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Muggenthaler H, Bismann D, Eckardt N, Gassler N, Hubig M, Subramaniam JS, Mall G. Delayed occurrence of traumatic aortic dissection? Biomechanical considerations and literature. Int J Legal Med 2023; 137:353-357. [PMID: 36527463 PMCID: PMC9902402 DOI: 10.1007/s00414-022-02935-6] [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: 06/13/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
Chronic aortic dissections and pseudoaneurysms caused by chest trauma are rare and generally have to be critically distinguished from non-traumatic dissections and aneurysms. We present a well-documented case of a post-traumatic aortic dissection that ruptured about 9 months after chest trauma. A motorcyclist sustained fractures of the forearm and chest trauma with paravertebral rib serial fractures and hemopneumothorax. Nine months after the accident, echocardiography revealed a pseudoaneurysm that ruptured 3 months later and 1 month prior to the planned surgery. An autopsy showed pericardial tamponade following a rupture of the dissected aorta. Accident scene documentation was consistent with a head-on collision of the motorcycle against the left front side of the car. The relative speed was about 55 km/h. Aggravation of unspecific symptoms after discharge, initial CT imaging, and the absence of atherosclerosis or medial necrosis hold for a post-traumatic genesis of the dissection in our case. Initially, the accident insurance company rejected the regulation. In the second instance, they revised rejection based on our interdisciplinary expert opinion.
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Affiliation(s)
- H. Muggenthaler
- Institute of Legal Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - D. Bismann
- DEKRA Automobil GmbH, Auf dem Mittelfeld 3, 98693 Ilmenau Ilmenau, Germany
| | - N. Eckardt
- Department of Radiology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - N. Gassler
- Section Pathology, Institute of Legal Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - M. Hubig
- Institute of Legal Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | | | - G. Mall
- Institute of Legal Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
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2
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Edwards R, Khan N. Traumatic aortic injury: Computed tomography angiography imaging and findings revisited in patients surviving major thoracic aorta injuries. SA J Radiol 2021; 25:2044. [PMID: 33824749 PMCID: PMC8008191 DOI: 10.4102/sajr.v25i1.2044] [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: 11/05/2020] [Accepted: 12/15/2020] [Indexed: 12/03/2022] Open
Abstract
Blunt chest trauma related acute thoracic aortic injury (TAI) is a life-threatening condition that requires prompt diagnosis and appropriate management because of high mortality. Computed tomography angiography (CTA) is the imaging of choice for evaluation of patients with major chest trauma findings suspicious of TAI on chest radiography. This case series describes the CTA findings in four high-velocity incident survivors with associated TAIs, discusses the injury type and treatment, and reviews the literature.
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Affiliation(s)
- Richard Edwards
- Department of Diagnostic and Interventional Radiology, Faculty of Radiology, University of Pretoria, Pretoria, South Africa
| | - Nausheen Khan
- Department of Diagnostic Radiology and Imaging, Faculty of Radiology, University of Pretoria, Pretoria, South Africa
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3
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Al-Adawi SSH, Naiem A, Abdelhady I, Al-Sukaiti R, Al-Hajeri M, Stephen E, Al-Shamsi S, Al-Wahaibi K. Chronic Blunt Traumatic Thoracic Aortic Injuries: Report of three cases from Oman. Sultan Qaboos Univ Med J 2021; 21:e120-e123. [PMID: 33777433 PMCID: PMC7968914 DOI: 10.18295/squmj.2021.21.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/03/2020] [Accepted: 07/05/2020] [Indexed: 11/20/2022] Open
Abstract
Blunt thoracic aortic injuries are potentially lethal. Those who survive may form an organised haematoma in the periadventitial space resulting in a pseudoaneurysm, which may be identified incidentally decades later. While the role of thoracic endovascular aortic repair (TEVAR) in acute settings has been established, its role in chronic cases is yet to be defined. We report three cases that were diagnosed incidentally six, nine and 18 years after the injury. Two were managed by TEVAR while the third declined intervention and is on annual follow-up. Patients with asymptomatic and stable pseudoaneurysms of the descending thoracic aorta should be offered surveillance versus TEVAR because the risk of rupture is not negligible, whilst taking into account the patient’s level of physical activity. These three cases highlight the importance of early diagnosis of aortic injuries in blunt trauma and its grading.
