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Bjurlin MA, Tanquilut EM, Subram A, Kalkounos P, Merlotti GJ. Endovascular Stent Graft Treatment of Acute Thoracic Aortic Transections Due to Blunt Force Trauma. Surg Innov 2009; 16:147-54. [DOI: 10.1177/1553350609335277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endovascular stent graft treatment of acute thoracic aortic transections is an encouraging minimally invasive alternative to open surgical repair. Between 2006 and 2008, 16 patients with acute thoracic aortic transections underwent evaluation at our institution. Seven patients who were treated with an endovascular stent graft were reviewed. The mean Glasgow Coma Score was 13.0, probability of survival was .89, and median injury severity score was 32. The mean number of intensive care unit days was 7.7, mean number of ventilator support days was 5.4, and hospital length of stay was 10 days. Mean blood loss was 285 mL, and operative time was 143 minutes. Overall mortality was 14%. Procedure complications were a bleeding arteriotomy site and an endoleak. Endovascular treatment of traumatic thoracic aortic transections appears to demonstrate superior results with respect to mortality, blood loss, operative time, paraplegia, and procedure-related complications when compared with open surgical repair literature.
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Affiliation(s)
- Marc A. Bjurlin
- Division of Traumay, St. James Hospital and Health Centers, Midwestern University, Olympia Fields, Illinois
| | - Eugene M. Tanquilut
- Division of Vascular Surgery Department of Surgery, St. James Hospital and Health Centers, Midwestern University, Olympia Fields, Illinois
| | - Aswath Subram
- Division of Vascular Surgery Department of Surgery, St. James Hospital and Health Centers, Midwestern University, Olympia Fields, Illinois
| | - Peggy Kalkounos
- Division of Traumay, St. James Hospital and Health Centers, Midwestern University, Olympia Fields, Illinois
| | - Gary J. Merlotti
- Division of Traumay, St. James Hospital and Health Centers, Midwestern University, Olympia Fields, Illinois,
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Abstract
Multidetector CT is very useful in the evaluation of polytrauma patients. MDCT is valuable for the detection and treatment planning of vascular injuries, but it may not be available to hemodynamically unstable patients. Embolization of visceral and parietal branches of the aorta benefits from advances in catheter technology: hydrophilic catheters and microcatheters are very helpful in this context. Resorbable particles (such as gelatin) and coils are the most useful occlusive agents. Endovascular stenting of aortic rupture is nowadays considered in many centers as the best therapeutic option and can be proposed as an alternative to surgery.
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103
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[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]. Anaesthesist 2009; 57:782-93. [PMID: 18463834 DOI: 10.1007/s00101-008-1375-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.
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Abstract
INTRODUCTION Interest for traumatic thoracic aorta rupture stems from the fact that its number continually increases, and it can be rapidly lethal. OBJECTIVE The aim of this study is to present early and long term results as well as experiences of our team in surgical treatment of traumatic thoracic aorta rupture. METHOD Our retrospective study includes 12 patients with traumatic thoracic aorta rupture treated between 1985 and 2007.There were 10 male and two female patients of average age 30.75 years (18-74). RESULTS In six cases, primary diagnosis was established during the first seven days days after trauma, while in 6 more than one month later. In 11 cases, classical open surgical procedure was performed, while endovascular treatment was used in one patient. Three (25%) patients died, while two (16.6%) had paraplegia. Nine patinets (75%) were trated without complications, and are in good condition after a mean follow-up period of 9.7 years (from one month to 22 years). CONCLUSION Surgical treatment requires spinal cord protection to prevent paraplegia, using cardiopulmonary by-pass (three of our cases) or external heparin-bonded shunts (five of our cases). Cardiopulmonary by-pass is followed with lower incidence of paraplegia, however it is not such a good solution for patients with polytrauma because of haemorrhage. The endovascular repair is a safe and feasible procedure in the acute phase, especilly because of traumatic shock and polytrauma which contributes to higher mortality rate after open surgery. On the other hand, in chronic postrauamatic aortic rupture, open surgical treatment is connected with a lower mortality rate and good long-term results. There have been no published data about long-term results of endovascular treatment in the chronic phase.
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105
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Alsac JM, Boura B, Desgranges P, Fabiani JN, Becquemin JP, Leseche G. Immediate endovascular repair for acute traumatic injuries of the thoracic aorta: A multicenter analysis of 28 cases. J Vasc Surg 2008; 48:1369-74. [DOI: 10.1016/j.jvs.2008.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 07/08/2008] [Accepted: 07/11/2008] [Indexed: 10/21/2022]
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106
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Botta L, Russo V, Savini C, Buttazzi K, Pacini D, Lovato L, La Palombara C, Parlapiano M, Di Bartolomeo R, Fattori R. Endovascular treatment for acute traumatic transection of the descending aorta: Focus on operative timing and left subclavian artery management. J Thorac Cardiovasc Surg 2008; 136:1558-63. [DOI: 10.1016/j.jtcvs.2008.07.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 04/23/2008] [Accepted: 07/26/2008] [Indexed: 10/21/2022]
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107
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108
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Xenos ES, Abedi NN, Davenport DL, Minion DJ, Hamdallah O, Sorial EE, Endean ED. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008; 48:1343-51. [DOI: 10.1016/j.jvs.2008.04.060] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 03/25/2008] [Accepted: 04/25/2008] [Indexed: 10/21/2022]
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109
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Abstract
The management of thoracic vascular injury has improved dramatically over the past two decades. The availability of multi-row detector CT has facilitated early diagnosis and incorporation of minimally invasive endograft repair for traumatic aortic injury has improved mortality and paraplegia rates. This review evaluates the available data on stent-graft repair of acute blunt traumatic aortic injury and traumatic great vessel injury with regard to safety and efficacy in comparison with conventional open surgical repair.
