E-mail address: jean.baptiste.ricco@univ-poitiers.fr (Jean-Baptiste Ricco).</footnote>
<figure><img src="image_2.png" /><figcaption>**Figure 1.** Thoracic endovascular stent graft stenosis after blunt thoracic aortic injury. (A) Pre-operative computed tomography angiography (CTA) showing the hypodense hyperplastic bud protruding into the lumen at the lower extremity of the endograft with details visible on the CTA cross section. (B) Aortography showing focal stenosis at the end of the endoprosthesis and the result after remodelling with a 20 mm diameter, 40 mm long balloon of the bare nitinol stent placed astride the endograft with no residual stenosis or downstream dissection.</figcaption></figure>

REFERENCES

1. Boutin L, Caballero MJ, Guarrigue D, Hammad E, Rennuit I, Delhaye N, et al.; TraumaBase Group. Blunt traumatic aortic injury management, a French TraumaBase analytic cohort. *Eur J Vasc Endovasc Surg* 2022;63:401-9.

2. García Reyes ME, Gonçalves Martins G, Fernández Valenzuela V, Domínguez González JM, Maeso Lebrun J, Bellmunt Montoya S. Long-term outcomes of thoracic endovascular aortic repair focused on bird beak and oversizing in blunt traumatic thoracic aortic injury. *Ann Vasc Surg* 2018;50:140-7.

3. Martinelli O, Malaj A, Faccenna F, Ruberto F, Alunno A, Totaro M, et al. Open conversion for recurrent endograft occlusion after endovascular treatment of blunt traumatic aortic injury: a peculiar case report. *Ann Vasc Surg* 2020;67:568.

4. Nieuwstraten JA, Statius van Eps RG, Wever JJ, Veger HTC. Focal aortic dissection with significant stenosis: a rare long term complication after TEVAR for blunt traumatic aortic

injury in an adolescent patient. *EJVES Vasc Forum* 2023;60:33-6.

5. Hostalrich A, Canaud L, Ozdemir BA, Chaufour X. Severe thoracic aorta stenosis after endovascular treatment of blunt thoracic aortic injury. *Semin Thorac Cardiovasc Surg* 2019;31:227-9.

Keywords:

Blunt thoracic aortic injury, BTAI, TEVAR, Thoracic endovascular stent graft stenosis

Available online 4 March 2024

© 2024 The Authors. Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

https://doi.org/10.1016/j.ejvs.2024.03.001