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Rudra P, Cardoso R, Echevarria S, Kaya B, Abdullah R, Baskara Salian R, Bhindar SZ, Zerin A, Patel T, Abdin Z, Al-Tawil M. Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e41078. [PMID: 37519486 PMCID: PMC10375940 DOI: 10.7759/cureus.41078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Blunt aortic injury is the second most prevalent cause of patient fatalities post-trauma, closely following head injuries as the leading cause. In recent years, thoracic endovascular aortic repair (TEVAR) has evidently improved survival rates and reduced complications in patients suffering from blunt traumatic aortic injury (BTAI) in comparison to open surgery and non-operative management. It is difficult to characterize the appropriate criteria for the timing of TEVAR, whether early or delayed for BTAI, considering the discrepancies related to timing. Electronic databases, including PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase, were searched through April 2023. The primary outcomes were short-term mortality and hospital and intensive care unit (ICU) stays. Time to TEVAR, acute respiratory distress syndrome, sepsis, deep vein thrombosis, delayed stroke, and renal failure were also evaluated. We included a total of seven studies, comprising 4177 patients who met the inclusion criteria. Short-term mortality was significantly higher in the early TEVAR group (RR: 1.86; 95% confidence interval (CI); (1.26-2.74); p<0.001; I2=33%). In contrast, the ICU length of stay was significantly shorter in the early group (mean difference: -2.82 days; 95% CI; (-4.09 - -1.56); p<0.0001; I2=55%). There was no significant difference between both groups in the presenting profile or postoperative complications. Patients undergoing delayed TEVAR had markedly lower mortality rates but a longer ICU stay. The need for future studies with more robust designs is imperative to investigate the factors influencing the timing of repair and the associated outcomes.
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Affiliation(s)
- Pranathi Rudra
- Internal Medicine, Gandhi Medical College, Secunderabad, IND
| | - Rayner Cardoso
- Medical School, All India Institue of Medical Sciences, Jodhpur, IND
| | | | - Berfin Kaya
- Obstetrics and Gynaecology, Faculty of Medicine, Izmir Kâtip Celebi University, Izmir, TUR
| | - Ramal Abdullah
- Medical School, Foundation University Medical College, Foundation University School of Health Sciences (FUSH), Islamabad, PAK
| | | | - Shah Zaib Bhindar
- Orthopaedic Surgery, Ghurki Trust and Teaching Hospital, Lahore, PAK
| | - Annu Zerin
- Internal Medicine, All India Institute of Medical Sciences, Bhubaneswar, IND
| | - Tirath Patel
- Medical School, American University of Antigua, St. John's, ATG
| | - Zain Abdin
- Critical Care Medicine, IMG Helping Hands, Albuquerque, USA
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Ghanem M, Meyer F, Halloul Z. Covering/Overstenting of the left subclavian artery (LSA) in thoracic endovascular repair (TEVAR) to treat various thoracic/thoracoabdominal aortic lesions: Is revascularization of the left arm a must?
(A retrospective cohort study with 12 years of experience to describe the real-world situation of daily clinical practice and the literature review). POLISH JOURNAL OF SURGERY 2022. [DOI: 10.5604/01.3001.0015.7090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Pathologies of the descending thoracic aorta inwardly extended towards the aortic arch actually shorten the proximal landing zone for aortic prosthesis. This, in turn, worsens the feasibility of the aorta for endovascular therapeutic options of those pathologies.
Objective: This work considers the blockage of the left subclavian artery (LSA) through endovascular treatment of the pathologies of the descending aorta as a main work question, which is based on the hypothesis that there is no necessity for primary standard revascularization of the LSA in TEVAR with LSA covering. The researchers have 12 years of experience in treatment of different thoracic aortic lesions. Their experience will also be reviewed in this paper.
Design: Retrospective unicenter cohort study in consecutive patients order to describe the real-world situation of daily clinical practice
Material: All the patients who had undergone endovascular, hybrid, or open operative therapy of variant pathologies of descending aorta were included in this study.