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Affiliation(s)
- Eric K Hoffer
- Department of Radiology, Section of Vascular and Interventional Radiology, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756, United States.
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110
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Affiliation(s)
- David G Neschis
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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111
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Kische S, Akin I, Ince H, Rehders TC, Schneider H, Ortak J, Nienaber CA. Reparación mediante implantación de stents en enfermedades agudas y crónicas de la aorta torácica. Rev Esp Cardiol 2008. [DOI: 10.1157/13126047] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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112
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Endovascular repair of traumatic thoracic aortic disruptions with “stacked” abdominal endograft extension cuffs. J Vasc Surg 2008; 48:841-4. [DOI: 10.1016/j.jvs.2008.05.055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Revised: 05/14/2008] [Accepted: 05/14/2008] [Indexed: 11/19/2022]
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113
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Lin HL, Lee WC, Chen CW, Kuo LC, Chan HM. Delayed surgery in a complex trauma patient with aortic rupture, blunt head trauma and liver laceration: a case report. Kaohsiung J Med Sci 2008; 24:270-3. [PMID: 18508425 DOI: 10.1016/s1607-551x(08)70152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Aortic rupture is a critical condition in trauma patients. Most patients are killed at the scene of the accident. A patient who survives long enough to reach hospital also has a high risk of rupture during management. We report a patient who was transferred from a municipal hospital with the emergency complex of blunt head trauma and chest and abdominal contusion. Chest computed tomography scan revealed aortic rupture. Liver laceration with hemodynamic stability and brain concussion were also diagnosed in the emergency room. She was admitted to the trauma intensive care unit without emergency surgery. She received aorta repair after 5 days of observation. After the operation, the patient recovered very well. Delayed surgery for aortic rupture as a treatment choice may be of benefit in selected complex trauma cases.
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Affiliation(s)
- Hsing-Lin Lin
- Department of Trauma, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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114
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Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular Stent-Graft or Open Surgical Repair for Blunt Thoracic Aortic Trauma: Systematic Review. J Vasc Interv Radiol 2008; 19:1153-64. [DOI: 10.1016/j.jvir.2008.05.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 05/10/2008] [Accepted: 05/18/2008] [Indexed: 10/21/2022] Open
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115
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Lin PH, Huynh TT, Kougias P, Wall MJ, Coselli JS, Mattox KL. Endovascular Repair of Traumatic Thoracic Aortic Injuries: A Critical Appraisal. Asian Cardiovasc Thorac Ann 2008; 16:337-45. [DOI: 10.1177/021849230801600419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blunt trauma to the thoracic aorta is life-threatening, with instant fatality in at least 75% of victims. If left untreated, nearly half of those who survive the initial injury will die within the first 24 hours. Surgical repair has been the standard treatment of blunt aortic injury, but immediate operative intervention is frequently difficult due to concomitant injuries. Although endovascular treatment of traumatic aortic disruption is less invasive than conventional repair via thoracotomy, this strategy remains controversial in young patients due to anatomical considerations and device limitations. This article reviews the likely advantages of endovascular interventions for blunt thoracic aortic injuries. Potential limitations and clinical outcomes of this minimally invasive technique are also discussed.
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Affiliation(s)
- Peter H Lin
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Tam T Huynh
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Panagiotis Kougias
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Mathew J Wall
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Ben Taub General Hospital Houston, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Texas Heart Institute at St. Luke's Episcopal Hospital
| | - Kenneth L Mattox
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Ben Taub General Hospital Houston, USA
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116
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Mohan I, Hitos K, White G, Harris J, Stephen M, May J, Swinnen J, Fletcher J. Improved Outcomes with Endovascular Stent Grafts for Thoracic Aorta Transections. Eur J Vasc Endovasc Surg 2008; 36:152-157. [DOI: 10.1016/j.ejvs.2008.03.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 03/28/2008] [Indexed: 11/30/2022]
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117
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Retrograde embolization of the left vertebral artery in a type II endoleak after endovascular treatment of aortic thoracic rupture: technical note. Cardiovasc Intervent Radiol 2008; 32:169-73. [PMID: 18661175 DOI: 10.1007/s00270-008-9397-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 06/25/2008] [Accepted: 07/01/2008] [Indexed: 10/21/2022]
Abstract
Endoleak is a frequent complication after endovascular repair of aortic rupture. We describe the case of a female patient with traumatic aortic injury, treated with endograft, who developed a type II endoleak through the left subclavian and vertebral arteries. Both arteries originated independently from the aortic arch, and were managed with coil embolization of each vessel. We also report our experience with treating the left vertebral artery by placing a microcatheter through the right vertebral one.
