Emergency endovascular interventions for acute thoracic aortic rupture: Four-year follow-up

Endovascular treatment for life-threatening hemoptysis due to rupture of descending thoracic aortic aneurysm: A case series

INTRODUCTION AND IMPORTANCE

Aortic aneurysm is an uncommon but life-threatening cause of hemoptysis. Treatments include surgery and/or endovascular intervention, each with its own advantages and disadvantages. Endovascular intervention is associated with good early and medium-term outcomes.

CASE PRESENTATIONS

We report three cases of hemoptysis due to ruptured thoracic aortic aneurysm who underwent endovascular intervention. In all three cases, endovascular grafts were placed in the descending thoracic aorta, the number of grafts used was 1, the average time to stop hemoptysis was 4 to 5 days, and the length of hospital stay was between 6 and 8 days. No intravascular fistula, renal failure, prolonged mechanical ventilation and other major cardiovascular events were reported.

CLINICAL DISCUSSION

Endovascular treatment for descending TAA has been demonstrated to be safe and effective, particularly in emergencies in which patients presented with life-threatening hemoptysis, due to its rapid access to the aorta. In our experience at a tertiary hospital in southern Vietnam, the procedural time for a thoracic endovascular aortic repair is relatively brief and can last between 15 and 30 min. Thus, endovascular treatment for ruptured TAA can substantially improve patient prognosis, reduce mortality and complications.

CONCLUSION

The implementation of endovascular intervention can help improve prognosis, reduce mortality and complications in patients with hemoptysis due to ruptured thoracic aortic aneurysm.

A novel endovascular treatment for transcatheter aortic valve embolization

In the present report, we have described the case of an 82-year-old obese man who had required transcatheter aortic valve replacement to treat severe symptomatic aortic stenosis. During implantation, the balloon-mounted valve became dislodged and embolized to the ascending aorta. A second valve was successfully implanted after several failed attempts to reposition the first one into the aortic annulus. The dislodged valve became further embolized and landed in the distal descending aorta, partially obstructing the splanchnic, renal, and lower extremity blood flow. It was rotated with flexible forceps and permanently secured in the distal thoracic aorta using a thoracic endoprosthesis, rendering it harmless.

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.

Improved midterm outcomes after endovascular repair of nontraumatic descending thoracic aortic rupture compared with open surgery

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become first-line treatment for descending thoracic aortic rupture (DTAR), but its midterm and long-term outcomes remain undescribed. This study evaluated whether TEVAR would improve midterm outcomes of nontraumatic DTAR relative to open surgical repair (OSR).

METHODS

Between December 1999 and October 2018, 118 patients with DTAR were treated with either OSR (n = 39) or TEVAR (n = 79) at a single center. Primary end points were 30-day and long-term all-cause mortalities. Secondary end points included stroke, permanent spinal cord ischemia (SCI), prolonged ventilation support or tracheostomy, permanent hemodialysis, and aortic reintervention.

RESULTS

Thirty-day mortality was significantly lower with TEVAR (OSR, 38.5%; TEVAR, 16.5%; P = .01). Stroke (15.6% vs 3.8%; P = .03), permanent SCI (15.6% vs 2.5%; P = .02), prolonged ventilation (30.8% vs 8.9%; P = .002), and tracheostomy (12.8% vs 2.5%; P = .04) were significantly lower after TEVAR than OSR. Need for hemodialysis trended higher after OSR (12.8% vs 5.1%; P = .2). Mean follow ups were 1048 ± 1591 days for OSR group and 828 ± 1258 days for TEVAR. All-cause mortality at last follow-up was significantly lower after TEVAR than OSR (35.4% vs 66.7%; P = .001). Aortic reintervention was required more frequently within 30 days after TEVAR (15.2% vs 2.6%; P = .06). By multivariate analysis, TAAA was an independent predictor for mortality.

CONCLUSIONS

TEVAR improves both early and midterm outcomes of DTAR relative to OSR. TAAA was a predictor of mortality. Endovascular approach to DTAR may provide the greatest chance at survival.

