Traumatic Aortic Rupture: 30 Years of Experience

16-year outcomes of blunt thoracic aortic injury treated with thoracic endovascular aortic repair: A single-institution experience

BACKGROUND

Blunt thoracic aortic injury (BTAI) is associated with considerable mortality and morbidity. Thoracic endovascular aortic repair (TEVAR) has essentially replaced open aortic repair (OAR) with superior outcome. The objective of this study was to evaluate the early and intermediate-term outcomes in patients sustaining BTAI treated with TEVAR, and to evaluate the prevalence and impact of left subclavian artery (LSA) coverage.

METHODS

This retrospective analysis includes patients undergoing TEVAR for BTAI between February 2006 and December 2022 at the Helsinki University Hospital, Finland. The primary endpoints were 30-day and 2-year mortality, technical success of stent-graft system deployment, and procedural and device-related complications. The secondary endpoints pertained to reintervention events: conversion to OAR, re-TEVAR, any endovascular/surgical reinterventions for optimal stent-graft function, or any reinterventions during follow-up.

RESULTS

A total of 38 consecutive BTAI patients treated with TEVAR were included in the analyses. Median patient age was 45.5 years (range, 15-79) and 66% were male. The median follow-up period was 39 months. Technical success was 100%, 30-day mortality was 0%, and 2-year mortality was 11% in the study cohort. Coverage of LSA without revascularization (13/18) resulted in one postoperative nondisabling stroke (1/13), no paraplegia, and one had ischemic left arm findings (1/13). Only one patient required reintervention (LSA embolization; 1/38).

CONCLUSION

In this institutional series, we provide further evidence in favor of TEVAR for BTAI treatment. We demonstrated that TEVAR is linked to highly favorable outcomes in the short and intermediate term, and coverage of LSA without revascularization was quite well tolerated.

Hemoptysis as a rare manifestation of missed blunt thoracic aorta injury, a case report

INTRODUCTION AND IMPORTANCE

Blunt thoracic aorta injury is one of the most fatal injuries in multiple trauma patients and most of these injuries lead to death at the scene. Some patients remain undiagnosed because of the lack of specific symptoms for these injuries. Hemoptysis as a presentation of a neglected blunt aortic trauma is a very rare condition. In this study, we present a case with a 7-month delay in presentation and diagnosis.

CASE PRESENTATION

A 49-year-old man with a complaint of intermittent hemoptysis was presented to the clinic. He had a history of chest trauma following falling 7 months ago. His physical examination was unremarkable. On Computed Tomography Angiography (CTA) pseudoaneurysm of the descending aorta was detected and the patient was treated urgently with a stent graft.

CLINICAL DISCUSSION

Blunt thoracic aorta injury may occur following deceleration traumas. Descending aorta is the most involved segment but other segments may be involved as well. Bleeding can be stopped by tamponading the aorta with its overlying pleura. In some cases, pseudoaneurysms are formed and may remain undiagnosed for a long time after index trauma. CTA is the most useful diagnostic study and when the diagnosis is made, urgent treatment is mandatory. Although endovascular repair has significantly lower mortality and morbidity, open surgical repair may be inevitable in some cases.

CONCLUSION

Thoracic aorta injury should be suspected in any patient with severe deceleration trauma and CTA should be used promptly for the diagnosis and treatment of these potentially fatal injuries.

Blunt Thoracic Aortic Injury

Blunt thoracic aortic injury (BTAI) is a potentially fatal condition that needs prompt recognition and expedited management. Clinical manifestations of BTAI are not straight forwarding and may be misdiagnosed. The grade of aortic injury is an important determinant of perioperative mortality and morbidity, as well as the indication of treatment, along with the presence of concomitant lesions of other involved organs. The mainstay of treatment nowadays for hemodynamically stable patients who survive the trauma scene is represented by delayed endovascular repair whenever anatomically and clinically feasible. Endovascular repair, in fact, is burdened by lower perioperative mortality and morbidity rates if compared to open surgical repair, but concerns remain about the need for long-term surveillance and radiation exposure in patients who are at a younger age than patients treated for the aneurysmal disease. The aim of the paper is to provide an update on the diagnostic modalities and strategies of treatment for patients affected by BTAI.

Analysis of imaging characteristics of blunt traumatic aortic dissection: an 8-year experience

BACKGROUND

Traumatic aortic dissection (TAD) has a low incidence but extremely high mortality. It always presents atypical clinical manifestations that are easily missed or misdiagnosed. This study mainly aims to describe the imaging characteristics and management of TAD patients.

METHODS

A retrospective analysis of 27 blunt TAD patients was performed between 2013 and 2020. Demographic features, imaging characteristics, and management were analyzed.