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118
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Navid F, Gleason TG. Great vessel and cardiac trauma: diagnostic and management strategies. Semin Thorac Cardiovasc Surg 2008; 20:31-8. [PMID: 18420124 DOI: 10.1053/j.semtcvs.2007.11.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2007] [Indexed: 11/11/2022]
Abstract
Blunt and penetrating trauma to the chest can result in great vessel or cardiac injury. Both the diagnosis and management of these thoracic injuries have evolved from more invasive to less invasive strategies paralleling the advent of sophisticated imaging tools and the development of endovascular therapies. Despite these advances, conventional open repair and reconstruction techniques remain important and are often the definitive means toward effective management of these severely injured patients. The following review outlines the historical perspective, diagnosis, and management of blunt thoracic aortic, blunt cardiac, and penetrating cardiac injuries.
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Affiliation(s)
- Forozan Navid
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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119
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Methodius-Ngwodo WC, Burkett AB, Kochupura PV, Wellons ED, Fuhrman G, Rosenthal D. The Role of CT Angiography in the Diagnosis of Blunt Traumatic Thoracic Aortic Disruption and Unsuspected Carotid Artery Injury. Am Surg 2008; 74:580-5; discussion 585-6. [DOI: 10.1177/000313480807400703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We have replaced aortography and open thoracic surgery to diagnose and treat blunt traumatic thoracic aortic disruption (TTAD) in favor of CT angiography (CTA) and endovascular repair. The purpose of this study is to review our experience with the management and outcomes of TTAD and associated carotid artery injuries. In January 2003, we initiated a protocol that used CTA to evaluate all patients with suspected TTAD from blunt trauma. When TTAD was diagnosed, patients were managed by endovascular repair using abdominal aortic extension cuffs. Twenty-nine patients with TTAD were managed by endovascular repair. In all patients, abdominal endograft extension cuffs successfully excluded the traumatic disruptions. Six (21%) of these patients had concomitant, unsuspected carotid artery injury diagnosed by CTA. One patient had bilateral carotid artery dissections, sustained irreversible brain injury, and died. Four patients with common carotid dissections were successfully treated by anticoagulation and made uneventful recoveries. One patient with a common carotid–innominate artery dissection and pseudoaneurysm underwent endovascular repair. This study indicates that CTA and endovascular repair provide accurate diagnostic and therapeutic results in the management of blunt TTAD. Furthermore, CTA should include arch and cervical views to detect an unsuspected, concomitant carotid artery injury.
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Affiliation(s)
| | - Allison B. Burkett
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - Paul V. Kochupura
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - Eric D. Wellons
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - George Fuhrman
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - David Rosenthal
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
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120
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Pérez LR, Chan GK. Clinical decision making and management of blunt traumatic thoracic aortic injuries. Air Med J 2008; 27:139-43. [PMID: 18456176 DOI: 10.1016/j.amj.2008.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2007] [Revised: 01/09/2008] [Accepted: 01/30/2008] [Indexed: 11/19/2022]
Affiliation(s)
- Leanne R Pérez
- Stanford Hospital and Clinics, Stanford Life Flight, Stanford, CA 94305-5246, USA.
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121
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Moainie SL, Neschis DG, Gammie JS, Brown JM, Poston RS, Scalea TM, Griffith BP. Endovascular Stenting for Traumatic Aortic Injury: An Emerging New Standard of Care. Ann Thorac Surg 2008; 85:1625-9; discussion 1629-30. [DOI: 10.1016/j.athoracsur.2008.01.094] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Revised: 01/24/2008] [Accepted: 01/28/2008] [Indexed: 11/27/2022]
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122
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Canaud L, Alric P, Branchereau P, Marty-Ané C, Berthet JP. Lessons learned from midterm follow-up of endovascular repair for traumatic rupture of the aortic isthmus. J Vasc Surg 2008; 47:733-8. [PMID: 18381134 DOI: 10.1016/j.jvs.2007.12.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 11/29/2007] [Accepted: 12/06/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Ludovic Canaud
- Department of Vascular and Thoracic Surgery, Hospital A de Villeneuve, Montpellier, France.
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123
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Abstract
PURPOSE OF REVIEW Trauma remains a leading cause of death across all age groups. Thoracic injury is a contributing cause in approximately half of these. Despite being potentially life threatening, most thoracic trauma is managed nonoperatively or with an intercostal catheter. Only 10% of thoracic trauma patients will require emergency thoracotomy. Many more will undergo emergency or urgent surgical intervention for coexisting injuries. Thoracic injuries are dynamic. It is crucial for the anesthesiologist to continually reassess the patient, so that the manifestations of evolving injuries may be detected as early as possible and appropriate management decisions made. Up-to-date knowledge of injury patterns, mechanisms, pathophysiology, and operative and nonoperative management will facilitate optimal management of these patients. RECENT FINDINGS There is recent literature discussing the surgical, anesthetic and critical care management of a range of thoracic injuries resulting from either blunt or penetrating trauma. SUMMARY Initial resuscitation and surgical management of patients with thoracic trauma continue to evolve. Improvements in prehospital care and diagnostic techniques as well as development of minimally invasive interventions mean that the anesthesiologist may be required to provide care to unstable patients in an expanded range of scenarios and environments.