Hemoptysis secondary to rupture of infected aortic aneurysm- a case report

Background

Massive hemoptysis is a life-threatening condition and can arise as a complication of various conditions. It rarely occurs as a complication of a ruptured thoracic aortic aneurysm. Even rarer are conditions where pseudoanurysms of aorta result due to infection.

Case presentation

A 30 year-old female patient presented with left sided chest pain, intermittent fever, cough and massive hemoptysis. A pseudo-aneurysm of proximal descending thoracic aorta at the level of the left Subclavian artery was noted over CT scan.

Upon performing a left posterolateral thoracotomy, the aneurysm was seen to have ruptured into the apical segment of left upper lobe, contained mainly by a thrombus. The anterior wall of the pseudoaneurysm was debrided and a bovine pericardial patch was used to repair the aortic defect. Cultures of the tissue obtained showed Enterobacter species, therefore the patient was prescribed 6 weeks of IV antibiotics following surgery. Post-operative CT scan revealed reduced diameter of the aorta. She was discharged in good health and remains well at follow up evaluation.

Conclusions

We present a case of hemoptysis caused by a ruptured descending aorta aneurysm into left lung. The aneurysm was secondary to infection by Enterobacter. Surgical repair of the concerned region of aorta was effective, without any major sequelae. To the best of our knowledge, no such cases have been reported previously.

Thoracic Aortic Stent Grafting in Patients with Connective Tissue Disorders: A Word of Caution

Objective

Use of thoracic Stent-graft in patients with connective tissue disorders (CTD) remains limited. We herein report 3 patients with CTD who underwent stent grafting.

Methods and Results

Case 1; A male Marfan patient was operated for thoraco-abdominal aneurysm. On computed tomography (CT), large false aneurysm at the proximal anastomosis was documented which was excluded with a 30 mm Talent stent-graft with 10–15% oversize. Case 2; A female with Ehlers-Danlos syndrome had undergone resection of descending aortic thoracic aneurysm presented with an enlarging aneurysm distal to the graft. Three Talent stent-grafts (15% oversize) were deployed with balloon dilatation to exclude the aneurysm. The immediate postoperative period was complicated by an extensive intramural hematoma of the descending aorta with hemothorax, managed conservatively. Case 3; A female Marfan patient had undergone Bentall procedure and mitral repair followed with resection of the proximal descending aorta. Three months later a false aneurysm at the distal anastomosis was treated with a 24 mm Valiant stent-graft (30% oversize). Aortic dissection distal to stent was documented on the early postoperative CT. The dissected aneurysm enlarged significantly with a type I distal endoleak during follow-up. Concomitantly, the patient presented a class III dyspnea owing to a severe mitral regurgitation. The patient underwent a successful MVR and stent-graft explantation with replacement of the descending aorta.

Conclusion

Significant complications supervened when stent-grafts were deployed in native aorta. We thus recommend that deploying a stent-graft in a CTD diseased aorta should be considered a relative contraindication. In cases with prohibitive or high risk surgery, use of a stent-graft with minimal radial force and minimal oversizing without balloon dilatation should be considered.

Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study

OBJECTIVE

The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA).

METHODS

This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan-Meier estimator and multivariable Cox regression.

RESULTS

There were 140 patients (age [mean ± SD] 74.1 ± 8.8 years; 56% men; aneurysm size 64.8 ± 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0-132 months). The Kaplan-Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00-1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.19-4.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15-3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20-8.81; p = .001), stroke (HR 2.63; 95% CI 1.37-5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69-25.35; p = .001) were all associated with mortality.

CONCLUSIONS

This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.

Thoracic Trauma: Injuries, Evaluation, and Treatment

Thoracic injury is common in high-energy and low-energy trauma, and is associated with significant morbidity and mortality. Evaluation requires a systematic approach prioritizing airway, respiration, and circulation. Chest injuries have the potential to progress rapidly and require prompt procedural intervention. For the diagnosis of nonemergent injuries, a careful secondary survey is essential. Although medicine and trauma management have evolved throughout the decades, the basics of thoracic trauma care have remained the same.

The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAAs). The aim of this study was to assess national trends in the use of TEVAR for the treatment of rTAA and to determine its impact on perioperative outcomes.

