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Endograft Collapse After Thoracic Stent-Graft Repair for Traumatic Rupture

2009; Elsevier BV; Volume: 87; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2008.09.012

1552-6259

Harold L. Lazar, Praveen Kerala Varma, Oz M. Shapira, Jorge A. Soto, Palma M. Shaw,

Trauma Management and Diagnosis

Endovascular stent grafting has emerged as a new strategy for repair of traumatic aortic disruptions; however, this technique is not without complications. In this report, we describe a case of endograft collapse after a traumatic aortic rupture. Endovascular stent grafting has emerged as a new strategy for repair of traumatic aortic disruptions; however, this technique is not without complications. In this report, we describe a case of endograft collapse after a traumatic aortic rupture. Endovascular stent grafting has emerged as a new strategy for the repair of traumatic aortic disruptions [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar]. This less invasive approach is especially useful for patients with multiple, severe injuries in whom prolonged periods of anticoagulation and extracorporeal support are contraindicated. However, this technique is not without complications. In this report, we describe a case of endograft collapse after the successful deployment of endovascular stents for a traumatic aortic tear in a patient with multi-system trauma.A 24-year-old man was transported to the Boston Medical Center with multiple injuries from blunt trauma after a motor vehicle accident. These included bilateral pulmonary contusions that required ventilatory support, a right ventricular contusion, an open fracture of the left ulnar and radius, a fracture of the left clavicle, and bilateral subarachnoid hemorrhages of the frontal lobes associated with a subdural hematoma. A chest computed tomographic scan revealed a 2 × 1 cm pseudoaneurysm of the proximal descending aorta just distal to the left subclavian artery. Given his multiple injuries and concern over systemic anticoagulation, a decision was made to repair this injury with an endovascular stent graft. A 26 mm × 10 cm Gore TAG endovascular stent graft (W. L. Gore & Assoc, Flagstaff, AZ) was inserted through a cut-down in the right femoral artery and was positioned just proximal to the orifice of the left subclavian artery. A second 26 mm × 10 cm graft was inserted to correct a type 1 retrograde leak. The patient made a slow but complete recovery and was discharged home 1 month after stenting, at which time a computed tomographic scan showed good placement of both stents. However, 3 months later, a follow-up computed tomographic scan now showed infolding of the inner stent with significant compromise of the aortic lumen (Fig 1). Although the patient was asymptomatic, a decision was made to return to the operating room for stent removal. An arterial cannula was placed in the left femoral artery and venous cannulae were inserted into the inferior and superior vena cavae through the left femoral and right internal jugular veins. A left thoracotomy was performed and the chest entered through the fourth interspace. After systemic cooling to 18°C, circulatory arrest was initiated. A complete transverse aortotomy was made 1.5 cm distal to the left subclavian artery and both grafts were removed. The collapse of the inner graft was clearly visualized (Fig 2). All residual thrombus was removed and the aorta was repaired using a No. 22 Hemashield interposition graft (Boston Scientific Corp, Wayne, NJ). The total circulatory arrest time was 23 minutes. The patient tolerated the procedure well and was discharged home on postoperative day 6. He is now fully recovered from all his injuries and has returned to an active lifestyle.Fig 2Excised endografts. Note that the cross-sectional view of the excised endografts shows significant infolding of the inner graft.View Large Image Figure ViewerDownload (PPT)CommentThe presence of multiple life-threatening injuries made this patient an ideal candidate for endovascular stenting. However, the aorta of patients with traumatic injuries differs from atherosclerotic diseased vessels for which these grafts were originally designed. These patients are younger and have normal, smaller proximal aortic diameters, such that grafts are usually oversized by 10% to 20% [3Mohs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Endoprostheses must be placed in a more steeply, angulated aortic arch, and the subclavian artery orifice is often covered to increase the length of the proximal landing zone. Since smaller endografts are not available, large mismatches between the diameter of the aorta and the endograft may occur, thus increasing the risk for endograft collapse. Currently, there are no endografts available that have been specifically designed to treat thoracic aortic injuries.Endovascular stent collapse has been more commonly seen with the Gore TAG device (W. L. Gore) after removal of its longitudinal spine, which resulted in a less rigid stent configuration [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 4Makaroun M.S. Dillavou E.D. Kee S.T. et al.Endovascular treatment of thoracic aortic aneurysms: results of the phase II multi-center trial of the Gore TAG thoracic endoprosthesis.J Vasc Surg. 2005; 41: 1-9Abstract Full Text Full Text PDF PubMed Scopus (536) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. Patients may present with chest pain or be asymptomatic [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. The collapse may occur within 24 hours after stent implantation or after 3 months [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. Once the diagnosis is made, graft collapse must be treated expeditiously to avoid total aortic closure and distal malperfusion. Therapy is dictated by the extent and location of the collapse. If the collapse involves only the proximal segment, it may be possible to insert another endograft to stabilize the proximal portion of the collapsed endograft [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 3Mohs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. This technique can only be used if there is a sufficient neck available to stabilize the endograft without compromising the orifices of the innominate or left carotid arteries. If there is only a focal area of collapse, it may be possible to balloon the endograft and maintain patency