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Affiliation(s)
- John T Moloney
- Department of Anaesthesia and Perioperative Medicine, The Alfred, Melbourne, Victoria, Australia.
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124
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Reddy VS. Minimally Invasive Techniques in Thoracic Trauma. Semin Thorac Cardiovasc Surg 2008; 20:72-7. [DOI: 10.1053/j.semtcvs.2008.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2008] [Indexed: 11/11/2022]
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125
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Lesèche G, Alsac JM, Castier Y. Rupture aiguë post-traumatiquede l’isthme aortique. JOURNAL DE CHIRURGIE 2008; 145:115-21. [PMID: 18645550 DOI: 10.1016/s0021-7697(08)73719-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- G Lesèche
- Service de chirurgie vasculaire, thoracique et transplantation pulmonaire, hôpital Bichat-Claude-Bernard, AP-HP, Université Paris-7, Denis-Diderot - Paris.
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126
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Vascular Trauma. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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127
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Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, Eggebrecht H, Elefteriades JA, Erbel R, Gleason TG, Lytle BW, Mitchell RS, Nienaber CA, Roselli EE, Safi HJ, Shemin RJ, Sicard GA, Sundt TM, Szeto WY, Wheatley GH. Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts⁎⁎Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts has been supported by Unrestricted Educational Grants from Cook, Inc and Medtronic, Inc. Ann Thorac Surg 2008; 85:S1-41. [PMID: 18083364 DOI: 10.1016/j.athoracsur.2007.10.099] [Citation(s) in RCA: 553] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 10/17/2007] [Accepted: 10/18/2007] [Indexed: 01/15/2023]
Affiliation(s)
- Lars G Svensson
- Center for Aortic Surgery and Marfan Syndrome Clinic, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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128
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Is Distal Aortic Perfusion in Traumatic Thoracic Aortic Injuries Necessary to Avoid Paraplegic Postoperative Outcomes? ACTA ACUST UNITED AC 2008; 64:115-20. [DOI: 10.1097/ta.0b013e3180413e13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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129
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Go MR, Barbato JE, Dillavou ED, Gupta N, Rhee RY, Makaroun MS, Cho JS. Thoracic endovascular aortic repair for traumatic aortic transection. J Vasc Surg 2007; 46:928-33. [PMID: 17980279 DOI: 10.1016/j.jvs.2007.06.049] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Revised: 06/20/2007] [Accepted: 06/22/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND Traumatic transection of the thoracic aorta is a highly morbid injury. Treatment may be delayed while attention focuses on concomitant injuries. Thoracic endovascular aortic repair (TEVAR) is effective but remains controversial in these often-young patients. We reviewed our experience in acute and subacute treatment of these injuries with TEVAR. METHODS A retrospective analysis of five men and five women who underwent TEVAR for aortic transection from 1999 to 2007 was conducted. Procedures were performed with standard endovascular techniques. Follow-up included computed tomography at 1 month and yearly thereafter. RESULTS Mean age was 44 years (range, 20 to 84 years). Motor vehicle accidents accounted for 7 injuries, a snowmobile accident for 1, skydiving for 1, and balloon angioplasty of a coarctation for 1. Average diameter of the proximal landing zone was 25 mm (range, 23 to 29 mm). Mean external iliac size was 10 mm (range, 7 to 15 mm), and no conduits were required. Immediate technical success was 90%, with no 30-day mortality. Seven patients underwent repair acutely (< or =24 hours) and three patients subacutely (range, 4 days to 2 months) for pseudoaneurysm. Four patients had procedures for concomitant injuries before their transection was repaired (3 laparotomies and a fixation for open fracture). One endoleak was noted, which resolved by the 1-month follow-up. The lone device-related complication was an endograft collapse at 5 months managed by repeat endografting, which was complicated by aortoesophageal fistula requiring esophagectomy and open reconstruction. No iliac injuries occurred. At 20-months of mean follow-up (range, 2 to 70 months), all patients are alive and well. CONCLUSIONS TEVAR for traumatic aortic transection is feasible, with good initial success. Repair can be delayed in selected cases. Continued surveillance is necessary to ensure good long-term outcomes in these young patients. Care must be taken when performing TEVAR for this off-label indication because these devices are designed for the larger aortic diameters of aneurysm patients.
