This case highlights the efficacy of TEVAR in controlling hemorrhage from the avulsion of aortic branches related to cross-clamping of the descending aorta performed during RT.
RT is considered a last resort in the management of patients with major trauma. It is performed in patients with penetrating or blunt thoracic trauma or exsanguinating abdominal injury, if appropriate resources are available, for definitive injury management. Indications for RT include direct cardiac compression, cardiac tamponade, treatment of cardiac or thoracic injury, prevention of air embolism, and cross-clamping of the aorta [1]. An aortic clamp may be lifesaving when performing acute resuscitation for severe hemorrhagic shock. Occlusion of the thoracic aorta decreases blood loss and results in increased blood pressure, which improves perfusion to the heart, lungs, and brain without sacrificing blood flow to the abdomen, pelvis, and lower extremities. Aortic cross-clamping is an essential procedure for critical trauma patients with unstable hemodynamics and risk of imminent cardiac arrest.
RT is a favorable method for patients facing imminent cardiac arrest due to cardiac tamponade and tension pneumothorax that can lead to chest trauma. For patients with hemorrhagic shock in non-thoracic trauma without imminent cardiac arrest, on the other hand, REBOA is more favorable option and less invasive procedure than RT. In our case, we first performed REBOA, since the patient had non-thoracic trauma without imminent cardiac arrest. However, the procedure of REBOA resulted in further progression of shock; therefore, REBOA was switched to aortic cross-clamping with RT to prevent cardiac arrest. It is true that cross-clamping of the aorta with RT is a more invasive procedure than balloon occlusion of the aorta in REBOA. To prevent cardiac arrest, however, it is more important to make decisions, such as switching from REBOA to RT or initiating with RT in patients who are deteriorating rapidly.
It is important to recognize and comprehend the complications associated with RT. Some complications of RT have been reported in previous studies, such as lacerations of the heart, aorta, and avulsion of the aortic branches supplying blood to the mediastinum [5,6,7]. However, to our knowledge, there are no studies on the pathophysiology, incidence, and appropriate management of these complications and the percentage of these complications and related survival outcomes are unclear.
The complication reported in this case could have been prevented had the aortic clamp been applied with periaortic dissection under direct visualization of the aorta. However, it may be difficult to perform these procedures under emergent conditions. In this case, hemorrhage from the avulsion of aortic branches related to cross-clamping of the aorta was successfully controlled with TEVAR. To the best of our knowledge, this is the first report on TEVAR as a therapeutic modality for achieving hemostasis at the site of avulsion of aortic branches.