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\begin{document}

\title{Thoracic endovascular aortic repair improves the quality of life in
young patients with traumatic aortic injury}



\author[1]{kentaro kiryu}%
\author[2]{Takayuki Kadohama}%
\author[3]{Itaru Igarashi}%
\author[3]{Genbu Yamaura}%
\author[3]{Fuminobu Tanaka}%
\author[2]{Daichi Takagi}%
\author[1]{Yoshinori Itagaki}%
\author[3]{Takuya Wada}%
\author[3]{Yuya Yamazaki}%
\author[3]{Hiroshi Yamamoto}%
\affil[1]{Akita University Graduate School of Medicine School of Medicine}%
\affil[2]{Akita University}%
\affil[3]{Akita University Graduate School of Medicine School of Medicine Department of Cardiovascular Surgery}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
Background \& Aim: Traumatic aortic injury (TAI) is a life-threatening
condition. We present cases of 7 patients with TAI limited at the
isthmus. Case description: Seven patients with TAI were treated between
January 2015 and December 2018; TAI was caused by motor vehicle crashes
in all cases. The patient characteristics and the post-operation data
were collected and analyzed. We performed thoracic endovascular aortic
repair (TEVAR) for five patients during their first hospitalization
using Relay Plus\selectlanguage{ngerman}® (Japan Lifeline, Japan). While patient 6 underwent
TEVAR 5 years after the injury, patient 7 was recommended conservative
care because she had dementia. Since most of these patients did not have
a history of hypertension, they were not on antihypertensive medications
after TEVAR. Conclusions: In cases of TAI, intervention by TEVAR in the
acute phase improves the patient's quality of life. Additionally, TEVAR
is expected to prevent TAI from enlarging to form an aortic aneurysm.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Abstract}

Background \& Aim: Traumatic aortic injury (TAI) is a life-threatening
condition. We present cases of 7 patients with TAI limited at the
isthmus.

Case description: Seven patients with TAI were treated between January
2015 and December 2018; TAI was caused by motor vehicle crashes in all
cases. The patient characteristics and the post-operation data were
collected and analyzed. We performed thoracic endovascular aortic repair
(TEVAR) for five patients during their first hospitalization using Relay
Plus\selectlanguage{ngerman}\textsuperscript{®} (Japan Lifeline, Japan). While patient 6
underwent TEVAR 5 years after the injury, patient 7 was recommended
conservative care because she had dementia. Since most of these patients
did not have a history of hypertension, they were not on
antihypertensive medications after TEVAR.

Conclusions: In cases of TAI, intervention by TEVAR in the acute phase
improves the patient's quality of life. Additionally, TEVAR is expected
to prevent TAI from enlarging to form an aortic aneurysm.

Keywords: Traumatic aortic injury, Thoracic endovascular aortic repair,
aneurysm, dissection, trauma

\textbf{Introduction}

Traumatic aortic injury (TAI) is a life-threatening condition with a
wide range of clinical manifestations, ranging from hemodynamic
stability to fatality, and requires local aortic dissection. Most TAI
patients are young and do not have a history of hypertension. However,
for patients with TAI and multiple organ injuries, the timing of the
surgical interventions is critical, unlike for patients with aneurysms
due to arteriosclerosis. We present cases of 7 patients with TAI limited
at the isthmus. Thoracic endovascular aortic repair (TEVAR) was
performed urgently in 5 patients during their first hospitalization.

\textbf{Case description}

We treated 7 patients with TAI (5 men and 2 women; mean age 56 ± 10
years) between January 2015 and December 2018; TAI was caused caused by
motor vehicle crashes in all cases. The patients underwent TEVAR with
Relay Plus\textsuperscript{®} (Japan Lifeline, Japan). The patient
characteristics have been summarized in Table 1. The post-operation data
for the patients are shown in Table 2.

In 5 cases, TEVAR was performed in the acute phase of the injury
(Fig.1). The average time between hospitalization and surgery was 27
days. In patients 1-4, the circulation was stable, and hence computed
tomography (CT) was performed first. However, patient 5 was in shock due
to a superior vena cava (SVC) injury, which was treated prior to TEVAR
during the same operation.

Patients 1, 2, 4, and 5 were young and did not have a history of
hypertension. Therefore, after the operation, they did not require
antihypertensive medications.

In patient 6, we detected enlargement of a dissecting aortic aneurysm 5
years after the initial injury. We, therefore, could not perform Zone 3
TEVAR (Fig.2). Patient 7 had a history of dementia. Since she had no
enlargement of the aorta, we just continued with follow-ups.

\textbf{Discussion}

TAI is the second most common cause of death after head injury. It has a
wide variety of clinical manifestations ranging from hemodynamic
stability to fatality. \textsuperscript{1} About 81\% of the TAI cases
are caused by motor vehicle crashes and have the same underlying
mechanism. \textsuperscript{1} All 7 patients in our study were also
injured in motor vehicle crashes.