RESULTS

Twenty-seven patients with type B aortic dissection (age 56.04±16.07 years, 20 men) were included. Aortic intimal tears were mostly initiated from the aortic isthmus. The sizes of the proximal intimal tears in the greater curvature were larger than those in the lesser curvature (1.78±0.56 cm vs. 1.24±0.52 cm, P=0.031). Compared with those in the control group, the maximum diameters of the aortic arch, thoracic aorta, and abdominal aorta in the TAD patients were all significantly widened (all P<0.050). Multivariate logistic regression analysis showed that the maximum diameter of the thoracic aorta was an independent risk factor for TAD, with a predictive value with an area under the receiver operating characteristic curve (AUC) of 0.673. Finally, 26 patients successfully underwent delayed thoracic endovascular aortic repair (TEVAR), and the remaining one patient was treated conservatively. No progression of aortic dissection or death occurred during the six-month follow-up period.

CONCLUSIONS

In blunt trauma, the aortic isthmus is the most common site of proximal intimal tears. An accurate diagnosis of TAD requires an overall consideration of medical history and imaging characteristics. Delayed TEVAR might be an effective therapeutic option for TAD.

A Comparison of Clinical Outcomes of Endovascular Repair Versus Open Surgery for Ruptured Descending Thoracic Aorta

OBJECTIVE

The comparisons between thoracic endovascular aortic repair for ruptured thoracic aorta (TEVAR) and open surgery (OS) have not been well documented, although both procedures have been widely utilized. We performed a systematic review and meta-analysis to investigate the effectiveness and safety between TEVAR and OS in the repair of ruptured descending thoracic aorta.

METHODS

PubMed, Embase, and Cochrane Library databases were searched to find relevant studies to assess TEVAR and OS outcomes. The comparative parameters were perioperative mortality (30 day/in-hospital), 1 year mortality, paraplegia or paraparesis, renal insufficiency, stroke, pulmonary embolism, re-intervention rate, pulmonary complications, and cardiac complications. A fixed-effects model was applied to calculate the odds ratio (OR) with a 95% confidence interval (CI) on pooled outcomes from different studies.

RESULTS

Eighteen observational trials involving 2088 patients were evaluated (TEVAR=560; OS=1528). Meta-analysis showed that TEVAR in repairing the ruptured descending thoracic aorta was associated with lower perioperative mortality (OR=0.47; 95% CI: 0.34-0.66; p<0.01), 1 year mortality (OR=0.46; 95% CI: 0.29-0.75; p<0.01), renal insufficiency incidence (OR=0.56; 95% CI: 0.33-0.93; p=0.03), and pulmonary complications (OR=0.69; 95% CI: 0.52-0.92; p=0.01) when compared with OS. There was no significant difference between TEVAR and OS in terms of paraplegia, stroke, pulmonary embolism, cardiac complications, and early re-intervention rates. However, the late re-intervention rate was higher in the TEVAR group than that in the OS group.

CONCLUSIONS

When repairing the ruptured descending thoracic aorta, TEVAR may be performed rapidly and safely. TEVAR is associated with lower rates of perioperative morbidity and early postoperative complications than OS.

Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life

Purpose

Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL).

Methods

Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population.

Results

Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01).

Conclusion

This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01432-y) contains supplementary material, which is available to authorized users.

A Case of Traumatic Aortic Transection Presenting With Hemorrhagic Shock

BACKGROUND

Aortic transection, or aortic rupture, is a rare diagnosis in trauma patients and carries a high mortality.

CASE REPORT

We present the case of a 61-year-old man presenting to a Level I trauma center after being struck by a motor vehicle, found to have an aortic transection. He was initially hypotensive and resuscitated with blood products due to concern for hemorrhagic shock. Aortic injury was suspected after chest x-ray study demonstrated a widened mediastinum. Traumatic thoracic aortic transection with pseudoaneurysm was diagnosed on computed tomography of the aorta, and the patient was taken to the operating room for thoracic endovascular repair of the aorta. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diagnosis of aortic injury can be challenging, especially in trauma patients presenting with hypotension. Aortic injury must be suspected in patients presenting after a high-velocity mechanism injury. It is an uncommon cause of hemorrhagic shock in trauma patients and must be considered even if other traumatic injuries are identified, as it commonly occurs with other significant injuries. Although chest x-ray study can be useful, a negative chest x-ray study does not rule out aortic injury. Aortic injury is a time-sensitive diagnosis, and early identification is key to these patients surviving to receive definitive management in the operating room.

Die traumatische Aortenruptur

Verkehrsunfälle sind für den größten Teil der traumatischen Aortenrupturen verantwortlich, meist zusammen mit weiteren schweren Begleitverletzungen. Die prähospitale Sterblichkeit ist hoch. Bei Verdacht auf eine beteiligte Aortenverletzung, aufgrund eines hohen traumatic aortic injury scores, ist eine Computertomographie durchzuführen. Es erfolgt eine Triage der Verletzungen, und die Versorgungspriorität der Aorta richtet sich nach dem Schweregrad der Aorten- und Begleitverletzungen sowie dem Zustand des Patienten. Bis zur definitiven Versorgung der aortalen Läsion muss der Blutdruck konsequent gesenkt werden. Grad I und II können in Einzelfällen unter enger Kontrolle inital konservativ gemanagt werden. Grad III (gedeckte Ruptur) und Grad IV (freie Ruptur) benötigen eine raschestmögliche Versorgung (interventionell, chirurgisch). In ausgesuchten Fällen kann auch eine verzögerte Versorgung günstig sein.