by inserting a Palmaz stent (Johnson & Johnson, Cordis, Miami Lakes, FL) [5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. An operative approach was chosen in this patient since the collapse involved the length of the entire endograft. Furthermore, the long-term durability of endovascular stents for thoracic aortic injuries is unknown, and the life expectancy of this young patient exceeds the experience with all existing endografts. Deep hypothermic circulatory arrest has been successfully used to remove endografts after type 1 endoleaks in the thoracic aorta [6Mohammadi S. Dumont E. Voisine P. Dagenais F. Operative strategy for open surgery after failed thoracic aortic stent grafting.J Thorac Cardiovasc Surg. 2007; 134: 1044-1046Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. We used this technique because the stent crossed the orifice of the left subclavian artery, and it would not have been possible to safely clamp the aorta above the endograft. In addition, the endograft can be adherent to the aortic wall, and circulatory arrest allows all the graft material and any thrombotic debris to be safely removed under direct vision.Endovascular stenting remains a viable therapeutic option for the treatment of acute aortic tears, especially in those patients with multiple life-threatening injuries. Nevertheless, the long-term durability of these grafts is unknown, and the potential for collapse makes long-term follow-up with computed tomographic scans mandatory. Endovascular stent grafting has emerged as a new strategy for the repair of traumatic aortic disruptions [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar]. This less invasive approach is especially useful for patients with multiple, severe injuries in whom prolonged periods of anticoagulation and extracorporeal support are contraindicated. However, this technique is not without complications. In this report, we describe a case of endograft collapse after the successful deployment of endovascular stents for a traumatic aortic tear in a patient with multi-system trauma. A 24-year-old man was transported to the Boston Medical Center with multiple injuries from blunt trauma after a motor vehicle accident. These included bilateral pulmonary contusions that required ventilatory support, a right ventricular contusion, an open fracture of the left ulnar and radius, a fracture of the left clavicle, and bilateral subarachnoid hemorrhages of the frontal lobes associated with a subdural hematoma. A chest computed tomographic scan revealed a 2 × 1 cm pseudoaneurysm of the proximal descending aorta just distal to the left subclavian artery. Given his multiple injuries and concern over systemic anticoagulation, a decision was made to repair this injury with an endovascular stent graft. A 26 mm × 10 cm Gore TAG endovascular stent graft (W. L. Gore & Assoc, Flagstaff, AZ) was inserted through a cut-down in the right femoral artery and was positioned just proximal to the orifice of the left subclavian artery. A second 26 mm × 10 cm graft was inserted to correct a type 1 retrograde leak. The patient made a slow but complete recovery and was discharged home 1 month after stenting, at which time a computed tomographic scan showed good placement of both stents. However, 3 months later, a follow-up computed tomographic scan now showed infolding of the inner stent with significant compromise of the aortic lumen (Fig 1). Although the patient was asymptomatic, a decision was made to return to the operating room for stent removal. An arterial cannula was placed in the left femoral artery and venous cannulae were inserted into the inferior and superior vena cavae through the left femoral and right internal jugular veins. A left thoracotomy was performed and the chest entered through the fourth interspace. After systemic cooling to 18°C, circulatory arrest was initiated. A complete transverse aortotomy was made 1.5 cm distal to the left subclavian artery and both grafts were removed. The collapse of the inner graft was clearly visualized (Fig 2). All residual thrombus was removed and the aorta was repaired using a No. 22 Hemashield interposition graft (Boston Scientific Corp, Wayne, NJ). The total circulatory arrest time was 23 minutes. The patient tolerated the procedure well and was discharged home on postoperative day 6. He is now fully recovered from all his injuries and has returned to an active lifestyle. CommentThe presence of multiple life-threatening injuries made this patient an ideal candidate for endovascular stenting. However, the aorta of patients with traumatic injuries differs from atherosclerotic diseased vessels for which these grafts were originally designed. These patients are younger and have normal, smaller proximal aortic diameters, such that grafts are usually oversized by 10% to 20% [3Mohs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Endoprostheses must be placed in a more steeply, angulated aortic arch, and the subclavian artery orifice is often covered to increase the length of the proximal landing zone. Since smaller endografts are not available, large mismatches between the diameter of the aorta and the endograft may occur, thus increasing the risk for endograft collapse. Currently, there are no endografts available that have been specifically designed to treat thoracic aortic injuries.Endovascular stent collapse has been more commonly seen with the Gore TAG device (W. L. Gore) after removal of its longitudinal spine, which resulted in a less rigid stent configuration [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 4Makaroun M.S. Dillavou E.D. Kee S.T. et al.Endovascular treatment of thoracic aortic aneurysms: results of the phase II multi-center trial of the Gore TAG thoracic endoprosthesis.J Vasc Surg. 2005; 41: 1-9Abstract Full Text Full Text PDF PubMed Scopus (536) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. Patients may present with chest pain or be asymptomatic [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. The collapse may occur within 24 hours after stent implantation or after 3 months [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. Once the diagnosis is made, graft collapse must be treated expeditiously to avoid total aortic closure and distal malperfusion. Therapy is dictated by the extent and location of the collapse. If the collapse involves only the proximal segment, it may be possible to insert