Methods: Various parameters were investigated, including therapeutic procedures such as i) pure endovascular vs. hybrid; ii) year of therapy; iii) symptomatic vs. asymptomatic status of the patients; iv) variant epidemiological factors (age, sex, risk factors, mortality, and follow up); v) overstenting/blocking of the LSA; vi) complications of applied therapies; vii) further operations/interventions to treat such complications; viii) radiologic aortic measurements (such as lumen extensions, false lumen measurements, distance to the supra-aortic and visceral vessels); and ix) multiple other pathological features. Different statistical parameters were also examined. Survival was analysed by the Kaplan–Meier assessment in the group of whole patients vs. the group of over-stented patients. Here the analysis of variance is performed for the independent parameters for the revascularized patients—not the revascularized patients—who had undergone LSA coverage. For statistical approval, U-test was used. The p-value < 0.05 was considered significantly different. The literature review was achieved by a search in PubMed, Google scholar, Research Gate, ScienceDirect, and Cochrane library by using the following terms endovascular, TEVAR, revascularization, stroke, and left-subclavian-artery ischemia. The literature is classified accordingly in relation to the main topic. In fact, the literature undergoes further analysis if it goes with or against our hypothesis.
Results: Overall, 112 patients were enrolled in the study. There was no significant difference comparing the not-revascularized vs. the revascularized group of patients, considering the consequences on cerebrovascular blood circulation (in particular, n=1 case [4.8 %] vs. no case [0 %]; p=1) or the spinal cord ischemia (n=2 [9.5 %] vs. n=1 [7.1 %]; p=1). As the main result, there was no case of manifest left arm ischemia and deaths (mortality, 0). Survival was in both groups as follows: 22 [95% CI, 14.154–29.904] months vs. 43 [95% CI, 33.655–51.921] months with no significant statistical difference (p>0.05) . The only statistically significant risk factor found was renal insufficiency (p, 0.028), but this too is considered a trend by the urgency of revascularization. Postoperatively, pneumonia showed a trend of higher frequency (p=0.058) in the revascularized cases (n=0 in the not-revascularized vs. n=3 [21.4 %] in the revascularized cases). There was no significant difference in the occurance of postoperative neurovascular complications (such as cerebrovascular accidents, spinal cord ischemia, or left arm ischemia) by comparing the groups of not-revascularized and revascularized patients.
Conclusion: The revascularization of the overstented LSA due to TEVAR should be limited to certain indications, including i) the inadequate intracerebral circle of Willis; ii) the predominantly perfused left vertebral artery with inadequate blood perfusion via the right vertebral artery (e.g., by stenosis), iii) anatomic variance such as the left vertebral artery originating directly from the aortic arch (and must be blocked by TEVAR); iv) the need of an adequate left internal thoracic artery for coronary-artery-bypass grafting (CABG); v) the need of patent LSA for the dialysis shunt of the left arm. However, there is no appropriate evidence as yet based on sufficient study results achieved in trials with an advanced design (such as [double-]blind, multicenter randomized study) that appears to be urgently required.
