Endovascular Treatment of a Blunt Traumatic Abdominal Aortic Injury with a Commercially Available Stent Graft

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Seat Belt Aortic Dissection: A Case Report

Eighteen-year-old restrained male driver involved in a flip over motor vehicle accident resulting in a seatbelt injury triad ( rectus abdominis muscle disruption, injury to the sigmoid colon and infra-renal aortic dissection). The patient did well after the surgical resection of the sigmoid colon, repair of the rectus abdominis muscle and endovascular repair of the aorta. Our objective is to shed light on this potentially fatal injury. 

Successful Endovascular Therapy in an Elderly Patient with Severe Hemorrhage Caused by Traumatic Injury

An 85-year-old female suffered pelvic fracture, multiple rib fractures, right hemopneumothorax, and blunt abdominal aortic injury in a traffic accident. After transfer to our hospital, transcatheter arterial embolization (TAE) was performed immediately for hemorrhage from the bilateral internal iliac arteries. Enhanced computed tomography (CT) after TAE showed an increase of hematoma and extravasation at the bifurcation of the abdominal aorta. Therefore, emergency abdominal endovascular aortic repair was performed on the same day. On the 3rd day after transfer, metabolic acidosis worsened suddenly, and enhanced CT revealed intestinal necrosis. Emergency surgery for the intestinal necrosis was performed. The patient was transferred to the previous hospital on the 31st day after transfer. Endovascular treatment is useful for elderly patients with severe trauma. However, the preservation and/or reconstruction of the blood flow to important organs should be monitored.

Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma

The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.

Recycling and Reinforcing Intimomedial Flap of the Infrarenal Aorta Using Anterior Longitudinal Ligament in Patients With Acute Trauma With Bowel Injuries

We present a patient with blunt abdominal trauma with severe acute right limb ischemia and clinical signs of diffuse peritonitis. Computed tomography angiography showed circumferential dissection of the infrarenal aorta with occlusion of the right common iliac artery. We opted for simultaneous abdomen exploration and open repair of injured aorta. Critical weakening of the aortic wall with imminent rupture was identified intraoperatively. Aortotomy cranially from bifurcation showed circumferential intimomedial dissection. The fixation of fragile intimomedial flap of aortic dissection was achieved with reinforcement using an anterior longitudinal ligament. The long aortoiliac arteriotomy was repaired using a great saphenous vein patch. Patient had uneventful postoperative course and was discharged after 7 days. In patients with abdominal polytrauma with peritonitis, and no available endovascular tools, open surgery for circumferential aortic dissection is possible and successful. Described reinforcement of the posterior aortic wall to the anterior longitudinal ligament should be added to the armamentarium of aortic injury treatment.

Endovascular treatment of abdominal aortic aneurysm in a 26-year-old man. A case report and 10-year follow-up

We present endovascular treatment of abdominal aortic aneurysm in a 26-year-old man with a 10-year follow-up. A young patient presenting with an abdominal aortic aneurysm is extremely rare, and data describing this population are limited. Open aneurysm repair (OAR) is the treatment of choice in these patients. However, since its introduction, endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. The long-term durability and late complications after EVAR may have more significance when considering the optimal treatment for young patients with a longer life expectancy. Our good long-term outcome will help to support the use of EVAR as a reasonable alternative to OAR in young patients with suitable anatomic findings.

Endovascular management of lap belt-related abdominal aortic injury in a 9-year-old child

Blunt abdominal aortic trauma is a rare occurrence in children with only a few patients having been reported in the literature. Most such cases have been described in the context of lap belt injuries. We report a 9-year-old boy who suffered lap belt trauma to the abdomen during a high-speed road traffic accident resulting to the well-recognized pattern of blunt abdominal injury, that is, the triad of intestinal perforation, fractures of the lumbar spine, and abdominal aortic injury. The latter presented with lower limb ischemia due to dissection of the infrarenal aorta and right common iliac artery. Revascularization was achieved by endovascular means using 2 self-expanding stents in the infrarenal aorta and the right common iliac artery. This case is one of the few reports of lap belt-related acute traumatic abdominal aortic dissection in a young child and highlights the feasibility of endovascular management in the pediatric population.

Endovascular repair of a blunt abdominal aortic injury

Blunt abdominal aortic injury is an uncommon traumatic finding. In the past, treatment options have traditionally consisted of open operative repair; however, the development of endovascular surgery has created new interventional possibilities. This case is presented to demonstrate the applications of endovascular abdominal aortic repair for a blunt traumatic injury.

Vascular trauma in geriatric patients: a national trauma databank review

BACKGROUND

The epidemiology of vascular injuries in the geriatric patient population has not been described. The purpose of this study was to examine nationwide data on vascular injuries in the geriatric patients and to compare this with the nongeriatric adult patients with respect to the incidence, injury mechanisms, and outcomes.

METHODS

Geriatric patients aged 65 or older with at least one traumatic vascular injury were compared with an adult cohort aged 16 years to 64 years with a vascular injury using the National Trauma Databank version 7.0.

