Ann Thorac Surg 2008;86:786. doi:10.1016/j.athoracsur.2008.06.070
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Sina L. Moainie, MD,
Bartley P. Griffith, MD
Department of Surgery, Division of Cardiac Surgery, University of Maryland Medical Center, 22 S Greene St, N4W94, Baltimore, MD 21201-1544
(Email: smoainie{at}mac.com; bgriffith{at}smail.umaryland.edu).
The ever-elusive optimal treatment of traumatic aortic injury is addressed by Yamaguchi and colleagues [1] through their introduction of a novel curved aortic stent-graft. Traumatic aortic rupture poses a clinical paradox in that patients with the most severe degrees of aortic injury are also those that are the poorest operative candidates due to the highest incidence of intracranial and intra-abdominal trauma in these patients. The introduction of aortic stent-grafts in 1991 by Parodi and colleagues [2] has significantly improved our ability to treat these patients by eliminating the need for thoracotomy and left-heart bypass, thus decreasing treatment-related morbidity. The currently available aortic stent-grafts have offered a possible improvement in comparison with conventional open surgery, but they are still suboptimal because they do not adequately conform to the distal aortic arch in younger patients with aortas having a small radius of curvature. A second weakness of commercially available stent-grafts is that even the smallest thoracic aortic stent-grafts currently available (measuring 26 mm in diameter) are too large for the relatively small aortic diameters of younger trauma patients, which in our experience averages 22.0 mm. Both graft oversizing and inadequate conformation to the aortic curvature lead to the dreaded complication of graft collapse. At our center, we have addressed this limitation of endovascular technology by using multiple, short segment abdominal aortic stent-graft extension cuffs, allowing improved conformation to aortic angulation through articulation of the short-segment grafts [3]. Yamaguchi and colleagues [1] provide an alternate solution to the lack of conformability of currently available stent-grafts to the distal aortic arch by introducing an aortic graft that is designed with the anatomical configuration of the thoracic aorta in mind. Although the article is weakened by a limited number of patients and lack of post-procedure follow-up, the authors do identify a new alternative for treating this challenging clinical problem. The curved Matsui-Kitamura graft is an ideal example of the implementation of the cardiac surgeons' knowledge and experience with thoracic aortic anatomy, physiology, and pathophysiology in the development of improved devices designed specifically for the thoracic aorta. With the increasing presence of cardiac surgeons in the endovascular therapeutics arena, we can look forward to continued technologic advances in endovascular therapy for cardiovascular disease.
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References
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- Yamaguchi M, Sugimoto K, Tsukube T, et al. Curved nitinol stent-graft placement for treating blunt thoracic aortic injury: an early experience Ann Thorac Surg 2008;86:780-786.[Abstract/Free Full Text]
- Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms Ann Vasc Surg 1991;5:491-499.[Medline]
- Moainie SL, Neschis DG, Gammie JS, et al. Endovascular stenting for traumatic aortic injury: an emerging new standard of care Ann Thorac Surg 2008;85:1625-1630.[Abstract/Free Full Text]
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Curved Nitinol Stent-Graft Placement for Treating Blunt Thoracic Aortic Injury: An Early Experience
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Ann. Thorac. Surg. 86: 780-786.
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