title: Intravascular ultrasound is a critical tool for accurate endograft sizing in the management of blunt thoracic aortic injury.
abstract: BACKGROUND
  Accurate measurement of true aortic luminal diameter (ALD) is critical for endograft sizing in endovascular treatment of blunt thoracic aortic injury (BTAI), but ALD is dynamic and changes with respect to patients' hemodynamic status. This study aimed to characterize how ALD at the time of diagnosis of BTAI compares with ALD at the time of endovascular repair and later at follow-up.
  
  
  METHODS
  This is an Institutional Review Board-approved, single-institution retrospective analysis of prospectively obtained data. Patients were included who presented between July 2007 and December 2012 with computed tomography angiography (CTA)-diagnosed BTAI; who underwent thoracic endovascular aortic repair (TEVAR); and who underwent preoperative CTA, intraoperative intravascular ultrasound (IVUS), and postimplantation CTA. Comparison measurements of the ALD were made among CTA and IVUS images at the level of the left subclavian artery (LSCA) and between initial CTA and postimplantation CTA at 10, 15, and 20 cm distal to the LSCA. Theoretical endograft sizes were determined and compared for each ALD at the LSCA.
  
  
  RESULTS
  Twenty-two patients were included in the analysis. Mean age was 38 ± 14 years (range, 17-61 years), with 82% men and mean Injury Severity Score of 43 ± 11 (range, 24-66). Mean time from emergency department admission to initial CTA was -1.2 ± 5 hours (range, -13 to 11.5 hours; negative time implies imaging at an outside facility before admission). Mean time from initial CTA to IVUS was 1.2 ± 1.4 days (range, 2.5 hours-5.7 days) and from IVUS to postimplantation CTA 33 ± 45 days (range, 17 hours-169 days). Overall, ALD measured by IVUS was significantly larger than that by initial CTA (Δ2.5 ± 3.1 mm; P < .05). ALD was also larger at 10, 15, and 20 cm distal to the LSCA in comparing the postimplantation CTA with the initial CTA (Δ2.4, 2.0, and 2.0 mm, respectively; all P < .05). More than half the devices would be sized differently with ALD measured by IVUS at the time of TEVAR vs initial CTA.
  
  
  CONCLUSIONS
  The ALD of patients with BTAI is significantly larger when it is measured by IVUS at the time of TEVAR compared with at the time of initial CTA. This difference in ALD may translate to undersizing of endografts used in TEVAR for BTAI. IVUS at the time of TEVAR provides a more accurate measurement of the actual ALD and should be used for endograft sizing for patients with BTAI.
authors.affiliation: Division of Vascular Surgery, Harborview Medical Center, Seattle, Wash.
authors.forename: Gabriel A
authors.initials: GA
authors.lastname: Wallace
authors.affiliation: Division of Vascular Surgery, Harborview Medical Center, Seattle, Wash.
authors.forename: Benjamin W
authors.initials: BW
authors.lastname: Starnes
authors.affiliation: Division of Vascular Surgery, Harborview Medical Center, Seattle, Wash.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Hatsukami
authors.affiliation: Division of Vascular Surgery, Harborview Medical Center, Seattle, Wash.
authors.forename: Michael
authors.initials: M
authors.lastname: Sobel
authors.affiliation: Division of Vascular Surgery, Harborview Medical Center, Seattle, Wash.
authors.forename: Niten
authors.initials: N
authors.lastname: Singh
authors.affiliation: Division of Vascular Surgery, Harborview Medical Center, Seattle, Wash. Electronic address: nam@uw.edu.
authors.forename: Nam T
authors.initials: NT
authors.lastname: Tran
mesh_terms: D000293:Adolescent; D000328:Adult; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging* / Q000293:injuries / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation*; D057510:Endovascular Procedures / Q000295:instrumentation*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D012189:Retrospective Studies; D013997:Time Factors; D061665:Time-to-Treatment; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D057772:Vascular System Injuries / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D014861:Washington; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D055815:Young Adult