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Affiliation(s)
- Mohammad Ghanem
- Division of Vascular Surgery; Department of General, Abdominal, Vascular and Transplant Surgery; Otto-von-Guericke University with University Hospital; Magdeburg, Germany
| | - Frank Meyer
- Dept. of General, Abdominal and Vascular Surgery, University Hospital at Magdeburg, Magdeburg (Germany)
| | - Zuhir Halloul
- Division of Vascular Surgery; Department of General, Abdominal, Vascular and Transplant Surgery; Otto-von-Guericke University with University Hospital; Magdeburg, Germany
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Zhu C, Piao H, Wang Y, Li B, Zhang Y, Xu J, Wang T, Zhu Z, Xu R, Li D, Liu K. A New Aortic Arch Inclusion Technique with Frozen Elephant Trunk for Aortic Arch Aneurysm Treatment. Int Heart J 2020; 61:1229-1235. [PMID: 33116020 DOI: 10.1536/ihj.20-069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Various surgical techniques have been proposed for treating aortic arch aneurysm (AAA); however, the optimal treatment has not been well defined. This study introduces a new aortic arch inclusion technique with frozen elephant trunk (FET) for AAA treatment.A retrospective analysis was performed among 22 patients for AAA surgical treatment between March 2010 and March 2019. Patients were classified into Z1, Z2, and Z3 groups based on the origins of aneurysms. A stent graft with a 10 cm stented graft and 5-9 cm proximal vascular prosthesis was released into the descending thoracic aorta as FET through an incision in the aortic arch. The proximal vascular prosthesis was retracted into the aortic arch, trimmed to expose the orifices of the brachiocephalic vessels, and sutured inside the aortic arch using the inclusion technique. The proximal sealing location of the vascular graft was tailored to cover the origins of aneurysms.There was no 30-day mortality. No patient had postoperative stroke or paraplegia. Complete aneurysm thrombosis was achieved in all patients. One patient died of severe respiratory tract stenosis 3 months postoperatively. All other 21 patients were alive during 53.3 ± 36.5-month follow-up. Computed tomography angiography was obtained in 15 patients during follow-up. Endoleak was observed in one patient, and the other 14 patients were free from aneurysm-related or graft-related complications during follow-up.The aortic arch inclusion technique with FET provides an alternative technique in treating AAA with satisfactory mid-term follow-up results. A larger patient population with long-term follow-up results is warranted.
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Affiliation(s)
- Cuilin Zhu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Hulin Piao
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Yong Wang
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Bo Li
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Yixin Zhang
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Jinyu Xu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Tiance Wang
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Zhicheng Zhu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Rihao Xu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Dan Li
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Kexiang Liu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
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Sarquis LM, Michaelis W, Santos AL, Yokoyama RA, Delazeri MV, Martins ALDC, Martins RK, Gazola BB. Endovascular treatment of penetrating thoracic aorta injury - case report. J Vasc Bras 2020; 19:e20200132. [PMID: 34211531 PMCID: PMC8217996 DOI: 10.1590/1677-5449.200132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/04/2020] [Indexed: 11/24/2022] Open
Abstract
In the current scenario, traumas with violent causes are responsible for large numbers of cases. Among these, thoracic aorta injury caused by penetrating trauma is a cause of elevated morbidity and mortality, demanding adequate diagnosis, and can now often be repaired using endovascular procedures. This treatment method has proven to be safer, with a lower rate of complications than open surgical procedures. After endovascular repair, it is necessary to conduct continuous monitoring of the patient's health and correct any complications related to the procedure that may emerge. The objective of this article is to describe a case of penetrating trauma of the thoracic aorta that was treated endovascularly, since the literature predominantly covers blunt trauma injuries.
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Affiliation(s)
| | - Wilson Michaelis
- Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil.
| | | | - Rogerio Akira Yokoyama
- Hospital do Trabalhador, Curitiba, PR, Brasil.
- Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil.
| | - Mariana Vieira Delazeri
- Hospital do Trabalhador, Curitiba, PR, Brasil.
- Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil.
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Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Nurs 2016; 22:99-110. [PMID: 25768967 DOI: 10.1097/jtn.0000000000000118] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.
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Review of short-term outcomes for TEVAR after blunt traumatic aortic injury. J Trauma Acute Care Surg 2015; 78:1210-5. [PMID: 26151524 DOI: 10.1097/ta.0000000000000659] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Attinà D, Buia F, Russo V, Pilato E, Lovato L, Bartolomeo RD, Zompatori M. Endovascular treatment of an aortic traumatic double rupture. J Cardiovasc Thorac Res 2015; 7:38-40. [PMID: 25859315 PMCID: PMC4378674 DOI: 10.15171/jcvtr.2015.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/31/2015] [Indexed: 11/09/2022] Open
Abstract
Traumatic thoracic aortic rupture is a life-threatening condition; aortic isthmus is the most common site of rupture, but in rare cases traumatic injury can localize elsewhere, such as at aortic arch or at the level of the diaphragm. In the past few years, endovascular treatment of traumatic aortic injury became a safe procedure, with lower mortality and complication, if compared with open surgery. We report a case of a 40-year-old-man admitted to emergency department after a violent car crash in which an aortic traumatic double rupture was successfully treated with two endovascular stent-grafts coverage.