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Affiliation(s)
- Sara S H Al-Adawi
- Department of General Surgery, Oman Medical Specialty Board, Muscat, Oman
| | - Ahmed Naiem
- Department of Vascular Surgery, McGill University, Montreal, Canada
| | - Ibrahim Abdelhady
- Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Rashid Al-Sukaiti
- Department of Radiology, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Edwin Stephen
- Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Khalifa Al-Wahaibi
- Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat, Oman
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4
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Wada T, Oyama S, Ohuchi S, Kadohama T, Takagi D, Kiryu K, Igarashi I, Yamamoto H. Calcified Aortic Wall Removal for Dysphagia Aortica Caused by Chronic Traumatic Aortic Pseudoaneurysm. Ann Vasc Surg 2021; 74:520.e23-520.e26. [PMID: 33556508 DOI: 10.1016/j.avsg.2021.01.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/01/2021] [Accepted: 01/17/2021] [Indexed: 11/17/2022]
Abstract
In this study, we report a case of a 45-year-old man with dysphagia aortica secondary to chronic traumatic aortic pseudoaneurysm of the aortic isthmus. He had been involved in a motor vehicle accident 27 years earlier. Computed tomography demonstrated a severely calcified aortic pseudoaneurysm of the aortic isthmus that compressed the esophagus extrinsically. An invasive surgical procedure involving a graft replacement and removal of the calcified aortic wall released the esophageal compression and completely improved the patient's symptoms. To the best of our knowledge, a case of dysphagia aortica caused by calcified pseudoaneurysm has never been reported.
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Affiliation(s)
- Takuya Wada
- Department of Cardiovascular surgery, Nakadori General Hospital, Akita, Japan.
| | - Shogo Oyama
- Department of Cardiovascular surgery, Nakadori General Hospital, Akita, Japan
| | - Shingo Ohuchi
- Department of Cardiovascular surgery, Nakadori General Hospital, Akita, Japan
| | - Takayuki Kadohama
- Department of Cardiovascular surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Daichi Takagi
- Department of Cardiovascular surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Kentaro Kiryu
- Department of Cardiovascular surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Itaru Igarashi
- Department of Cardiovascular surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroshi Yamamoto
- Department of Cardiovascular surgery, Akita University Graduate School of Medicine, Akita, Japan
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5
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Abstract
Aortic injury remains a major contributor to morbidity and mortality from acute thoracic trauma. While such injuries were once nearly uniformly fatal, the advent of cross-sectional imaging in recent years has facilitated rapid diagnosis and triage, greatly improving outcomes. In fact, cross-sectional imaging is now the diagnostic test of choice for traumatic aortic injury (TAI), specifically computed tomography angiography (CTA) in the acute setting and CTA or magnetic resonance angiography (MRA) in follow-up. In this review, we present an up-to-date discussion of acute traumatic thoracic aortic injury with a focus on optimal and emerging CT/MR techniques, imaging findings of TAI, and potential pitfalls.
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Affiliation(s)
- Lewis D Hahn
- 1 Department of Radiology, Stanford University School of Medicine, Stanford, USA
| | - Anand M Prabhakar
- 2 Divisions of Cardiovascular and Emergency Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Evan J Zucker
- 1 Department of Radiology, Stanford University School of Medicine, Stanford, USA
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6
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Abstract
Nonoperative management of both blunt and penetrating injuries can be challenging. During the past three decades, there has been a major shift from operative to increasingly nonoperative management of traumatic injuries. Greater reliance on nonoperative, or "conservative" management of abdominal solid organ injuries is facilitated by the various sophisticated and highly accurate noninvasive imaging modalities at the trauma surgeon's disposal. This review discusses selected topics in nonoperative management of both blunt and penetrating trauma. Potential complications and pitfalls of nonoperative management are discussed. Adjunctive interventional therapies used in treatment of nonoperative management-related complications are also discussed. REPUBLISHED WITH PERMISSION FROM Stawicki SPA. Trends in nonoperative management of traumatic injuries - A synopsis. OPUS 12 Scientist 2007;1(1):19-35.
