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Thu Oct 18 16:48:55 BST 2007

Same here, in the Middle East
Mickey

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Karim Brohi
Sent: Thursday, October 18, 2007 5:44 PM
To: Trauma &amp, Critical Care mailing list
Subject: Re: Thoracic Aortic Stent Graft Migrations & enfoldings

Ken

No one should be putting oversized stents into anybody.  If the
correct size is not available then open repair is the only option (or
transfer to Europe!)

Most major manufacturers now have a 22mm stent graft which is
appropriate for most cases.  I don't know about their FDA status.  In
fact the limiting factor here is more commonly the small size of the
iliac arteries compared to the delivery device.

Karim

On 18/10/2007, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
> 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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