Als bevorzugte Versorgungsform hat sich die interventionelle Stentgrafttherapie etabliert.

Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis

INTRODUCTION

To provide an overview of the experience of endovascular treatment for traumatic thoracic aortic lesions (TTAL). Thoracic aortic injury secondary to high-energy chest trauma constitutes an emergency situation with potentially devastating outcome. In the present time, the majority of patients are treated with thoracic endovascular aortic repair. The aim of this study was to provide a systematic overview of endovascular aortic repair in patients with TTAL with special attention to perioperative mortality, paraplegia, stroke, influence of left subclavian artery (LSA) coverage herein, and long-term stent-related complications.

EVIDENCE ACQUISITION

PubMed and Embase were searched for studies describing endovascular treatment of TTAL in the period between January 1st, 2000 and January 30th, 2016. The methodological quality of articles was assessed using the MINORS score and PRISMA guidelines. Data on early mortality, perioperative complications, and long-term stent-related complications were extracted.

EVIDENCE SYNTHESIS

A total of 2005 reports were screened, and 74 publications were finally included in the analysis describing treatment of 1882 patients. Early mortality rate, paraplegia rate, and stroke rate were 7.5%, 0.4%, and 1.5%, respectively. LSA coverage did not increase the risk of stroke. The severity of injuries had a positive association on early mortality. Late stent related mortality and morbidity were uncommon.

CONCLUSIONS

TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications but is associated with a moderate risk of left arm ischemia. Long-term stent-related complications are rare, but the available data is limited.

Air bubbles are released by thoracic endograft deployment: An in vitro experimental study

Purpose:

Embolic stroke is a dreaded complication of thoracic endovascular aortic repair. The prevailing theory about its cause is that particulate debris from atherosclerotic lesions in the aortic wall are dislodged by endovascular instruments and embolize to the brain. An alternative source of embolism might be air trapped in the endograft delivery system. The aim of this experimental study was to determine whether air is released during deployment of a thoracic endograft.

Methods:

In an experimental benchtop study, eight thoracic endografts (five Medtronic Valiant Thoracic and three Gore TAG) were deployed in a water-filled transparent container drained from air. Endografts were prepared and deployed according to their instructions for use. Deployment was filmed and the volume of air released was collected and measured in a calibrated syringe.

Results:

Air was released from all the endografts examined. Air volumes ranged from 0.1 to 0.3 mL for Medtronic Valiant Thoracic and from <0.025 to 0.04 mL for Gore TAG. The largest bubbles had a diameter of approximately 3 mm and came from the proximal end of the Medtronic Valiant device.

Conclusion:

Air bubbles are released from thoracic endografts during deployment. Air embolism may be an alternative cause of stroke during thoracic endovascular aortic repair.

Chronic False Aneurysm after a Healed Rupture of the Aortic Isthmus: TEVAR, Hybrid Surgery, or Open Arch Repair?

We report a case of post-traumatic chronic false aneurysm of the aortic isthmus in a 34-year-old man who had been involved in a car accident 10 years earlier. An initial chest X-ray demonstrated a calcified mass in the upper mediastinum and computed tomography scan revealed a false aneurysm of the aortic isthmus arising above the left subclavian artery. Partial covered rupture of the aorta is not always easy to diagnose and can remain clinically silent in a polytrauma patient. The duration from rupture to false aneurysm formation may extend over many years. This chronic lesion can be managed by surgery, by an endovascular procedure, or by a combined procedure. This case report highlights the current therapeutic approach. A debranching procedure was done in view of a secondary exclusion of the huge false aneurysm by a stent graft. Unfortunately, the false aneurysm ruptured during the procedure and a replacement of the aortic arch and the isthmus under total circulatory arrest was successfully done. The patient was doing well at 9-month follow-up.

Chronic Thoracic Aortic Aneurysm Presenting 29 Years following Trauma

Blunt, nonpenetrating injuries of the thoracic aorta are uncommon and associated with a high mortality rate within the first hour. Aortic injury is missed in 1-2% of patients that survive to hospital, and a chronic thoracic aortic aneurysm may subsequently form. We present a case in which a chronic thoracic aortic aneurysm was diagnosed 29 years following a significant motor vehicle accident. We discuss the epidemiology, presentation, and management of this uncommon consequence of blunt, nonpenetrating aortic injury. Our case illustrates an important clinical lesson; a past medical history of trauma should not be overlooked at any patient assessment.