METHODS

Patients admitted with an rTAA between 1993 and 2012 were identified from the National Inpatient Sample. Patients were grouped in accordance with their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis.

RESULTS

A total of 12,399 patients were included, with 1622 (13%) undergoing TEVAR, 2808 (23%) undergoing open repair, and 7969 (64%) not undergoing surgical treatment. TEVAR has been increasingly used from 2% of total admissions in 2003-2004 to 43% in 2011-2012 (P < .001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%; P < .001) and nonoperative treatment (69% to 45%; P < .001). The proportion of patients undergoing surgical repair has increased for all age groups since 1993-1994 (P < .001 for all) but was most pronounced among those aged 80 years with a 7.5-fold increase. After TEVAR was introduced, procedural mortality decreased from 36% in 2003-2004 to 27% in 2011-2012 (P < .001); mortality among those undergoing nonoperative treatment remained stable between 63% and 60% (P = .167). Overall mortality after rTAA admission decreased from 55% to 42% (P < .001). Since 2005, mortality for open repair was 33% and 22% for TEVAR (P < .001). In adjusted analysis, open repair was associated with a twofold higher mortality than TEVAR (odds ratio, 2.0; 95% confidence interval, 1.7-2.5).

CONCLUSIONS

TEVAR has replaced open repair as primary surgical treatment for rTAA. The introduction of endovascular treatment appears to have broadened the eligibility of patients for surgical treatment, particularly among the elderly. Mortality after rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality as well as the increased proportion of patients undergoing surgical repair.

Case-report: endovascular treatment of aortic pseudo-aneurysm caused by Fishbone

Aortic pseudo-aneurysm (APA) is a rare disease in clinic. Because of its relative rarity, we are far from making any conclusion regarding the natural history and appropriate therapeutic strategy for this condition. This study is to investigate the treatment effect of interventional therapy in aortic pseudo-aneurysm. A woman of 68 years old diagnosed with APA caused by fishbone was treated with stent grafts. After treatment, the therapeutic effect was assessed by measuring the size of trauma. The patient recovered well after stent grafts treatment, as her trauma was minimal. However, some complications of intravascular interventional treatment were observed. Compared with conventional surgery, interventional therapy of intravascular stent grafts has its merits. Therefore, this strategy was worthy to apply in the treatment of aortic pseudo-aneurysm.

One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial)

OBJECTIVE

One-year outcomes of the RESCUE trial (endovascular aortic repair using Valiant Captivia for blunt thoracic aortic injury) are reported.

METHODS

RESCUE is a prospective, nonrandomized, multicenter trial. Fifty patients with blunt thoracic aortic injury were enrolled between April 2010 and January 2012. One-year outcomes included secondary procedures, device-, procedure-, and/or aorta-related adverse events, and all-cause mortality.

RESULTS

Mean patient age was 40.7 ± 17.4 years; 76% of patients were male. Fifty-two thoracic stent grafts were implanted within a median of 1 day of injury. Seventy percent (35 of 50) of aortic injuries were grade III or higher, including 1 free rupture. The mean Injury Severity Score was 37.6 ± 14.3. Vascular access, device delivery, and deployment were successful in all patients. The left subclavian artery was completely covered in 40% (20 of 50) and partially covered in 18% of patients (9 of 50). There were no strokes or spinal cord injuries. Median procedure time was 90.5 minutes; median hospital stay was 11 days. All-cause mortality within 1 year was 12%. There were no conversions to open repair. Four patients (8%) had subclavian artery revascularization; 1 preoperatively; 3 others postoperatively on days 8, 36, and 103. There were no device-related adverse events. During follow-up, 1 patient (2%) had aortic-related and 9 patients (18%) had procedure-related adverse events.

CONCLUSIONS

TEVAR has favorable early midterm outcomes in the treatment of blunt thoracic aortic injury, and remains the treatment modality of choice. Longevity of the stent grafts in this young patient population has yet to be established.

Emergent repair of acute thoracic aortic catastrophes: a comparative analysis

OBJECTIVE

To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR).

DESIGN

Single-center retrospective review (April 2001-January 2010).

SETTING

Academic medical center.