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Affiliation(s)
- Domenico Attinà
- Cardio-Thoracic-Vascular Department, Cardiothoracic Radiology Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Francesco Buia
- Cardio-Thoracic-Vascular Department, Cardiothoracic Radiology Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Vincenzo Russo
- Cardio-Thoracic-Vascular Department, Cardiothoracic Radiology Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Emanuele Pilato
- Cardio-Thoracic-Vascular Department, Cardiac Surgery Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Luigi Lovato
- Cardio-Thoracic-Vascular Department, Cardiothoracic Radiology Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardio-Thoracic-Vascular Department, Cardiac Surgery Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Maurizio Zompatori
- Cardio-Thoracic-Vascular Department, Cardiothoracic Radiology Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy
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Antonopoulos CN, Sfyroeras GS, Kallinis A, Kakisis JD, Liapis CD, Petridou ET. Epidemiology of concomitant injuries in traumatic thoracic aortic rupture: a meta-analysis. Vascular 2014; 22:395-405. [PMID: 24459130 DOI: 10.1177/1708538113518205] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic thoracic aortic rupture is a highly lethal injury. For those who arrive alive at the hospital, it is of utmost importance to quickly evaluate concomitant injuries and prioritize therapeutic interventions. We aimed to review the frequency of concomitant injuries in patients with thoracic aortic rupture, according to anatomic location and type of injury. A systematic literature search of six medical databases led to the identification of 90 publications; 27 categories of thoracic aortic rupture concomitant injuries were thereafter created. The respective pooled proportions and 95% confidence intervals were calculated and ranked in order of frequency. Among the 7258 patients studied, orthopedic fractures were the most frequent thoracic aortic rupture concomitant injury, amounting to a high pooled proportion of almost 70%, followed by thoracic injury in ∼50% and abdominal injury in over 40%. Pooled proportion for any type of head injury was also high (37%) pointing to the multiple-injury type of lesions among thoracic aortic rupture victims. Thoracic aortic rupture is a devastating injury, but rarely occurs as a sole traumatic entity. The recognition of concomitant thoracic, abdominal, head injuries and fractures after thoracic aortic rupture is of paramount importance. Future studies should focus on the impact of these injuries upon survival, morbidity and disability of multiple-injured thoracic aortic rupture patients.
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Affiliation(s)
- Constantine N Antonopoulos
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece Department of Hygiene, Epidemiology and Medical Statistics, Athens University, Medical School, Athens, Greece
| | - George S Sfyroeras
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - Aristides Kallinis
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - John D Kakisis
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - Christos D Liapis
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - Eleni Th Petridou
- Department of Hygiene, Epidemiology and Medical Statistics, Athens University, Medical School, Athens, Greece
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Di Eusanio M, Folesani G, Berretta P, Petridis FD, Pantaleo A, Russo V, Lovato L, Di Bartolomeo R. Delayed Management of Blunt Traumatic Aortic Injury: Open Surgical Versus Endovascular Repair. Ann Thorac Surg 2013; 95:1591-7. [DOI: 10.1016/j.athoracsur.2013.02.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 02/13/2013] [Accepted: 02/25/2013] [Indexed: 10/27/2022]
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Steuer J, Wanhainen A, Thelin S, Nyman R, Eriksson MO, Björck M. Outcome of endovascular treatment of traumatic aortic transection. J Vasc Surg 2012; 56:973-8. [DOI: 10.1016/j.jvs.2012.03.259] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/21/2012] [Accepted: 03/21/2012] [Indexed: 10/28/2022]
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Canaud L, Alric P, Branchereau P, Joyeux F, Hireche K, Berthet JP, Marty-Ané C. Open versus endovascular repair for patients with acute traumatic rupture of the thoracic aorta. J Thorac Cardiovasc Surg 2011; 142:1032-7. [DOI: 10.1016/j.jtcvs.2010.11.051] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 11/04/2010] [Accepted: 11/19/2010] [Indexed: 11/29/2022]
