Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia

Acute Traumatic Thoracic Aortic Injury: Considerations and Reflections on the Endovascular Aneurysm Repair

Traumatic rupture of the thoracic aorta is a life-threatening lesion and it occurs in 10 to 30% of fatalities from blunt thoracic trauma and is the second most common cause of death after head injury. Immediate surgery is often characterized by a high mortality and morbidity rate. Delayed repair of traumatic aortic injuries has significant survival benefits and a much lower mortality rate compared with early open repair. Despite developments in operative techniques, there still remains considerable operative mortality and morbidity associated with a surgical approach even if delayed. Endovascular stent grafts for the thoracic aorta represents an alternative to the conventional approach for traumatic aortic rupture. Because of the lower invasivity avoiding thoracotomy and use of heparin, endovascular repair can be applied in acute patients without the risk of destabilizing pulmonary, head or abdominal traumatic lesions. However, despite the good deal of convincing evidence for endovascular treatment for thoracic aortic diseases and for traumatic aortic injuries as a valid and efficacious alternative to surgery, several reports show a variety of late complications of thoracic endografts especially for first-generation stent-grafts. In light of this, is the endovascular treatment really safe, efficacious and free from complications in the long term? This manuscript aims to offer a moment of reflection on this important chapter of aortic pathology.

Trend of management of traumatic thoracic aortic injuries in a single center

The purpose of this study was to review the shift in the trend of management and mid-term outcomes of all patients who sustain thoracic aortic injury. A Retrospective analysis was performed of all patients sustaining blunt thoracic aortic trauma admitted to our unit. Forty-seven patients were presented with injury to the thoracic aorta following blunt chest injury. Ten patients underwent open surgical repair of their thoracic aortic injury. The mean age ± SD (range) was 29.4 ± 7.9 years (18-41) with a mean Injury Severity Score (ISS) of 41 ± 14.7 (25-75). Fifteen patients underwent thoracic endovascular repair for blunt aortic transections with a mean age of 35.1 ± 14.5 years (17-65), mean ISS of 40.8 ± 13.9 (20-75) and an average length of hospital stay of 25.6 ± 14.5 days (3-77). The mean aortic diameter proximal to the aortic injury was 23.46 ± 3.02 mm (19-28) with a mean aortic angulation of 58.46° ± 17.73 (44-80°). The mean oversizing was 24.4 ± 5.4% (17-32%). At our institution, there has been a paradigm shift in the emergent repair of blunt thoracic aortic injury from open surgery to endovascular repair. Oversizing of the stent-graft did not translate to a poorer outcome.

Evaluation of the outcome of traumatic thoracic aortic rupture in patients in a trauma and critical care center

OBJECTIVES

Multiple injuries may lead to traumatic thoracic aortic rupture (TTAR), which can be fatal. We evaluated the relationship between the clinical findings and outcomes of 26 patients with TTAR who were treated at our institution.

METHODS

A total of 26 patients (men, 21; women, 5; average age, 45.8 ± 19.6 years) with a diagnosis of TTAR received from 1999 to 2009 were studied. We categorized patients into groups based on the outcome (survival or death) and investigated the relationship between the outcome and the following factors: injury mechanism, vital signs, other combined injuries, injury severity score (ISS), revised trauma score, and probability of survival (Ps).

RESULTS

Of the 26 TTAR patients, 7 underwent emergency operations, 5 underwent delayed operations, 1 received conservative treatment, and 13 suffered cardiopulmonary arrest immediately after consultation and died. Of the 13 patients who died, 11 died within 2 hours after injury because of bleeding. Two of the 7 patients who underwent emergency operations died within 1 day of consultation, whereas all those who underwent delayed operations survived. Patients who underwent TTAR repair had a relatively favorable outcome. Analysis of the relationship between the clinical data and outcome showed that a young age was significantly correlated with survival, and that the Glasgow coma scale (GCS), heart rate, respiratory rate, or occurrence of shock were not significantly related to the outcome. The abbreviated injury scale (AIS) was used to score the severity of multiple injuries, and ISS was calculated from the AIS score. ISS was significantly higher in the death group (P = 0.007). ISS did not significantly differ among body parts (P = 0.077), but ISS of the extremities was higher than those of other parts. Pelvic fractures were frequent in the death group. Our strategy, whereby the patient initially underwent pelvic external fixation followed by TTAR repair was found to be very effective. The P-values calculated by the trauma and injury severity score method were significantly higher in the survival group (both, P = 0.007).