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Affiliation(s)
- Stanislaw P A Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
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7
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Saey V, Vandecasteele T, van Loon G, Cornillie P, Ploeg M, Delesalle C, Gröne A, Gielen I, Ducatelle R, Chiers K. Friesian horses as a possible model for human acquired aortopulmonary fistulation. BMC Res Notes 2016; 9:405. [PMID: 27527829 PMCID: PMC4986238 DOI: 10.1186/s13104-016-2201-5] [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: 04/15/2016] [Accepted: 08/03/2016] [Indexed: 01/24/2023] Open
Abstract
Background Acquired aortopulmonary fistulation is a rare condition in humans. It usually results as a late complication of a true or pseudoaneurysm of the thoracic aorta. It is most commonly associated with trauma or surgery, less commonly with atherosclerosis, inflammation, hypertension or Marfan’s syndrome. Aortopulmonary fistulation is also seen as a rare complication of acute aortic dissection. On rare occasions, acquired aortopulmonary fistulation is reported in aged patients without any of the above mentioned triggering factors. Thus, these cases should be considered as idiopathic aortopulmonary fistulation. Clearly, the pathogenesis of this condition is not yet completely understood. Friesian horses are highly inbred and are affected by several genetic conditions. Rupture of the thoracic aorta has a relatively high prevalence in Friesian horses and is often characterized by the formation of a pseudoaneurysm with subsequent fistulation into the pulmonary artery. Affected animals may survive for several weeks to months. Findings Here we performed vascular casting in three affected Friesian horses. In all three cases, an aortic rupture at the caudoventral side of the aorta was connected with a rupture of the main pulmonary artery just proximal to its bifurcation. Conclusions Affected Friesians show a consistent location and configuration of the aortic rupture site, very similar to the human condition and therefore could act as a spontaneous model to study this disease. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-2201-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- V Saey
- Department of Pathology, Bacteriology and Poultry Diseases, Ghent University, Merelbeke, Belgium.
| | - T Vandecasteele
- Department of Morphology, Ghent University, Merelbeke, Belgium
| | - G van Loon
- Department of Large Animal Internal Medicine, Ghent University, Merelbeke, Belgium
| | - P Cornillie
- Department of Morphology, Ghent University, Merelbeke, Belgium
| | - M Ploeg
- Department of Pathobiology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - C Delesalle
- Department of Comparative Physiology and Biometrics, Ghent University, Merelbeke, Belgium
| | - A Gröne
- Department of Pathobiology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - I Gielen
- Department of Veterinary Medical Imaging and Small Animal Orthopaedics, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - R Ducatelle
- Department of Pathology, Bacteriology and Poultry Diseases, Ghent University, Merelbeke, Belgium
| | - K Chiers
- Department of Pathology, Bacteriology and Poultry Diseases, Ghent University, Merelbeke, Belgium
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8
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Nizet C, Van Damme H, Boesmans E, Lavigne JP, Creemers E, Defraigne JO. Chronic False Aneurysm after a Healed Rupture of the Aortic Isthmus: TEVAR, Hybrid Surgery, or Open Arch Repair? Ann Vasc Surg 2015; 31:205.e11-6. [PMID: 26631770 DOI: 10.1016/j.avsg.2015.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 07/25/2015] [Accepted: 07/29/2015] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Christophe Nizet
- Department of Cardiovascular Surgery, University Hospital Sart Tilman, Liège, Belgium.