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Endovascular Repair Compared With Operative Repair of Traumatic Rupture of the Thoracic Aorta: A Nonsystematic Review and a Plea for Trauma-Specific Reporting Guidelines. ACTA ACUST UNITED AC 2011; 71:1059-72. [DOI: 10.1097/ta.0b013e3182288783] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reynolds TS, Donayre CE, Somma CG, Poggio WG, Kim KM, Nguyen T, White R. Endovascular management of blunt aortic injury with an associated aberrant right subclavian artery: a report of three cases. Ann Vasc Surg 2011; 25:979.e7-12. [PMID: 21764549 DOI: 10.1016/j.avsg.2011.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2010] [Revised: 04/25/2011] [Accepted: 05/12/2011] [Indexed: 11/17/2022]
Abstract
Traumatic rupture of the aorta in the rare setting of the aberrant right subclavian artery (ARSA) requires special consideration to prevent the occurrence of a devastating posterior cerebral circulation stroke. We present three cases managed by using an endovascular approach, with a discussion of important preoperative and operative issues. Three patients involved in motor vehicle collisions with multiple injuries were managed at two institutions. Computed tomography revealed transection of the aorta with incidental ARSA. All three cases were managed with a different approach. One patient did not undergo a preoperative bypass because imaging confirmed an adequate landing zone distal to the origin of the left subclavian artery. Two patients received preoperative right carotid-to-subclavian bypass for anticipated endograft coverage of both subclavian arteries to preserve single vertebral arterial flow. In one patient, an endovascular occlusion device was deployed in the ARSA before aortic endograft deployment. In the other, ARSA occlusion was performed 4 days later for a persistent type II endoleak. The patient who underwent bypass and preoperative ARSA occlusion suffered a fatal posterior circulation stroke shortly after surgery. The other two patients had no procedural complications and have not required any reinterventions at follow-up after 2 and 5 years. One patient is still undergoing rehabilitation after 5 years of follow-up for traumatic brain injury unrelated to the endograft repair. Although the incidence of ARSA is very low, preoperative imaging and assessment of cerebral blood flow are critical to prevent a perioperative stroke. Revascularization, if required to achieve a secure proximal landing zone, must be performed before endograft deployment. Bilateral subclavian revascularization is indicated if anomalies of the cerebral circulation are present.
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Affiliation(s)
- Tyler S Reynolds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
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Sugiura T, Imoto K, Uchida K, Yanagi H, Machida D, Okiyama M, Yasuda S, Manaka H. Evaluation of the vertebrobasilar system in thoracic aortic surgery. Ann Thorac Surg 2011; 92:568-70. [PMID: 21704975 DOI: 10.1016/j.athoracsur.2011.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 04/03/2011] [Accepted: 04/06/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND We evaluated the probability of vertebrobasilar system malperfusion due to occlusion of the left subclavian artery as assessed by preoperative magnetic resonance angiography in patients scheduled to undergo thoracic aortic surgery. METHODS (Study 1) From January 2000 through March 2009, we studied variations of vertebral arteries in 301 patients scheduled to undergo thoracic aortic surgery. We classified vertebral artery variations into 3 categories according to the findings on preoperative magnetic resonance angiography: connection type, interrupted right vertebral artery, and interrupted left vertebral artery. (Study 2) From February 2007 through January 2010, we evaluated the cerebral complication in 41 patients who had occlusion of the left subclavian artery with a stent graft. RESULTS (Study 1) On preoperative magnetic resonance angiography, the vertebral artery was classified as connection type in 247 patients, interrupted right vertebral artery in 34, and interrupted left vertebral artery in 20. (Study 2) We performed subclavian obstruction test, left-right subclavian artery bypass, or left subclavian artery-left common carotid artery bypass to the 3 patients with interrupted right vertebral artery, respectively. Forty patients (98%) out of 41 patients had no complication after occlusion of the left subclavian artery. CONCLUSIONS Preoperative magnetic resonance angiography is useful for detection of the patients with high risk of vertebrobasilar system malperfusion due to occlusion of the left subclavian artery.
