徐偉峻1 曹乃文2 王偉林1 陳嘉哲1 湯堯舜1 廖立民1 黃宏昌1 陳瑞杰1 臺北醫學大學附設醫院 外科部 急症外傷外科1 心臟血管外科2 Thoracic aortic endografting as a rescue for traumatic aortic injury and tracheal rupture: case report 06349495 徐偉峻1 曹乃文2 王偉林1 陳嘉哲1 湯堯舜1 廖立民1 黃宏昌1 陳瑞杰1 臺北醫學大學附設醫院 外科部 急症外傷外科1 心臟血管外科2

Pre-Hospital Course 33 years old male had sustained motorcylce-motorvehicle collision Sent to ER by EMT Notable right forearm deformity and abrasion over right knee 2

Chief Complaint Chest tightness with shortness of breath Right forearm pain

Primary Survey Airway Patent, Neck collar(+) Breathing RR: 16/min, SpO2:99% in room air Breathing sound: decrease over left lung field Circulation BP:90/64 mmHg, HR:108/min Heart sound: regular, no murmur, no distant sound Pelvic stability: stable FAST: no ascites, no pericardial effusion Disability E4V5M6, Consciousness: clear and oriented Pupil size:2/2 mm, Light reflex:+/+ Exposure Temp: 36.8℃ Wound: subcutaenous emphysema noted over neck base and bilateral chest wall Deformity of right forearm

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Impression Thoracic aorta transection (BTAI grade III) Tracheal rupture with pneumomediastenium Right pneumothorax Left hemothorax Right radial fracture (Gallazzi fracture)

外傷嚴重度評估

Laryngeal Injury Classification

外傷性主動脈破裂 根據統計，80%的傷患無法撐到醫院即死亡；而被送達醫院的病患，在24小時內死亡率也超過50% 在外傷中小於1%的發生率卻占了外傷死亡原因的16% 外傷性主動脈破裂是造成外傷病患死亡原因的第二位，其死亡率僅次於顱內出血。 根據統計，80%的傷患無法撐到醫院即死亡；而被送達醫院的病患，在24小時內死亡率也超過50% (Fox N et al.; J Trauma Acute Care Surg. 2015 Jan;78(1):136-46.)

Mechanism of Traumatic Aortic Dissection N Engl J Med 2008; 359:1708-1716

Grading of Traumatic Aortic Dissection ENDOVASCULAR TODAY NOVEMBER 2014

OP findings Endograft was available when we finished right femoral percutaneous cannulation Aortography: contrast extravasation at aortic arch

OP findings TEVAR (thoracic endovascular aortic repair) with endovascular graft 34x80 mm and 32x80 was applied just beyond left cartoid artery, covering left subclavin ostium, with extension to descending thoraci aorta No more contrast extravastion was detected by aortography

OP findings Right femoral cannulation was closed with percutaneous closure devices (Proglide, Abbot)

3 months follow up CT scan 16

Post-OP Follow Up 17

Discussion Traumatic aortic injury 25% could be sent to hospital; thoracotomy surgery: 28% mortality; 16% paraplegia; delayed rupture 3-5% Non-operative management 46% mortality Comparison: conventional surgery: endovascular repair= 21%: 0% in mortality (Tehrani; Ann Thorac Surg 2006) (Murad; J Vasc Surg 2011) (Rosseau; J Thorac Cardiovasc Surg 2005)

Discussion Endovascular Tx for blunt aortic injuries: mortality: 6.8-12.8%; paraplegia: 0% 2011 Annual meeting of society of vascular surgery guidelines for traumatic thoracic aortic injuries: suggest that endovascular repair be performed preferentially over open surgical repair or nonoperative management. (Neschis; NEJM 2008)

Discussion One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial) All endografts=Valiant (Medtronic) 1 yr mortality 12%; paraplegia 0% (Khoynezhad; J Thorac Cardiovasc 2015)

Discussion

Conclusion In this specific patient with difficult airways, TEVAR was safely performed under local anesthesia, subsequent ORIF was performed under nerve block

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