RESULTS

During the study period, 29,736 (1.6%) patients with a vascular injury were identified. Of those, geriatric patients accounted for 7.6% (2,268) and the nongeriatric adult patients accounted for 83.1% (n=24,703). Compared with the nongeriatric adult patients, the geriatric vascular patients had a significantly higher Injury Severity Score (26.6±17.0 vs. 21.3±16.7; p<0.001) and less frequently sustained penetrating injuries (16.1% vs. 54.1%; p<0.001). The most commonly injured vessels in the elderly were vessels of the chest (n=637, 40.2%), including the thoracic aorta and innominate and subclavian vessels. The overall incidence of thoracic aorta injuries was significantly higher in geriatric patients (33.0% vs. 13.9%; p<0.001) and increased linearly with progressing age. After adjusting for confounding factors, geriatric patients demonstrated a fourfold increase in mortality following vascular injuries (adjusted odds ratio, 3.9; 95% confidence interval, 3.32-4.58; p<0.001).

CONCLUSION

Vascular trauma is rare in the geriatric patient population. These injuries are predominantly blunt, with the thoracic aorta being the most commonly injured vessel. Although vascular injuries occur less frequently than in the nongeriatric cohort, in the geriatric patient, vascular injury is associated with a fourfold increase in adjusted mortality.

Seatbelt Triad: Severe Abdominal Wall Disruption, Hollow Viscus Injury, and Major Vascular Injury

The triad of seatbelt-related severe abdominal wall disruption, hollow viscus injury, and distal abdominal aortic injury after a motor vehicle collision is uncommon. We present a small case series involving those three clinical features with the goal of preventing a future missed diagnosis of the distal abdominal aortic injury in particular.

Endovascular repair of an actively hemorrhaging stab wound injury to the abdominal aorta

Traumatic injury of the abdominal aorta is rare and potentially lethal (Yeh et al., J Vasc Surg 42(5):1007-1009, 2005; Chicos et al., Chirurgia (Bucur) 102(2):237-240, 2007) as it can result in major retroperitoneal hemorrhage, requiring an urgent open surgery. In case of concomitant bowel injury or other conditions of hostile abdomen, endovascular repair can be an alternative treatment. This case report deals with a 50-year-old man presenting at the emergency ward with three stab wounds: two in the abdomen and one in the chest. During explorative laparotomy, liver laceration and bowel perforation were repaired. One day later, abdominal CT-scan revealed an additional retroperitoneal hematoma associated with an aortic pseudoaneurysm, located anteriorly 3 cm above the aortic bifurcation. Because of the risk of graft infection, an endovascular repair of the aortic injury using a Gore excluder stent-graft was performed. Radiological and clinical follow-up revealed a gradual shrinkage of the pseudo-aneurysm and no sign of graft infection at two years' follow-up.

Endovascular Repair of an Actively Hemorrhaging Aortoduodenal Fistula

Aortoenteric fistulae require urgent definitive intervention and traditionally carry a high mortality. We describe a patient who suffered a traumatic aortic dissection following an auto versus pedestrian collision. He underwent open fenestration of his infrarenal aorta and visceral resection, complicated by abdominal sepsis and enterocutaneous fistulae. One month later he developed massive hematemesis, and endoscopic examination revealed an aortoduodenal fistula. Due to an impassable abdominal wall, a stent-graft repair was performed. This report describes the successful use of endovascular techniques to achieve immediate hemostasis in an actively hemorrhaging aortoduodenal fistula. An endovascular approach provides a valuable option in settings where a hostile abdomen precludes the traditional open technique and may serve as a bridge to later definitive repair.

Patient factors and operating room resuscitation predict mortality in traumatic abdominal aortic injury: A 20-year analysis

BACKGROUND

Injuries to the abdominal aorta are rare and remain one of the most lethal causes of early death in trauma. The purposes of this study were to identify primary predictors of mortality and to examine the impact of a well-established operating room resuscitation protocol on survival in patients with traumatic aortic injury.

METHODS

A 20-year retrospective review was performed of medical records and autopsy reports of trauma patients admitted with confirmed injury to the abdominal aorta. Data on patient demographics, admission characteristics, operative findings, and the initial location of resuscitation were collected. The main outcome measure was death.

RESULTS

Abdominal aortic injuries were diagnosed in 60 patients. Their average age was 26.5 years, and the mean transport time was 10 minutes. The overall mortality rate (MR) was 73%. With the exclusion of 18 patients considered dead on arrival, the MR decreased to 61%. The mechanism of injury was blunt in 20% (MR 92%) and penetrating in 80% (MR 68%). Acidosis, defined as a pH <7.2 (MR 81%) or a base deficit >10 (MR 77%), was a predictor of death (P < .0001). Patients resuscitated directly in the operating room had a significantly lower MR (40%) than those resuscitated in the trauma room (MR 78%; P < .02). The lack of retroperitoneal tamponade (P < .02), the presence of associated intra-abdominal injuries (P < .001), and the location of aortic injury at the subdiaphragmatic (18%; MR 90%) or suprarenal location (37%; MR 71%; P < .005) at exploration resulted in significantly higher patient mortality. Surgical management consisted of primary repair in 26, end-to-end repair in 1, interposition graft in 8, or patch in 1. Resuscitative thoracotomy was performed in 27 patients (45%), with an overall MR of 92%.

CONCLUSION

Despite advances in fluid resuscitation, operative strategy, and transport during the past 20 years, the mortality of traumatic injury to the abdominal aorta remains high. Shock, acidosis, suprarenal aortic injury, and a lack of retroperitoneal tamponade all independently contribute to mortality and should raise the suspicion for a potentially lethal aortic injury in a severely injured patient. Rapid identification and resuscitation in the operating room may therefore be the only factors to improve current survival rates in such devastating injuries.