CONCLUSION

To treat TTAR, it is important to accurately evaluate the damage due to multiple injuries and apply an appropriate treatment strategy. Immediate repair of TTAR after bleeding due to combined injury improves the outcome. (English Translation of Jpn J Vasc Surg 2012; 21:5-9).

[Management of traumatic aortic rupture. About 37 cases]

OBJECTIVES

The aim of this study was to review our experience in the management of traumatic rupture of the aortic isthmus, to evaluate the results of surgery and endovascular exclusion and to develop an adequate therapeutic strategy based on the existence and severity of associated injuries.

MATERIAL

A series of 37 patients presenting posttraumatic aortic rupture associated with other severe lesions was collected from 2000 to 2012. There were 33 males and four females, mean age 38 years. In this series, 25 patients underwent surgical treatment and 12 endovascular exclusion.

RESULTS

Six patients died during or after surgery. Overall mortality was 16% (24% in the surgery group). The postoperative period was uneventful in all patients treated with the endovascular procedure. Postoperative computed tomography controls at one week, 1 month and 12 months showed good positioning of the stent without endoleakage.

CONCLUSION

Traumatic aortic rupture is often the result of a severe high-energy chest trauma. Other serious injuries are often associated. Results of immediate surgical repair are associated with high morbidity and mortality. The advent of endovascular treatment has revolutionized the treatment of traumatic aortic rupture, especially in patients with a high surgical risk.

[Surgical accesses to the major mediastinal vessels in thoracic trauma]

Trauma is the most common cause of death in the economically active population and thoracic trauma is directly or indirectly responsible for one quarter of these deaths. Lesions to the large thoracic vessels are associated with immediate or early death in the hospital setting. Patients admitted alive can be classified as stable or unstable. The access route to be elected for management of these veins will depend on this status, as well as on the anatomical particularities of the patient, which may require combined incisions for adequate access. This article provides a review and discussion of lesions to these structures as well as access routes to them.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.

[Endovascular treatment of traumatic ruptures of the thoracic aorta]

Traumatic rupture of the descending aorta is an acute life-threatening event. The most common cause is deceleration trauma resulting in a sudden stretching of the aortic isthmus as for example in car and motorcycle accidents and falls from a great height. Exemplified by a case report of a multiply injured 57-year-old male the diagnostic pathways, therapy and postoperative complications are presented.

[Intrathoracic injuries]

Severe intrathoracic injuries are uncommon but immediately life-threatening. These injuries are mostly associated with polytrauma. After stabilization of polytraumatized patients imaging is a prerequisite for treatment and operation planning. The assessment warrants an interdisciplinary approach primarily between the specialties of anesthesia, trauma surgery and thoracic surgery and further specialties should be involved depending on the injury pattern. This article gives an overview about the current management of the most important intrathoracic injuries.

Endovascular repair of thoracic aortic injury: current thoughts and technical considerations

Thoracic aortic traumatic injury is a highly morbid event. Mortality and paraplegia rates after emergent open repair remain high. Now, however, thoracic aortic endografting for trauma (TAET) is commonly used. It is appealing due to reduction of operative stress for the multiply injured trauma victim. This minimizing of stress and risk is secondary to avoidance of thoracotomy, single-lung ventilation, aortic cross-clamping, and the more complex anesthetic techniques required. Early and midterm results from TAET delineate improved outcomes, yet access and aortic constraints continue to challenge TAET. Questions regarding longer-term durability of endografts in younger patients remain unanswered. Broader application of TAET within endovascular programs is challenged by appropriate imaging, operating suite inventories, and the logistics and personnel required for TAET. Currently developed thoracic endograft devices are not ideal for TAET due to platform size and graft diameter. This is changing, however, as new modifications have been developed and trials are ongoing. In light of these collective factors, the management paradigm for traumatic aortic injury is beginning to favor TAET.

Hypothermic circulatory arrest for acute traumatic aortic rupture associated with shock

PURPOSE

Hypothermic circulatory arrest is considered to be a contraindication in acute traumatic aortic rupture (TAR) because full heparinization and hypothermia may lead to fatal bleeding if concomitant hemorrhagic injuries are present. However, in extremely emergent situations, rapid volume infusion via cardiotomy vacuums and the institution of hypothermic circulatory arrest appears to be the only method for saving patients with uncontrollable bleeding. In this study, we evaluate the feasibility of hypothermic circulatory arrest for treating patients with TAR with hemorrhagic shock.

METHODS

Ten patients (nine men and one woman; mean age, 35 ± 18 years), with acute TAR caused by blunt chest trauma and in a shock state, underwent surgery between 1999 and 2007. All ten patients exhibited rupture of the isthmus, and polytraumatism was frequent. Any life-threatening blood loss from other injuries was surgically treated before aortic surgery. All patients were operated on with standard cardiopulmonary bypass under hypothermic circulatory arrest.