TAI has generally been thought to be a rapidly decelerating injury.
Parmley et al., in a study of 275 patients with TAI, found that 239
(87\%) died during the first hour.\textsuperscript{2} They also found
that of the patients who arrived alive at the medical facility, 15\%
died from an aortic rupture within a few days.

Hershberger et al., in a study of 1126 cases of TAI, reported that in
818, the injury was in the thoracic aorta.\textsuperscript{3} Simon
Sevitt reported that in all the cases of TAI studied, the injury was at
the isthmus,\textsuperscript{4} which is consistent with our findings.
The factors that influence the location of the TAI
include\textsuperscript{4}:

\begin{enumerate}
\tightlist
\item
  Upward displacement of the heart and mediastinum from a cranially
  directed impact on the lower chest.
\item
  Acute deceleration of the moving body producing tension-stress on the
  wall of the aorta. The deceleration can be directed cranially,
  caudally, or horizontally.
\item
  A combination of direct trauma to the thorax plus effects of
  deceleration, as seen in many drivers and front-seat passengers after
  frontal collisions of their vehicles.
\item
  An acute rise of intra-aortic pressure following a blow on the chest
  or deceleration.
\end{enumerate}

Azizzadeh et al. have classified TAI into 4 types,
\textsuperscript{5}while Fabian et al. have classified it into 6
types.\textsuperscript{6}Azizzadeh et al. have recommended that types \selectlanguage{english}III
and \selectlanguage{english}IV should be treated urgently. But in most cases, there are other
injuries as well, which makes it difficult to decide the right time to
operate.

The characteristics of patients with TAI are different from those with a
common aortic rupture or dissection. While Hershberger et al. have
reported TAI in relatively young patients with an average age of 41
years,\textsuperscript{3} Azizzadeh et al. have reported it in
children.\textsuperscript{5} Compared to patients with a common aortic
aneurysm, patients with TAI have a healthy aorta, no history of
hypertension, and, therefore, are not on heart-related medications. The
average age of the patients in our study was 56.3 years, and only 3 of
them underwent any medical intervention before the onset of TAI.

Most patients with TAI have multiple injuries. Therefore, careful
examination is needed in each case to determine the right time for
intervention, and patients should be monitored closely to see how they
adapt to the intervention. TEVAR has recently been recommended for Class
I TAI. Compared to a cardio-pulmonary bypass, TEVAR requires fewer doses
of heparin.

Hershberger et al. reported mortality rates of 15-50\% and 9.5\%
following conventional open-heart surgery and TEVAR,
respectively.\textsuperscript{3} While paraplegia occurred in 9-19\% of
the patients who underwent open-heart surgery, it occurred in only
0.24\% of those who underwent TEVAR. In a study comparing open-heart
surgery and TEVAR, Ott et al. found that both the mortality rates and
incidence of paraplegia were 16\% and 0\%, respectively, in the two
groups. Therefore, TEVAR is considered safe and useful, although
prolonged follow-ups are required to monitor the long-term effects of
TEVAR on the patient's health. There was no incidence of mortality or
paraplegia in our study.

In conservative cases, TAI has been shown to enlarge and form a
dissecting aortic aneurysm, \textsuperscript{8, 9} as seen in patient 5
in this study. In a study of chronic traumatic thoracic aneurysms,
Finkelmeier et al. have reported that 41\% of the patients had either
died or had indications of expansion, 5 years after the
injury.\textsuperscript{8} At 20 years, after the initial injury, there
was only a 33\% probability of being alive and free of signs or symptoms
of aneurysm expansion. They also found that the survival rates in
patients who did and did not undergo operative repair 10 years after
surgery were 85\% and 66\%, respectively.\textsuperscript{8}

In this study, we have reported 7 cases of TAI localized at the isthmus,
all caused by motor vehicle crashes. We performed TEVAR in the acute
phase of the TAI in 5 patients, and 4 of them were in stable condition.
Patient 5 showed signs of shock, and therefore, we repaired the SVC
prior to performing TEVAR in the same operation. We followed-up patient
6 by CT and detected an enlarged aortic aneurysm 5 years later. If we
had performed TEVAR in the acute or subacute phase, instead of in the
chronic phase, we could have intervened as Zone 3 TEVAR.

Patient 7 was treated conservatively since she had dementia and was at a
high risk of bleeding following the use of heparin. Patients 1, 2, 4,
and 5 were young, with no history of hypertension. Therefore, they did
not have to take medications for hypertension, which we believe
contributed to their quality of life. However, prolonged follow-up data
will have to be evaluated to determine the long-term effects of TEVAR in
these patients.