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Affiliation(s)
- Tadahisa Sugiura
- Cardiovascular Center, Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan.
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Management of the Left Subclavian Artery during Endovascular Stent Grafting for Traumatic Aortic Injury – A Systematic Review. Eur J Vasc Endovasc Surg 2011; 41:758-69. [DOI: 10.1016/j.ejvs.2011.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 01/04/2011] [Indexed: 11/19/2022]
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17
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Cindy M, Sabrina H, Kim D, Geert M, Inge F. Traumatic Aortic Rupture: 30 Years of Experience. Ann Vasc Surg 2011; 25:474-80. [DOI: 10.1016/j.avsg.2010.12.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 12/03/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
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18
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Weigang E, Parker JA, Czerny M, Lonn L, Bonser RS, Carrel TP, Mestres CA, Di Bartolomeo R, Schepens MA, Bachet JE, Vahl CF, Grabenwoger M. Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation? Eur J Cardiothorac Surg 2011; 40:858-68. [DOI: 10.1016/j.ejcts.2011.01.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 01/18/2011] [Accepted: 01/20/2011] [Indexed: 11/16/2022] Open
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Mosquera VX, Marini M, Lopez-Perez JM, Muñiz-Garcia J, Herrera JM, Cao I, Cuenca JJ. Role of conservative management in traumatic aortic injury: comparison of long-term results of conservative, surgical, and endovascular treatment. J Thorac Cardiovasc Surg 2011; 142:614-21. [PMID: 21269644 DOI: 10.1016/j.jtcvs.2010.10.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 09/29/2010] [Accepted: 10/24/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study is to compare early and long-term results in terms of survival and cardiovascular complications of patients with acute traumatic aortic injury who were conservatively managed with patients who underwent surgical or endovascular repair. METHODS From January 1980 to December 2009, 66 patients with acute traumatic aortic injury were divided into 3 groups according to treatment intention at admission: 37 patients in a conservative group, 22 patients in a surgical group, and 7 patients in an endovascular group. Groups were similar with regard to gender, age, Injury Severity Score, Revised Trauma Score, and Trauma Injury Severity Score. RESULTS In-hospital mortality was 21.6% in the conservative group, 22.7% in the surgical group, and 14.3% in the endovascular group (P = .57). In-hospital aortic-related complications occurred only in the conservative group. Median follow-up time was 75 months (range, 5-327 months). Conservative group survival was 75.6% at 1 year, 72.3% at 5 years, and 66.7% at 10 years. Surgical group survival remained at 77.2% at 1, 5, and 10 years, whereas survival in the endovascular group was 85.7% at 1 and 5 years (P = .18). No patient in the surgical or endovascular group required reintervention because of aortic-related complications, whereas 37.9% of the conservative group had an aortic-related complication that required surgery or caused the patient's death during the follow-up period. Cumulative survival free from aortic-related complications in the conservative group was 93% at 1 year, 88.5% at 5 years, and 51.2% at 10 years. Cox regression confirmed the initial type of aortic lesion (hazard ratio, 2.94; P = .002) and a Trauma Score-Injury Severity Score greater than 50% on admission (hazard ratio, 1.49; P = .042) as risk factors for the appearance of aortic-related complications. Two peaks in the complication rate of the conservative group were detected in the first week and between the first and third months after blunt thoracic trauma. CONCLUSIONS The advent of thoracic aortic endografting has enabled a revolution in the management of acute traumatic aortic injury in patients with multisystem trauma with a low in-hospital morbimortality. Nonoperative management may be only a therapeutic option with acceptable survival in carefully selected patients. The natural history of these patients has revealed a marked trend of late aortic-related complications developing, which may justify an endovascular repair even in some low-risk patients.