another endograft to stabilize the proximal portion of the collapsed endograft [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 3Mohs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. This technique can only be used if there is a sufficient neck available to stabilize the endograft without compromising the orifices of the innominate or left carotid arteries. If there is only a focal area of collapse, it may be possible to balloon the endograft and maintain patency by inserting a Palmaz stent (Johnson & Johnson, Cordis, Miami Lakes, FL) [5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. An operative approach was chosen in this patient since the collapse involved the length of the entire endograft. Furthermore, the long-term durability of endovascular stents for thoracic aortic injuries is unknown, and the life expectancy of this young patient exceeds the experience with all existing endografts. Deep hypothermic circulatory arrest has been successfully used to remove endografts after type 1 endoleaks in the thoracic aorta [6Mohammadi S. Dumont E. Voisine P. Dagenais F. Operative strategy for open surgery after failed thoracic aortic stent grafting.J Thorac Cardiovasc Surg. 2007; 134: 1044-1046Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. We used this technique because the stent crossed the orifice of the left subclavian artery, and it would not have been possible to safely clamp the aorta above the endograft. In addition, the endograft can be adherent to the aortic wall, and circulatory arrest allows all the graft material and any thrombotic debris to be safely removed under direct vision.Endovascular stenting remains a viable therapeutic option for the treatment of acute aortic tears, especially in those patients with multiple life-threatening injuries. Nevertheless, the long-term durability of these grafts is unknown, and the potential for collapse makes long-term follow-up with computed tomographic scans mandatory. The presence of multiple life-threatening injuries made this patient an ideal candidate for endovascular stenting. However, the aorta of patients with traumatic injuries differs from atherosclerotic diseased vessels for which these grafts were originally designed. These patients are younger and have normal, smaller proximal aortic diameters, such that grafts are usually oversized by 10% to 20% [3Mohs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Endoprostheses must be placed in a more steeply, angulated aortic arch, and the subclavian artery orifice is often covered to increase the length of the proximal landing zone. Since smaller endografts are not available, large mismatches between the diameter of the aorta and the endograft may occur, thus increasing the risk for endograft collapse. Currently, there are no endografts available that have been specifically designed to treat thoracic aortic injuries. Endovascular stent collapse has been more commonly seen with the Gore TAG device (W. L. Gore) after removal of its longitudinal spine, which resulted in a less rigid stent configuration [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 4Makaroun M.S. Dillavou E.D. Kee S.T. et al.Endovascular treatment of thoracic aortic aneurysms: results of the phase II multi-center trial of the Gore TAG thoracic endoprosthesis.J Vasc Surg. 2005; 41: 1-9Abstract Full Text Full Text PDF PubMed Scopus (536) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. Patients may present with chest pain or be asymptomatic [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. The collapse may occur within 24 hours after stent implantation or after 3 months [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. Once the diagnosis is made, graft collapse must be treated expeditiously to avoid total aortic closure and distal malperfusion. Therapy is dictated by the extent and location of the collapse. If the collapse involves only the proximal segment, it may be possible to insert another endograft to stabilize the proximal portion of the collapsed endograft [1Tehrani H.Y. Peterson B.G. Katariya K. et al.Endovascular repair of thoracic aortic tears.Ann Thorac Surg. 2006; 82: 873-878Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 2Hoornweg L.L. Dinkelman M.K. Goslings C. et al.Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multi-center analysis of 28 cases in the Netherlands.J Vasc Surg. 2006; 43: 1096-1102Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 3Mohs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. This technique can only be used if there is a sufficient neck available to stabilize the endograft without compromising the orifices of the innominate or left carotid arteries. If there is only a focal area of collapse, it may be possible to balloon the endograft and maintain patency by inserting a Palmaz stent (Johnson & Johnson, Cordis, Miami Lakes, FL) [5Steinbauer M.G.M. Stehr A. Pfister K. et al.Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease.J Vasc Surg. 2006; 43: 609-612Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. An operative approach was chosen in this patient since the collapse involved the length of the entire endograft. Furthermore, the long-term durability of endovascular stents for thoracic aortic injuries is unknown, and the life expectancy of this young patient exceeds the experience with all existing endografts. Deep hypothermic circulatory arrest has been successfully used to remove endografts after type 1 endoleaks in the thoracic aorta [6Mohammadi S. Dumont E. Voisine P. Dagenais F. Operative strategy for open surgery after failed thoracic aortic stent grafting.J Thorac Cardiovasc Surg. 2007; 134: 1044-1046Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. We used this technique because the stent crossed the orifice of the left subclavian artery, and it would not have been possible to safely clamp the aorta above the endograft. In addition, the endograft can be adherent to the aortic wall, and circulatory arrest allows all the graft material and any thrombotic debris to be safely removed under direct vision. Endovascular stenting remains a viable therapeutic option for the treatment of acute aortic tears, especially in those patients with multiple life-threatening injuries. Nevertheless, the long-term durability of these grafts is unknown, and the potential for collapse makes long-term follow-up with computed tomographic scans mandatory.