Paraplegia is one of the serious complications of TEVAR. In our cases,
however, TEVAR did not result in paraplegia. The collateral network
concept proposed by Griepp et al. describes the presence of various
collateral pathways in the spinal cord.\textsuperscript{10,
11}Therefore, covering only the aortic isthmus, as in our cases, reduces
the risk of paraplegia. Furthermore, we performed a left subclavian
artery bypass as a prophylactic measure against paraplegia.

Limitation of our report was the number of cases was small. So, it is
necessary to continue to accumulate cases.

\textbf{Conclusion}

Based on the 7 cases described in this study, particularly the one
involving a young patient with no history of hypertension, we believe
that TEVAR performed during the acute or sub-acute phase of injury is
effective. It contributes to a better quality of life by eliminating the
need for antihypertensive medications and potentially prolonging the
life span. Furthermore, our findings suggest that performing a simple
TEVAR before the TAI progresses to a chronic stage and becomes a
dissecting aortic aneurysm, is associated with fewer complications and a
lower risk of paraplegia.

Conflict of interest: The authors declare no conflicts of interest
directly relevant to the content of this manuscript.

\textbf{Author contributions Writing: KK}

\textbf{Review: TK, HY}

\textbf{Illustration: II}

\textbf{Data summarize: GY, FT, DT, YI, TW, YY}

\textbf{References}

\begin{enumerate}
\tightlist
\item
  \emph{Kato N},\emph{Dake MD},\emph{Miller DC},\emph{Semba
  CP},\emph{Mitchell RS},\emph{Razavi MK}, et al. Traumatic thoracic
  aortic aneurysm: treatment with endovascular stent-grafts. Radiology
  1997;205:657--662.
\item
  Parmley LF, Mattingly TW, Manion WC, Jahnke EJ. Nonpenetrating
  traumatic injury of the aorta. Circulation 1958;17:1086--1101.
\item
  \emph{Hershberger RC},\emph{Aulivola B},\emph{Murphy M},\emph{Luchette
  FA}. Endovascular grafts for treatment of traumatic injury to the
  aortic arch and great vessels. J Trauma 2009:67;660--671.
\item
  Sevitt S. The mechanisms of traumatic rupture of the thoracic aorta.
  Br J Surg 1977; 64:166--173.
\item
  Azizzadeh A, Ray HM, Dubose JJ, Charlton-Ouw KM, Miller CC, Coogan SM,
  et al. Outcomes of endovascular repair for patients with blunt
  traumatic aortic injury. J Trauma Acute Care Surg 2014;76:510--516.
\item
  Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney
  PA, et al. Prospective study of blunt aortic injury: Multicenter Trial
  of the American Association for the Surgery of Trauma. J Trauma
  1997;42:374--383.
\item
  Ott MC,\emph{Stewart TC},\emph{Lawlor DK},\emph{Gray DK},\emph{Forbes
  TL}. Management of blunt thoracic aortic injuries: endovascular stents
  versus open repair. J Trauma 2004;56:565-570.
\item
  Finkelmeier BA,\emph{Mentzer RM Jr},\emph{Kaiser DL},\emph{Tegtmeyer
  CJ},\emph{Nolan SP}. Chronic traumatic thoracic aneurysm. Influence of
  operative treatment on natural history: an analysis of reported cases,
  1950-1980. J Thoracic Cardiovasc Surg 1982;84:257--266.
\item
  \emph{Bacharach JM},\emph{Garratt KN},\emph{Rooke TW}. Chronic
  traumatic thoracic aneurysm: Report of two cases with the question of
  timing for surgical intervention.\emph{J Vasc Surg} 1993;17:780--783.
\item
  \emph{Griepp RB},\emph{Griepp EB}. Spinal cord perfusion and
  protection during descending thoracic and thoracoabdominal aortic
  surgery: the collateral network concept. Ann Thorac Surg
  2007;83:865--869.
\item
  Griepp RB, Ergin MA, Galla JD, Lansman S, Khan N, Quintana C, et
  al.\emph{Looking for the artery of Adamkiewicz: a quest to minimize
  paraplegia after operations for aneurysms of the descending thoracic
  and thoracoabdominal aorta.} J Thorac Cardiovasc Surg
  1996;112:1202--1215.
\end{enumerate}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Fig/Fig}

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\includegraphics[width=0.70\columnwidth]{figures/Fih/Fih}

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\textbf{Hosted file}

\verb`Table1_Patient_characteristics part5.docx`  available at \url{https://authorea.com/users/316887/articles/451318-thoracic-endovascular-aortic-repair-improves-the-quality-of-life-in-young-patients-with-traumatic-aortic-injury}

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\verb`Table2_operative_result part5.docx`  available at \url{https://authorea.com/users/316887/articles/451318-thoracic-endovascular-aortic-repair-improves-the-quality-of-life-in-young-patients-with-traumatic-aortic-injury}

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