PATIENTS

One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2).

MAIN OUTCOME MEASURES

Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months.

RESULTS

Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001).

CONCLUSION

Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

Open repair of blunt thoracic aortic injury remains relevant in the endovascular era

BACKGROUND

Thoracic endovascular aneurysm repair (TEVAR) has been a major advance in the treatment of blunt thoracic aortic injury (BTAI), although many patients still undergo open repair. This study was undertaken to evaluate outcomes with open repair and TEVAR for BTAI.

STUDY DESIGN

A retrospective review of all patients with BTAI at a single Level I trauma center from 2001 through 2009 was performed. Patients were grouped according to treatment modality, ie, open repair, TEVAR, or medical management. Direct comparison using standard statistical methods was made between patients undergoing open repair and TEVAR since late 2006 when TEVAR began at our institution using standard statistical methods. Outcomes variables included mortality, paraplegia, length of stay, ICU stay, and ventilator requirements.

RESULTS

There were 69 patients in the study, with 36 (52.2%) undergoing open repair, 10 receiving TEVAR (14.5%), 10 patients managed medically (14.5%), and 13 (18.8%) who died during triage. Overall mortality in the pre-TEVAR era was 29.6%. Since the introduction of TEVAR, there have been 8 open repairs. Patients undergoing open repair were significantly younger (32 vs 58 years; p = 0.002) and had smaller aortic diameter (18 mm vs 24.5 mm; p < 0.001) than those undergoing TEVAR. Overall mortality since the introduction of TEVAR has dropped to 12.0% (p = 0.097).

CONCLUSIONS

TEVAR and open repair should be viewed as complementary rather than competing modalities for the treatment of BTAI. Having both available allows selection of the most appropriate management technique for each patient, with subsequent improvement in outcomes.

Hybrid treatment of a ruptured aneurysm in the distal aortic arch: report of a case

An 80-year-old man was transferred to our hospital for surgical treatment of a ruptured aortic arch aneurysm. Based on a history of severe heart failure and coronary artery bypass, we considered him unsuitable for conventional open repair. He underwent a hybrid repair, in the form of supra-aortic vessel debranching followed by endoluminal aortic repair. Although the ostia of the left carotid and left subclavian arteries were occluded by the stent-graft, the left supra-aortic vessels and the left internal thoracic artery attached to the coronary artery were perfused through an extra-anatomic bypass from the right axillary artery to the left carotid artery and the left axillary artery. After additional endovascular repair for recurrent hemosputum, the patient recovered without complications. Although continued follow-up is necessary, acute hybrid arch repair seems feasible for treating ruptured aortic arch aneurysms, even in the setting of severe heart failure and a previous coronary artery bypass.

[Hemoptysis as the first sign of ruptured thoracic aorta]

Acute aortic rupture is associated with a high mortality. The leading symptoms are chest pain, dyspnea and hemodynamic instability as well as hemoptysis. In the current case report a patient with known coronary artery disease and prior coronary artery bypass surgery presented with hemoptysis. He was initially treated for a presumed gastroenterological disorder. The chest X-ray delineated a structure suggestive of aortic rupture and this diagnosis was confirmed by computed tomography. Emergency treatment was performed by implantation of an endovascular stent prosthesis. This procedure is currently regarded the standard treatment of rupture of the descending thoracic aorta. We conclude our case report with a discussion of epidemiology, symptoms, pathogenesis and therapy of this clinically dramatic disease.

Outcomes of Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysms

Background— Thoracic endovascular aortic repair offers a less invasive approach for the treatment of ruptured descending thoracic aortic aneurysms (rDTAA). Due to the low incidence of this life-threatening condition, little is known about the outcomes of endovascular repair of rDTAA and the factors that affect these outcomes.