RESULTS

All patients received prosthetic graft replacement. The overall hospital mortality was 10.0% (1/10). One patient died of intraabdominal and pulmonary bleeding during surgery, and the other nine were discharged without complications. There was no evidence of any new or increased hemorrhagic complications during heparinization in the nine surviving patients. Mean operation and circulatory arrest times were 305 ± 44 min and 27 ± 7 min, respectively.

CONCLUSION

Hypothermic circulatory arrest is feasible for saving TAR patients with unstable hemodynamics resulting from rupture, provided associated injuries are properly treated in advance.

[Acute traumatic thoracic aortic rupture in double localisation]

PURPOSE

Traumatic thoracic aortic rupture are commonly localised in one site essentially in the aortic isthmus but multiple localisation are not uncommon. The authors reported the case of a young man who had a double localisation of RTA after a violent car accident.

CASE REPORT

A 23-year-old man had a violent car crush involving sudden deceleration. He had multiple injuries essentially: a traumatic thoracic injury with acute posttraumatic aortic rupture in double localization, in the isthmus and in the descending thoracic aorta. He underwent thoracic endovascular aortic repair (TEVAR) with the use of stent graft three weeks after his car accident. The endovascular treatment was successful and no case of perigraft leakage has been detected during a meaning follow-up of five months.

CONCLUSION

The systematic analysis of the whole thoracic aortic vessel is crucial to not misdiagnose eventual multiple aortic rupture.

Injuries of the thoracic aorta and its branches

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Treating blunt aortic injuries with endografts: pros and cons of a meta-analysis

Modern management of blunt aortic injury (BAI) is based on evidence from mostly well-conducted meta-analyses as surrogates for prospective randomized controlled trials. There are several obvious pros and cons to this strategy. The advantages rest on the fact that it is unlikely that a prospective randomized trial comparing open surgical repair with endovascular repair will ever be conducted based on ethical grounds and the apparent survival advantage and reduced paraplegia rates associated with an endovascular approach; pooled data from high-volume studies provides for higher statistical power; and a well-conducted meta-analysis provides the ability to control for inter-study variation. The disadvantages of this approach are that meta-analyses are statistical examinations of scientific studies and not scientific studies in and of themselves; sources of bias cannot be controlled by the method of the analysis; and a heavy reliance on published studies can create exaggerated outcomes. Nonetheless, the studies reviewed in this article offer the best glimpse yet at the truth. The evidence grade to support endovascular over open repair for BAI is Level II (intermediate), which suggests that the described effect is plausible but is not quantified precisely or may be vulnerable to bias. The recommendation grade is B (provisional recommendation), which suggests that on balance of the evidence, endovascular repair for BAI is recommended with caution.

Tension hemothorax following endovascular thoracic aortic transection repair: case report

Thoracic aortic transection (TAT) is the second commonest cause of death from blunt trauma surpassed only by head injury and is associated with a mortality of 80% to 90%. The injury site is typically anteromedial at the aortic isthmus where differential shear forces act during rapid deceleration. The authors report a lateral aortic laceration managed by endovascular repair that required open thoracotomy for tension hemothorax resulting from an endoleak.

Clamp-and-Sew Technique for Traumatic Injuries of the Aorta: 20-Year Experience

Traumatic aortic injuries are associated with high morbidity and mortality, and the ideal operative approach for surgical management is unclear. We analyzed our results with the open clamp-and-sew technique over a 20-year period. Twenty patients with transected aorta were given interposition grafts; 19 of them had multisystem injuries. Mean aortic crossclamp time was 21.7 min (range, 12–30 min). Postoperative complications included pneumonia in 4 patients, acute renal failure in 1, recurrent laryngeal nerve injury in 2, chylothorax in 1, and sepsis of unknown etiology in one. There was no incidence of operation-related paraplegia. Although there was no 30-day mortality, one patient died after 90 days from diffuse axonal injuries to the brain. In experienced hands, the clamp-and-sew technique is effective and safe for the management of traumatic aortic transection.

