Commentary: Emergency Stent-graft Repair for Thoracic Aortic Injury

Emergency Stent-graft Repair for Thoracic Aortic Injury by Castelli et al. is an important paper that lends further credence to the notion that endovascular repair is rapidly becoming the new standard of care in the treatment of traumatic transection of the thoracic aorta. The results herein reported, like many others, are exciting and very promising. They seem to ‘overshadow’ anything and everything that standard surgical repair has accomplished over the past several decades as serious operative morbidity and mortality rates have remained high.

Thoracic stent-graft technologies can still be described as “work-in-progress,” and this certainly resonates with this clinical application. Young individuals are often the victims in trauma events, and they frequently have small-diameter aortas. Most, if not all, currently available thoracic endografts are too large for many of these patients — a significant shortcoming that industry will hopefully overcome in the near future. Lower-profile devices are also needed to facilitate introduction and delivery on patients with small-size access vessels — females in particular. Finally, I’d like to say a word about the issue of left subclavian artery coverage by the device. It is true, of course, that exclusion of this vessel is often necessary in this context. But it is not (always) a safe and complication-free maneuver. If possible, and time permitting, I would strongly suggest ascertaining normal antegrade flow in the contralateral (right) vertebral artery and — if possible — the intactness of the circle of Willis by MRA imaging.

Correspondence: frank.criado@medstar.net