Methods and Results— We retrospectively investigated the outcomes of 87 patients who underwent thoracic endovascular aortic repair for rDTAA at 7 referral centers between 2002 and 2009. The mean age was 69.8±12 years and 69.0% of the patients were men. Hypovolemic shock was present in 21.8% of patients, and 40.2% were hemodynamically unstable. The 30-day mortality rate was 18.4%, and hypovolemic shock (odds ratio 4.75; 95% confidence interval, 1.37 to 16.5; P =0.014) and hemothorax at admission (odds ratio 6.65; 95% confidence interval, 1.64 to 27.1; P =0.008) were associated with increased 30-day mortality after adjusting for age. Stroke and paraplegia occurred each in 8.0%, and endoleak was diagnosed in 18.4% of patients within the first 30 days after thoracic endovascular aortic repair. Four additional patients died as a result of procedure-related complications during a median follow-up of 13 months; the estimated aneurysm-related mortality at 4 years was 25.4%.

Conclusion— Endovascular repair of rDTAA is associated with encouraging results. The endovascular approach was associated with considerable rates of neurological complications and procedure-related complications such as endoleak.

Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies

OBJECTIVES

The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease.

BACKGROUND

The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials.

METHODS

Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies.

RESULTS

Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results.

CONCLUSIONS

Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.

Acute traumatic aortic injuries: posttherapy multidetector CT findings

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

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

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

Endovascular treatment of an aortobronchial fistula caused by a distal aortic arch mycotic aneurysm: report of a case

We report a case of an aortobronchial fistula causing massive hemoptysis, which was managed by emergency stent grafting. Although this procedure was successful initially, the aortobronchial fistula appeared again 7 months later. Aneurysmectomy, followed by rifampicin-soaked gelatin sealed polyester graft replacement and omentopexy, was performed under cardiopulmonary bypass. The patient, a 73-year-old woman, had an uneventful postoperative course and the infection was eradicated.

A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta

BACKGROUND

Successful repair of the ruptured (non-traumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), we describe our experience with TEVAR and DTAR in this high-risk setting to elucidate their evolving roles.

METHODS

Since the inception of our thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal (1) fistulae were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean 37.4 months).

RESULTS

Mean age was 65.9 years (DTAR 60.3 year vs TEVAR 71.3 years, P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR n = 4; 11.4% vs DTAR n = 9; 26.5%, P = .13). Median length of stay was shorter after TEVAR (8 days vs DTAR 15 days, P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR 67.4 months vs DTAR 65.0 months, P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02).

CONCLUSION

An endovascular approach for the ruptured (non-traumatic) descending thoracic aorta reduces early morbidity, mortality, and duration of hospitalization, while providing equivalent late outcomes even in an older group largely considered high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture.

Emergency endovascular repair of a ruptured descending thoracic aortic aneurysm in an octogenarian: report of a case

Emergency conventional surgical repair of the descending thoracic aorta remains a therapeutic challenge and is associated with a high risk of mortality. We describe a case of ruptured descending thoracic aortic aneurysm in an 87-year-old man who presented with chest and back pain. The patient underwent successful endovascular repair of the lesion with the use of Gore TAG thoracic endoprosthesis. Post-procedure computed tomography showed complete exclusion of the aneurysm without endoleaks. Endovascular repair is feasible and can be effective in such cases.

Degree of fusiform dilatation of the proximal descending aorta in type B acute aortic dissection can predict late aortic events

OBJECTIVE

Predicting the risk factors for late aortic events in patients with type B acute aortic dissection without complications may help to determine a therapeutic strategy for this disorder. We investigated whether late aortic events in type B acute aortic dissection can be predicted accurately by an index that expresses the degree of fusiform dilatation of the proximal descending aorta during the acute phase; this index can be calculated as follows: (maximum diameter of the proximal descending aorta)/(diameter of the distal aortic arch + diameter of the descending aorta at the pulmonary artery level).

METHODS

Patients with type B acute aortic dissection without complications (n = 141) were retrospectively analyzed to determine the predictors of late aortic events; these include aortic dilatation, rupture, refractory pain, organ ischemia, rapid aortic enlargement, and rapid enlargement of ulcer-like projections.