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Affiliation(s)
- Michael R Go
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical School, Pittsburgh, PA 15213, USA
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130
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Orend KH, Zarbis N, Schelzig H, Halter G, Lang G, Sunder-Plassmann L. Endovascular Treatment (EVT) of Acute Traumatic Lesions of the Descending Thoracic Aorta – 7 Years' Experience. Eur J Vasc Endovasc Surg 2007; 34:666-72. [PMID: 17716933 DOI: 10.1016/j.ejvs.2007.06.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 06/29/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To present a single centers' 7-year experience in the endovascular treatment of acute traumatic lesions of the descending thoracic aorta (ATL of the DTA). MATERIALS & METHODS Between March 1999 and December 2006, 34 consecutive acute traumatic lesions of the descending aorta (23 men, mean age 44 years) were treated endovascularly. Stentgrafts used were TAG Excluder, Zenith TX2 and Talent. In 23 patients the Left Subclavian Artery (LSA) was covered. Mean procedural duration was 20 to 75 minutes. RESULTS Exclusion of the rupture site was achieved in all cases with no conversion to open surgery. Overall 30-day mortality was 8.8%. Two patients died on post operative day (pod) 1 and one on pod 22 from cranial injuries. No death or neurological deficit related to the endovascular treatment was reported. Four type I endoleaks required treatment either by balloon reexpansion (n=2) or by additional stentgraft implantation (n=2). In two patients the stentgraft collapsed totally several days postoperatively. Two patients required secondary surgical procedures (iliac access complication and revascularisation of the left subclavian artery n=1). The average follow-up was 43.8 months (1-93 months). No stentgraft related abnormality has been subsequently documented. CONCLUSIONS The endovascular treatment of ATL of the DTA may offer the best means of therapy in a polytrauma patient.
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Affiliation(s)
- K H Orend
- Department of Thoracic and Vascular Surgery, University Hospital Ulm, Germany.
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131
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Kokotsakis J, Kaskarelis I, Misthos P, Athanasiou T, Kanakakis K, Athanasiou C, Romana C, Skouteli E, Lioulias A. Endovascular Versus Open Repair for Blunt Thoracic Aortic Injury: Short-Term Results. Ann Thorac Surg 2007; 84:1965-70. [DOI: 10.1016/j.athoracsur.2007.07.061] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Revised: 07/21/2007] [Accepted: 07/23/2007] [Indexed: 11/29/2022]
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132
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Bent CL, Matson MB, Sobeh M, Renfrew I, Uppal R, Walsh M, Brohi K, Kyriakides C. Endovascular management of acute blunt traumatic thoracic aortic injury: A single center experience. J Vasc Surg 2007; 46:920-7. [PMID: 17905557 DOI: 10.1016/j.jvs.2007.07.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 07/07/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Traumatic injury of the thoracic aorta is a life-threatening complication in patients who sustain deceleration or crush injuries. The magnitude of force necessary to cause blunt thoracic aortic injury results in a high proportion of concomitant injuries, posing a significant challenge for prioritizing management. Open surgical mortality is increased in the presence of coexisting head, lung, and abdominal injuries. Spinal cord ischemia may occur following aortic cross-clamping and operative hypotension. Endovascular stent-graft placement offers a safe, effective, and timely treatment option. The aim of this study was to assess our single center experience of endovascular repair following acute blunt traumatic aortic injury. METHODS Data from thirteen consecutive patients (mean age, 43.2 years; range, 16 to 84 years) with acute blunt traumatic aortic injury treated by endovascular stent-graft insertion between October 2001 and March 2007 was prospectively collected. Demographics, injury characteristics, technique, and complications were recorded. Follow-up data consisted of computed tomographic angiography and plain chest radiography at regular intervals. Mean and median follow-up after stent-graft implantation were 28.9 and 29 months, respectively. RESULTS All patients underwent endovascular repair within a median of 9 hours from hospital presentation. Two patients underwent carotico-carotid bypass immediately prior to endovascular stenting during a single anesthetic. Stent-graft implantation was technically successful in all patients. No patient required conversion to open surgical repair of the acute blunt traumatic aortic injury. Procedure-related paraplegia was zero. Complications included proximal migration of initial stent-graft in one patient and iliac artery avulsion in another patient with consequent ilio-femoral bypass. The median hospital stay was 17 days. There were no in-hospital deaths. CONCLUSION Endovascular repair is evolving as the procedure of choice for acute blunt traumatic aortic injury. Treatment of lesions that extend into the aortic arch is feasible with extra-anatomical bypass. In our study, endovascular repair of blunt traumatic aortic injury is a safe procedure with low morbidity and a mortality rate of zero.