Acute traumatic aortic injuries: posttherapy multidetector CT findings

Acute traumatic aortic injury is a life-threatening entity that requires emergent treatment. Treatment was once performed with left thoracotomy, resection of the damaged aortic segment, and placement of an interposition graft. Within the past decade, endovascular therapy has gained increased acceptance, primarily because of a significant decrease in mortality and morbidity compared with those of surgery. The authors reviewed the experience with management of acute traumatic aortic injuries at their institution, as well as that reported in the literature. Complications after endovascular repair include endoleak, endograft collapse, stroke, upper extremity ischemia, paraplegia, graft infection, endograft structural failure, missed injury or stent migration, and access site complications. After surgical repair, paraplegia and ischemia to other organs, graft dehiscence, graft infection, and graft stenosis may occur. With the growing use of endovascular management of acute traumatic aortic injuries and the increased likelihood of patient survival, the radiologist will be expected to be familiar with the findings in these patients and is positioned to play a critical role in early recognition of potential complications. Early diagnosis of the complications of therapy for aortic injury is imperative for reduction of mortality and morbidity.

Hybrid procedure for a traumatic aortic rupture consisting of endovascular repair and minimally invasive arch vessel transposition without sternotomy

Emergency surgical repair for acute traumatic aortic ruptures has been associated with a high peri-procedural mortality rate. Endovascular stent-grafting, as a less invasive procedure, has shown encouraging results. This report describes a patient with a short landing zone, who was treated by transposing the supra-aortic branch without sternotomy, followed by covered stent-grafting with an extended proximal bare portion to enhance fixation.

Vascular injuries after blunt chest trauma: diagnosis and management

Background

Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Methods

A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise.

Discussion

Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

Current management of traumatic rupture of the descending thoracic aorta

Traumatic rupture of the descending thoracic aorta remains a leading cause of death following major blunt trauma. Management has evolved from uniformly performing emergent open repair with clamp and sew technique to include open repair with mechanical circulatory support, medical management and most recently, endovascular repair. This latter approach appears, in the short term, to be associated with perhaps better outcome, but long term data is still accruing. While an attractive option, there are specific anatomic and physiologic factors to be considered in each individual case.

Endovascular treatment of blunt traumatic thoracic aortic injury

Blunt traumatic thoracic aortic injury (BTTAI) is a lethal injury associated with a prehospital mortality of 80% to 90%. Patients arriving in the emergency room and considered appropriate to undergo emergency open surgical repair still have a mortality rate of 15% to 30% because of severe associated injuries. Conventional open surgical repair requires a left thoracotomy, single lung ventilation, aortic-cross clamping and unclamping, with or without the adjunct use of partial or full cardiopulmonary bypass and systemic heparinization. All this leads to significant physiological stress and surgical trauma resulting in perioperative complications such as major blood loss, coagulopathy, myocardial infarction, stroke, respiratory failure, renal failure, bowel infarction, and paraplegia. Despite advances in anesthesia, critical care medicine, and surgical techniques, a recent meta-analysis showed no definite improvement in operative mortality over the past decade, following open surgical repair in patients with BTTAI. Endovascular repair of BTTAI does not require a thoracotomy, single lung ventilation, aorticcross clamping and unclamping, or systemic heparinization. As a result, endovascular repair of BTTAI has emerged as an effective, minimally invasive treatment alternative, especially in patients with severe concomitant injuries, which may be prohibitive to open surgical repair. Recent published studies have shown that endovascular repair of BTTAI is associated with lower morbidity, mortality, stroke, and paraplegia/paraparesis rates, when compared with open surgical repair of BTTAI.

Endovascular treatment of acute aortic isthmic rupture: concerning midterm results

BACKGROUND

We evaluated midterm results of endovascular management of traumatic aortic isthmic ruptures.

METHODS

Between 2001 and 2008, 10 patients (seven males, mean age 38 years) underwent endovascular treatment of an acute aortic rupture. Eight procedures were emergent, with four cases of hemodynamic instability with Glasgow scores of 3, 5, and 7. Associated traumas were severe brain, liver, and pelvic bone injuries. All procedures were performed with transoesophageal echocardiography monitoring. We used two AneuRx and nine Medtronic Talent or Valiant stent grafts.

RESULTS

All patients survived their traumatic isthmic rupture. In nine patients, stent-graft deployment was successful. One patient experienced a distal migration needing a laparotomy and deployment of an additional new thoracic stent graft. The mean intensive care unit stay was 48 hr (range 24-168). The mean hospital stay was 11 days (range 8-43). All patients were controlled clinically and by contrast computed tomography (CT) according to the EUROSTAR protocol. There were no endoleaks, stent graft-related complications, or late deaths during a mean follow-up of 49 months. The control CT showed a lack of apposition of the proximal part of the stent graft at the inner curve of the aortic arch in three patients.

CONCLUSION

The midterm results of endovascular treatment of acute traumatic aortic isthmic rupture are encouraging and compare favorably to the surgical approach. Late follow-up is required to exclude possible stent-graft complications, especially in young patients with angulated aortic arches.