RESULTS

The fusiform index in patients with late aortic events (0.59) was higher than that in patients without late aortic events (0.53, P < .01). Patients with a higher fusiform index exhibited aortic dilatation earlier than those with a lower fusiform index. By multivariate analysis, we conclude that the predominant independent predictors of late aortic events were a maximum aortic diameter of 40 mm or more, a patent false lumen, and a fusiform index of 0.64 or more (hazard ratios, 3.18, 2.64, and 2.73, respectively). The values of actuarial freedom from aortic events for patients with all 3 predictors at 1, 5, and 10 years were 22%, 17%, and 8%, respectively, whereas the values in those without these predictors were 97%, 94%, and 90%, respectively.

CONCLUSIONS

The degree of fusiform dilatation of the proximal descending aorta, a patent false lumen, and a large aortic diameter can be predominant predictors of late aortic events in patients with type B acute aortic dissection. Patients with these predictors should be recommended to undergo early interventions (surgery or stent-graft implantation) or at least be closely followed up during the chronic phase before such events develop.

Anatomic exclusion from endovascular repair of thoracic aortic aneurysm

OBJECTIVES

We sought to define the current anatomic barriers to thoracic aortic aneurysm (TAA) stent grafting to guide future device development.

METHODS

All patients presenting with TAA requiring repair were evaluated for endovascular repair during a 4-year period (2000 to 2004). The TAAs evaluated were those beginning distal to the left common carotid artery (LCCA) and ending proximal to the celiac artery. All patients in whom endovascular repair was indicated underwent cross-sectional imaging by computed tomography angiography and three-dimensional modeling of their thoracic and abdominal arterial anatomy. Patients were evaluated for endovascular TAA repair in the context of the inclusion/exclusion criteria of pivotal United States Food and Drug Administration trials of the Gore TAG and Medtronic Talent devices. Anatomic requirements included >or=20 mm of suitable proximal and distal neck length, and proximal and distal neck diameters of 20 to 42 mm. These trials allowed the use of femoral or iliac access, including the use of conduits, and permitted stent graft coverage of the left subclavian artery (LSA) after preliminary carotid-subclavian bypass. Patients rejected for medical reasons or who died during evaluation were not included in the review.

RESULTS

A total of 126 patients (73 men, 53 women) with TAA located between the LCCA and celiac artery were screened for endovascular repair, and 33 (26%) were rejected for anatomic reasons. The remaining 93 patients underwent endografting (59 Talent, 34 TAG). Rejection was not significantly different by gender (16/73 men, 17/53 women, P = .22, NS). Most patients (28/33) were rejected for more than one criterion. Hostile proximal neck characteristics were the most prevalent reason for disqualification, despite the ability to cover the LSA to extend the proximal seal zone. Many of these patients (16/28) also had distal neck anatomy unsuitable for grafting. Overall, 19 patients had hostile distal necks. Difficulties with vascular access (diseased or tortuous iliac arteries, or a small caliber aorta) that could not be overcome even by use of conduits occurred in a significant fraction of patients (10/33).

CONCLUSIONS

Most patients with a TAA located between the LCCA and the celiac artery can be treated by endovascular repair. Patients excluded from TAA stent graft protocols for anatomic reasons most commonly have hostile proximal neck features that preclude endovascular repair with currently available devices. Transposition of arch vessels to facilitate greater use of existing stent grafts or development of new stent graft designs are needed to expand the applicability of TAA endovascular repair.

Emergency stent-grafting for patients over 85 years of age with thoracic aortic rupture

Conventional open repairs of thoracic aortic ruptures carry a high mortality and morbidity in patients over 85 years of age. Less invasive procedures may therefore be required to treat such elderly patients. An 87-year-old woman and 92-year-old man who had undergone emergency endovascular stent-grafting for thoracic aortic ruptures survived to discharge, despite critical conditions on admission.