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Affiliation(s)
- Clare L Bent
- Department of Radiology, Barts and The London NHS Trust, London, United Kingdom
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133
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Pitton MB, Herber S, Schmiedt W, Neufang A, Dorweiler B, Düber C. Long-Term Follow-Up After Endovascular Treatment of Acute Aortic Emergencies. Cardiovasc Intervent Radiol 2007; 31:23-35. [PMID: 17943352 DOI: 10.1007/s00270-007-9175-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Revised: 07/12/2007] [Accepted: 08/29/2007] [Indexed: 11/30/2022]
Affiliation(s)
- M B Pitton
- Department of Diagnostic and Interventional Radiology, University Hospital of Mainz, Johannes Gutenberg University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
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134
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Marty B, Tozzi P, Ruchat P, Huber C, Doenz F, von Segesser LK. An IVUS-Based Approach to Traumatic Aortic Rupture, With a Look at the Lesion From Inside. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[689:aiatta]2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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135
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136
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Akowuah E, Baumbach A, Wilde P, Angelini G, Bryan AJ. Emergency repair of traumatic aortic rupture: Endovascular versus conventional open repair. J Thorac Cardiovasc Surg 2007; 134:897-901. [PMID: 17903503 DOI: 10.1016/j.jtcvs.2007.06.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 06/05/2007] [Accepted: 06/15/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Our objective was to compare early results of endovascular stenting for traumatic aortic rupture with conventional open repair. METHODS We conducted a retrospective review of consecutive cases of traumatic aortic rupture in a single institution from July 2000 to July 2006. RESULTS Fifteen cases were identified. The mean injury severity score was 43 +/- 10. Fourteen patients had the procedure within 24 hours of admission to the hospital. Seven patients underwent endovascular stenting and 8 underwent open repair. For endovascular stenting, there were no failed procedures, no periprocedural complications, and no periprocedural deaths. In 6 patients, there was no evidence of endoleak, stent migration, or late pseudoaneurysm formation. One patient required a second stent 2 years later to treat a stenosis in the original stent. For open repair, cardiopulmonary bypass was used in 7 of the 8 patients. Lower limb paraplegia developed postoperatively in 1 patient and another patient died of head injuries. There was a significant reduction in the mean duration of the procedure (2.2 +/- 0.90 vs 5 +/- 3.2 hours; P = 0.04), the mean intraoperative blood loss (311 +/- 20 vs 953 +/- 20 mL; P = .02), the mean number of units of blood and blood products used (0.43 +/- 1.1 vs 3 +/- 3 units; P = .026), and the mean dose of heparin required (5000 +/- 1700 vs 24,000 +/- 7500 IU; P = .001) in the endovascular stenting group. There was no difference in duration of ventilation, intensive treatment unit, or hospital stay. CONCLUSIONS Endovascular stenting is technically feasible and applicable to a range of cardiac patients. It takes less time than open repair, requires less heparin and blood products, and therefore simplifies management of other injuries. In hemodynamically stable patients, endovascular stenting is the treatment of choice for traumatic aortic rupture.
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Affiliation(s)
- Enoch Akowuah
- Department of Cardiothoracic Surgery, Bristol Heart Institute at the Bristol Royal Infirmary, Bristol, United Kingdom
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137
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Midgley PI, Mackenzie KS, Corriveau MM, Obrand DI, Abraham CZ, Fata P, Steinmetz OK. Blunt thoracic aortic injury: A single institution comparison of open and endovascular management. J Vasc Surg 2007; 46:662-8. [PMID: 17764869 DOI: 10.1016/j.jvs.2007.05.061] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 05/31/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To review the treatment of blunt thoracic aortic injuries (BAI) at a single institution over the past 12 years and compare pre-, peri-, and postoperative variables and outcomes of both open (OR) and thoracic endovascular (TEVAR) repair of these injuries. METHODS All cases of confirmed BAI from 1994 to present were included in this retrospective review. Data collected included demographic data, injury severity score, Glasgow coma score, arrival hemodynamic variables, and associated injuries. Operative data included: type of procedure (OR or TEVAR), duration of procedure, need for and amount of blood transfused, use of anticoagulation, type of anesthesia, and service performing the procedure. Outcomes evaluated were: death, paraplegia, length of stay, days ventilated, and procedure related complications. Specific to EVAR; access, stent graft type and number, presence of endoleak and long-term clinical and radiologic follow-up were evaluated. RESULTS Thirty cases of blunt thoracic aortic injury were identified. Two patients received no treatment and died, 28 patients were treated (OR 16, TEVAR 12) and included for comparison. There were no significant differences between groups with respect to preoperative variables with the exception of significantly more associated intra-abdominal injuries in the TEVAR group (P = .03). Five patients in the OR group (31.2%) died in the perioperative period. There were no deaths in the TEVAR group (P =.05). One OR patient (6.25%) suffered postoperative paraplegia. No paraplegia occurred in the TEVAR group. Intraoperative variables were similar between groups with the exception of mean units of blood transfused (OR 8.5 units, vs TEVAR 0.2 units, P = .002). Ten patients in the OR group either died or had a procedure related complication compared with none in the TEVAR group (P = .001). There was no difference in length of stay or length of mechanical ventilation between the groups. There were no procedure or device related complications in the TEVAR group during follow-up (mean 15.3 months, range 1 to 53.5 months). CONCLUSIONS Endovascular repair of BAI results in significantly less combined mortality and morbidity when compared to OR. Significantly less blood is needed intraoperatively in the TEVAR group. No complications from stent graft insertion have been observed during follow-up. Endovascular repair is replacing open repair as the treatment of choice for BAI at our institution.
