Endovascular Repair of Traumatic Aortic Rupture 143 A B C Fig. 2. (A) Pre-procedural an- giogram after debranching of the left subclavian artery, show- ing free blood flow to both arch vessels and the morphology and extent of the rupture site. Post- procedural angiogram (B) and CT scan (C) after stent-graft pla- cement, showing complete ex- clusion of the rupture site and good apposition of the endopro- sthesis, without endoleak around the stent-graft. Fig. 1. Preoperative CT scan showing an extraluminal hematoma of the distal aortic arch containing an aortic rupture. Fig. 3. Left supraclavicular wound. formed during deployment to ensure accurate proximal and distal positioning. The proximal bare stent was placed pre- cisely in the middle of the ascending aorta, allowing free blood flow to both arch vessels. Intraoperative angiography was used for post-procedural assessment of stent-graft positioning and endoleak (Fig. 2B). An in-hospital thoracic CT scan on post- operative day 12 (Fig. 2C) showed successful exclusion of the rupture site, with no any signs of endoleak or graft-related complications. At the first visit to the out-patient department, the patient was doing well and showed good healing of the supraclavicular incisional wound (Fig. 3). DISCUSSION Emergency open thoracotomy for traumatic aortic ruptures is associated with a peri-procedural mortality rate ranging between 17% and 21%, and a paraplegia rate as high as 7% (1, 2), due mainly to the large proportion of patients who present with multiple concomitant co-morbid conditions. Although delaying surgical repair of TAR may overcome the high mortality and morbidity risks associated with emergen- cy surgery, delaying open surgery has been found to have an in-hospital mortality risk of 2-5% (3, 4). Recent results have suggested that endovascular stent-grafting may be a viable, ‘minimally invasive’ alternative, which can achieve the same results as emergency open thoracotomy but with lower mor- tality and morbidity risks (5-7). Endovascular stent-grafting, however, has several drawbacks that may limit its broader application. For example, most TARs occur at the aortic isth- mus level, so the proximal landing zone in these patients is usually short. Furthermore, obligate coverage of the LSCA ostium is often required to achieve complete sealing of the rupture site, so it may cause ischemia or thrombosis (8, 9).