Endovascular stent-graft placement for vascular failure of the thoracic aorta

It still remains undetermined whether endovascular stent-graft placement (ESGP) is the optimal initial treatment for elective cases of thoracic aortic disease because of unknown long-term results. However, it is also recognized that ESGP contributes to better outcome as an initial treatment for aortic emergency, such as rupture, aortic injury, and complicated acute type B aortic dissection. Despite the fact that most patients are elderly, early mortality rates of ESGP are reportedly around 10% in cases of ruptured degenerative thoracic aortic aneurysm. Postoperative morbidity is also superior in ESGP compared with conventional open repair. Postoperative paraplegia has rarely occurred with ESGP. In cases of blunt aortic injury (BAI), other complications may also be present because of other serious injuries. ESGP has changed the surgical strategy for BAI and partially resolved some of the clinical dilemmas. Early mortality rate is almost zero when a stent graft can be placed before re-rupture. While BAI is a very good indication for ESGP, young patients need careful management and attention because of the unknown long-term outcome. In cases of complicated acute type B aortic dissection, the two main determinants of death, shock from rupture and visceral ischemia, could be managed by ESGP with or without conventional endovascular interventions. Recent reports disclosed less than 10% early mortality with ESGP for complicated acute aortic dissection. Even if the possibility of endotension remains, ESPG seems to be beneficial for these critical patients as the preferable initial treatment. The importance of close follow-up should be stressed to avoid some devastating late complications following ESGP.

Endovascular stent-graft repair of penetrating descending thoracic aortic ulcer

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients.

Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: A multicenter comparative trial

OBJECTIVE

Results are presented from the first completed multicenter trial directed at gaining approval from the US Food and Drug Administration of endovascular versus open surgical repair of descending thoracic aortic aneurysms.

METHODS

Between September 1999 and May 2001, 140 patients with descending thoracic aneurysms were enrolled at 17 sites and evaluated for a Gore TAG Thoracic Endograft. An open surgical control cohort of 94 patients was identified by enrolling historical and concurrent subjects. Patients were assessed before treatment, at treatment, and at hospital discharge and returned for follow-up visits at 1 month, 6 months, and annually thereafter.

RESULTS

One hundred thirty-seven of 140 patients had successful implantation of the endograft. Perioperative mortality in the endograft versus open surgical control cohort was 2.1% (n = 3) versus 11.7% (n = 11, P < .001). Thirty-day analysis revealed a statistically significant lower incidence of the following complications in the endovascular cohort versus the surgical cohort: spinal cord ischemia (3% vs 14%), respiratory failure (4% vs 20%), and renal insufficiency (1% vs 13%). The endovascular group had a higher incidence of peripheral vascular complications (14% vs 4%). The mean lengths of intensive care unit stay (2.6 +/- 14.6 vs 5.2 +/- 7.2 days) and hospital stay (7.4 +/- 17.7 vs 14.4 +/- 12.8 days) were significantly shorter in the endovascular cohort. At 1 and 2 years' follow-up, the incidence of endoleaks was 6% and 9%, respectively. Through 2 years of follow-up, there were 3 reinterventions in the endograft cohort and none in the open surgical control cohort. Kaplan-Meier analysis revealed no difference in overall mortality at 2 years.

CONCLUSIONS

In this multicenter study early outcomes with descending aortic endovascular stent grafting were very encouraging when compared with those of a well-matched surgical cohort. However, at 2 years' follow-up, there is an incidence of endoleaks and reinterventions associated with endovascular versus open surgical repair. Continued vigilant surveillance of patients treated with an endograft is important.

Placement of endovascular stent-grafts for emergency repair of acute traumatic aortic rupture: a single-centre experience

The aim of this retrospective study was to evaluate mid- and long-term results of endovascular stent-graft placement for emergency repair of acute traumatic thoracic aortic rupture. From 1996 through 2005, 22 consecutive patients (mean age: 38.7 years) underwent endovascular repair of acute traumatic thoracic aortic rupture located at the aortic isthmus in most cases. All patients were at high surgical risk due to severe associated injuries. The endografts were inserted via femoral or iliac artery access under fluoroscopic guidance. Follow-up was performed postinterventionally, at 6 and 12 months and yearly thereafter, and included clinical examination and computed tomography (CT) scans. Technical and clinical success rates were 86.3%. Mean follow-up was 31.7 months. Three patients developed early type I endoleak due to the inability of the rigid graft to adapt to the curved aortic contour. In two of them conversion to open surgery was necessary. One patient had late type I endoleak and died. No other complications were observed. The outcome was successful in most patients. The mid- and long-term results of our current study are promising. However, early type I endoleak represents a problem, especially in adolescent patients with a marked curvature of the aortic arch.