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Affiliation(s)
- Peter I Midgley
- Division of Vascular Surgery, McGill University, Montreal, Quebec, Canada
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138
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Rodd CD, Desigan S, Hamady MS, Gibbs RG, Jenkins MP. Salvage options after stent collapse in the thoracic aorta. J Vasc Surg 2007; 46:780-5. [PMID: 17903654 DOI: 10.1016/j.jvs.2007.03.059] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 03/01/2007] [Indexed: 11/25/2022]
Abstract
The endograft was originally developed to repair aneurismal disease of the infra-renal aorta and has since realised many other applications, including the treatment of arterial trauma. Traumatic transection of the thoracic aorta is a condition associated with a high mortality and affected patients often have multiple injuries. Endovascular repair of thoracic transection is an attractive option in those patients for whom open surgical repair would be highly dangerous and other groups have reported early technical success. However, we report 3 cases of young patients with traumatic thoracic aortic transection, initially treated successfully by endoluminal stenting, who developed the complication of stent collapse. We discuss here the options available to treat the complication.
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Affiliation(s)
- Caroline D Rodd
- Regional Vascular Unit, St. Mary's NHS Trust, London, United Kingdom.
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139
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Arslan B, Turba UC, Matsumoto AH. Thoracic aortic endograft collapse after endovascular treatment of a traumatic pseudoaneurysm. Semin Intervent Radiol 2007; 24:279-87. [PMID: 21326469 DOI: 10.1055/s-2007-985735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Aortic endograft placement is evolving into the standard of care for treatment of patients with anatomically suitable thoracic aortic aneurysms. Application of this technique and these devices in other thoracic aortic pathology, such as traumatic pseudoaneurysms, symptomatic type B aortic dissections, penetrating ulcers, and even mycotic aneurysms, appears to be promising. We report a case in which a stent graft was used to treat a post-traumatic pseudoaneurysm of the thoracic aorta. The case was complicated by delayed collapse of the endograft, which led to hypoperfusion of the extremities, kidneys, and intestines. Reestablishment of endograft patency and distal reperfusion was achieved by placement of two balloon-expandable stents within the endograft. Potential factors leading to the development of this complication are discussed.
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Affiliation(s)
- Bulent Arslan
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia
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140
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Gawenda M, Aleksic M, Reichert V, Jubel A, Gossmann A, Brunkwall J. Stent Grafts for Acute Traumatic Injury of the Thoracic Aorta: A Single-Centre Experience. Eur J Trauma Emerg Surg 2007; 33:388-94. [PMID: 26814732 DOI: 10.1007/s00068-007-7007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 06/03/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The presented study reveals the single centre experiences with the minimally invasive endovascular repair for acute traumatic thoracic aortic lesions in the care of multitrauma patients. METHODS We reviewed ten patients with acute traumatic thoracic aortic lesions treated with a thoracic aortic stent graft between April 2001 and December 2006. The prospective collected data included age, sex, injury severity score, type of endovascular graft, endovascular operation time, length of stay, length of stay in the intensive care unit, and mortality. Followup data consisted of contrast-enhanced spiral computed tomography at regular intervals. RESULTS All patients (m:f 5:5; median age, 46 years; interquartile range [IQR], 29-68.5 years) suffered severe traumatic injury, the median Injury Severity Score was 39.5 (IQR 37.3-43). All endovascular procedures were technically successful, and the median operating time for the endovascular procedure was 90 min (IQR, 65-120 min). The overall hospital mortality was 20% (n = 2), and all deaths were unrelated to the aortic rupture or stent placement. No incidence of paraplegia was present. No intervention-related mortality occurred during a median follow-up of 14.7 months (IQR, 9.7-55.8 months). CONCLUSION The endovascular approach to acute traumatic thoracic aortic lesions is feasible, safe, and effective in multitrauma patients. The low endovascular therapy-related morbidity and mortality in the postoperative period is encouraging. The results seem to be favorable to those published of open emergency repair.
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Affiliation(s)
- Michael Gawenda
- Division of Vascular Surgery, Medical Centre University of Cologne, Cologne, Germany. .,Division of Vascular Surgery, Medical Centre University of Cologne, Kerpener Strasse 62, 50924, Cologne, Germany.
| | - Marko Aleksic
- Division of Vascular Surgery, Medical Centre University of Cologne, Cologne, Germany
| | - Viktor Reichert
- Division of Vascular Surgery, Medical Centre University of Cologne, Cologne, Germany
| | - Axel Jubel
- Department of Trauma Surgery, Medical Centre University of Cologne, Cologne, Germany
| | - Axel Gossmann
- Institute of Radiology, Medical Centre University of Cologne, Cologne, Germany
| | - Jan Brunkwall
- Division of Vascular Surgery, Medical Centre University of Cologne, Cologne, Germany
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141
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Asmat A, Lee CN, Robless P. Thoracic stent graft versus surgery for traumatic thoracic transection. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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142
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Kische S, Rehders TC, Akin I, Ince H, Nienaber CA. Role of interventional repair in the thoracic aorta. Future Cardiol 2007; 3:399-412. [PMID: 19804231 DOI: 10.2217/14796678.3.4.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Endovascular treatment of chronic aneurysmatic diseases of the descending thoracic aorta has demonstrated encouraging peri-interventional mortality and morbidity and is accepted as a preferred strategy in experienced centers. The emergence of endovascular strategies for acute thoracic aortic pathologies is an even more exciting new territory for nonsurgical interventions considering the sobering results of open surgery. Although it is apparent that patients at high risk for open surgery will benefit from endovascular strategies, the exact role of stent-graft placement remains to be defined, as the community awaits solid long-term data and as devices and techniques continue to improve. While some indications and scenarios, such as acute type B dissection with associated malperfusion syndrome or imminent aortic rupture, have been shown to benefit from stent-graft treatment, others are less settled. The current paper discusses both the established and emerging indications, as well as technical and anatomical aspects of this fascinating therapeutic option.
