List Archives

Thu Oct 18 16:33:57 BST 2007

One of the problems in the United States, and especially prominent among  
young patients is that we have only ONE commercial graft approved by FDA for use  
in the thoracic aorta.  The smallest graft is 26 mm in diameter, and the  
average diameter of the thoracic aorta in 20 year olds is 18.5 mm.    TOO small 
an aorta for too LARGE a graft (even the smallest  available).    Enfolding and 
migration is much more common than  most in the small series reports of "we 
too use stent graft" have  cited.   Several series of such enfolding have been 
reported at the  thoracic surgery meetings.    PARAPLEGIA has been reported to 
 occur late because of the late enfolding and then thrombosis of the  aorta.  

I remind the readers that Dr. Demetriades presented the largest series of  
this injury at the recent AAST meeting.   The rate of paraplegia was  identical 
between the traditional open approach and the stent graft approach in  this 
large multicenter study among trauma centers with experienced persons  putting 
in the stent grafts.    I am aware of many more problems  than have been 
reported.     I do believe that if the data  is correct in tabulated series, then we 
ultimately should use stent grafts, as  in my tabulation the mortality and 
paraplegia mandates that for the routine  (real) cases, we use endografts.   
However the complication rate is  still TOO HIGH for common use, and these must 
be under strict  protocol.       

Furthermore, the criteria for insertion of endografts is far too liberal,  
with stent grafts being inserted in trivial injuries that would have NEVER had  
surgery in the old days.   

There will also be cases which, either initially, or later will require  open 
procuedures, as Dr. Demetriades pointed out.     We are  loosing experience 
with open procedures and ultimately, the open procedures, by  selection of more 
complex cases, will have a much higher complication and death  rate.   At 
that time, we MUST consider these open cases to be a  totally different complex 
cohort than we have in the past.  

k

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Thoracic Aortic Stent Graft Migrations & enfoldings