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Affiliation(s)
- Victor X Mosquera
- Department of Cardiac Surgery, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
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Murad MH, Rizvi AZ, Malgor R, Carey J, Alkatib AA, Erwin PJ, Lee WA, Fairman RM. Comparative effectiveness of the treatments for thoracic aortic transaction. J Vasc Surg 2011; 53:193-199.e1-21. [DOI: 10.1016/j.jvs.2010.08.028] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 08/10/2010] [Accepted: 08/10/2010] [Indexed: 11/15/2022]
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Mousa AY, Dombrovskiy VY, Haser PB, Graham AM, Vogel TR. Thoracic Aortic Trauma: Outcomes and Hospital Resource Utilization after Endovascular and Open Repair. Vascular 2010; 18:250-5. [DOI: 10.2310/6670.2010.00039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has evolved as a treatment option for the management of thoracic aortic trauma as an alternative to open thoracic aortic repair (OTAR). Population-level outcomes are not known and were evaluated. Secondary data analysis of the 2005–2006 Nationwide Inpatient Sample data was performed, and 1,561 patients with thoracic aortic injury (mean age 44.8 ± 18.8 years; men 77.2%) were identified. Of these, 510 underwent emergent surgical intervention: 240 OTAR (47%) and 270 TEVAR (53%). Males were more likely to undergo any surgery (77.2% vs 22.8%; p = .03). Hospital mortality after OTAR was greater compared to TEVAR (14.61% vs 7.43%; p = .009). OTAR patients were more likely to have pulmonary complications (37.8% vs 21.65; p < .0001) but were less likely to have stroke (2.1% vs 5.8%; p = .03) compared to TEVAR patients. After adjustment, OTAR patients remained more likely to die compared to TEVAR patients (OR 11.5; 95% CI 4.0–33.2). Hospital length of stay and hospital cost were significantly greater for OTAR than for TEVAR. An increase in patients with thoracic aortic injury undergoing repair was found (23.0% vs 40.3%; p < .0002). In trauma, TEVAR was associated with decreased hospital mortality, hospital use, and pulmonary complications but increased rates of stroke. Further implementation of TEVAR for management of thoracic aortic trauma may improve future outcomes and reduce hospital resource use.
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Affiliation(s)
- Albeir Y. Mousa
- *Division of Vascular Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, The Surgical Outcomes Research Group, New Brunswick, NJ
| | - Viktor Y. Dombrovskiy
- *Division of Vascular Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, The Surgical Outcomes Research Group, New Brunswick, NJ
| | - Paul B. Haser
- *Division of Vascular Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, The Surgical Outcomes Research Group, New Brunswick, NJ
| | - Alan M. Graham
- *Division of Vascular Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, The Surgical Outcomes Research Group, New Brunswick, NJ
| | - Todd R. Vogel
- *Division of Vascular Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, The Surgical Outcomes Research Group, New Brunswick, NJ
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Morgan TA, Steenburg SD, Siegel EL, Mirvis SE. Acute traumatic aortic injuries: posttherapy multidetector CT findings. Radiographics 2010; 30:851-67. [PMID: 20219840 DOI: 10.1148/rg.303105009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Tara A Morgan
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center and University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201, USA
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Reply to the Editor. J Thorac Cardiovasc Surg 2009. [DOI: 10.1016/j.jtcvs.2009.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Murphy EH, Dimaio JM, Dean W, Jessen ME, Arko FR. Endovascular Repair of Acute Traumatic Thoracic Aortic Transection With Laser-Assisted In-Situ Fenestration of a Stent-Graft Covering the Left Subclavian Artery. J Endovasc Ther 2009; 16:457-63. [DOI: 10.1583/09-2746.1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Canaud L, Alric P. Endovascular treatment for acute transection of the descending thoracic aorta. J Thorac Cardiovasc Surg 2009; 138:515-6; author reply 516-7. [PMID: 19619814 DOI: 10.1016/j.jtcvs.2009.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 04/11/2009] [Indexed: 11/25/2022]
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