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Affiliation(s)
- Stephan Kische
- Rostock School of Medicine, Division of Cardiology at the University Hospital Rostock, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany.
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143
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Halkos ME, Nicholas J, Kong LS, Burke JR, Milner R. Endovascular management of blunt abdominal aortic injury. Vascular 2007; 14:223-6. [PMID: 17026914 DOI: 10.2310/6670.2006.00038] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The endovascular management of blunt aortic injuries is being used more frequently in the trauma patient. Traumatic aortic injuries usually occur in the descending thoracic aorta near the origin of the left subclavian artery. Many reports in the literature demonstrate the efficacy of endovascular repair of blunt thoracic aortic injury. We report here an unusual case of abdominal aortic dissection secondary to blunt abdominal trauma following a fall. The patient also had associated intra-abdominal injuries requiring bowel resection and repair of small bowel mesenteric lacerations. He was treated with a bifurcated abdominal endograft with an excellent result after the initial operation was performed to treat the bowel injuries.
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Affiliation(s)
- Michael E Halkos
- Division of Vascular Surgery, Joseph B. Whitehead Department of Surgery, Emory University Hospital and Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
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144
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Johnson SB. Operative Approaches for Traumatic Thoracic Aortic Injury: Immediate Versus Delayed Therapy. ACTA ACUST UNITED AC 2007; 62:S24-5. [PMID: 17556950 DOI: 10.1097/ta.0b013e3180654004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Scott B Johnson
- Division of Thoracic Surgery, University of Texas Health Science Center at San Antonio, USA.
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145
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Abstract
Interventional radiologists (IRs) now play a major role in the management of thoracic aortic and great vessel trauma. The recent availability of a wide range of stent grafts able to treat vessels from 3 to 46 mm in diameter is clearly a significant contributor to this change. Stent grafts can now treat the majority of incomplete aortic injuries with much lower morbidity and mortality than open surgery. Short- to medium-term follow-up is encouraging, but the long-term durability is unknown, and close monitoring of these patients must continue. In great vessel trauma, stent grafts are a useful adjunct to balloon tamponade, embolization, and bare stents. As a result, a wide range of head neck and upper limb vascular injuries can be managed with less local trauma, blood loss, and physiological stress. The increased involvement of IR in the management of vascular trauma is not simply the result of technological advances. IRs have increasingly made themselves available to carry out these emergency procedures. IRs should assist in the development of trauma protocols and management algorithms that involve endovascular expertise early in the assessment of the major trauma patient.
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Affiliation(s)
- Simon J McPherson
- Department of Radiology, Leeds General Infirmary, Leeds, United Kingdom
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146
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Lettinga-van de Poll T, Schurink GWH, De Haan MW, Verbruggen JPAM, Jacobs MJ. Endovascular treatment of traumatic rupture of the thoracic aorta. Br J Surg 2007; 94:525-33. [PMID: 17443851 DOI: 10.1002/bjs.5795] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.
Methods
A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.
Results
A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.
Conclusion
Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.
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Affiliation(s)
- T Lettinga-van de Poll
- Department of Vascular Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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147
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148
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McPhee JT, Asham EH, Rohrer MJ, Singh MJ, Wong G, Vorhies RW, Nelson PR, Cutler BS. The Midterm Results of Stent Graft Treatment of Thoracic Aortic Injuries. J Surg Res 2007; 138:181-8. [PMID: 17292414 DOI: 10.1016/j.jss.2006.09.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 09/27/2006] [Accepted: 09/28/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.
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MESH Headings
- Accidents, Traffic/mortality
- Adult
- Aged
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/mortality
- Aneurysm, False/surgery
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/injuries
- Aorta, Thoracic/surgery
- Blood Vessel Prosthesis
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Postoperative Complications/mortality
- Retrospective Studies
- Stents
- Tomography, X-Ray Computed
- Treatment Outcome
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/surgery
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Affiliation(s)
- James T McPhee
- Division of Vascular Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
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149
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Imaging and Intervention of Large Arterial Trauma. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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150
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Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras 2007. [DOI: 10.1590/s1677-54492007000100009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The diagnosis and management of aortic lacerations has been gradually improving. Historically, aortic lacerations were a common cause of exsanguination with extremely high mortality rate. However, in modern trauma systems with advanced resuscitation and rapid radiology imaging, the diagnosis of an aortic injury is improving with an emphasis on preventing the progression of intimal flaps and pseudoaneurysms to frank dissection or rupture. Both diagnostic modalities and the paradigm of immediate operative intervention have changed. The evolution of endovascular stenting may play a future role in definitive care.
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