| | - Hendrik Van Damme
- Department of Cardiovascular Surgery, University Hospital Sart Tilman, Liège, Belgium
| | - Evelyne Boesmans
- Department of Cardiovascular Surgery, University Hospital Sart Tilman, Liège, Belgium
| | - Jean-Paul Lavigne
- Department of Cardiovascular Surgery, University Hospital Sart Tilman, Liège, Belgium
| | - Etienne Creemers
- Department of Cardiovascular Surgery, University Hospital Sart Tilman, Liège, Belgium
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9
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Miller S, Kumar P, Van den Bosch R, Khanafer A. Chronic Thoracic Aortic Aneurysm Presenting 29 Years following Trauma. Case Rep Surg 2015; 2015:470917. [PMID: 26351610 PMCID: PMC4550747 DOI: 10.1155/2015/470917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/26/2015] [Accepted: 08/05/2015] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Sarah Miller
- General Surgery, Timaru Hospital, South Canterbury 7910, New Zealand
| | - Prashant Kumar
- Emergency Medicine, Timaru Hospital, South Canterbury 7910, New Zealand
| | | | - Adib Khanafer
- Christchurch Hospital, Riccarton Avenue, Christchurch 8053, New Zealand
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10
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Iddriss A, Ziganshin BA, Tranquilli M, Elefteriades JA. Chronic Traumatic Thoracic Aortic Aneurysm: 40-Year Follow-Up. J Card Surg 2015; 30:586-8. [DOI: 10.1111/jocs.12573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Adam Iddriss
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
- Department of Surgical Diseases # 2; Kazan State Medical University; Kazan Russia
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
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11
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Cullen EL, Lantz EJ, Johnson CM, Young PM. Traumatic aortic injury: CT findings, mimics, and therapeutic options. Cardiovasc Diagn Ther 2014; 4:238-44. [PMID: 25009793 DOI: 10.3978/j.issn.2223-3652.2014.06.02] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 04/17/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Traumatic aortic injury (TAI) is rare, but frequently lethal. However, with prompt diagnosis, patients can undergo life-saving open or endovascular repair. Unfortunately, because these injuries are relatively rare, subtle forms of these injuries may be missed, and normal variants may mimic TAI leading to misdiagnosis. CONCLUSIONS We will discuss computed tomography findings of typical injury patterns of traumatic aortic injuries as well as treatment options, diagnostic pitfalls and injury mimics. These are highlighted with clinical case examples.
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Affiliation(s)
| | - Eric J Lantz
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Philip M Young
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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12
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Pseudoaneurisma postraumático tardío de aorta torácica. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2012.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Ikeda A, Sato F, Tokunaga C, Enomoto Y, Kanemoto S, Matsushita S, Hiramatsu Y, Sakakibara Y. Surgical repair for rupture of a chronic traumatic thoracic aneurysm 14 years after injury: report of a case. Surg Today 2011; 42:191-4. [PMID: 22068669 DOI: 10.1007/s00595-011-0001-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 02/06/2011] [Indexed: 11/24/2022]
Abstract
Traumatic thoracic aortic injury is a lethal condition. Because its mortality rate is extremely high in the acute phase, these patients rarely survive long enough for a chronic aneurysm to develop. We herein report a case of surgical repair for a ruptured chronic traumatic thoracic aneurysm. A 32-year-old man, who had been involved in a traffic accident 14 years earlier, was diagnosed with a rupture of a chronic traumatic thoracic aneurysm. Preoperative computed tomography showed that the ruptured aneurysm arose from the aortic isthmus and was accompanied by multiple daughter lesions. He underwent an aorta graft replacement with reconstruction of the left subclavian artery using both a median sternotomy and a left thoracotomy. The surgery was successful and the postoperative course was uneventful. Chronic traumatic thoracic aneurysm is usually a single lesion, and cases with daughter aneurysms have rarely been reported. We include a review of the previous literature and also discuss the etiology of this condition.
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Affiliation(s)
- Akihiko Ikeda
- Department of Cardiovascular Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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14
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Pirotte M, Lacroix V, Astarci P, Nardella J, Funken JC, El Khoury G, Noirhomme P, Verhelst R. Unsuccessful treatment of a collapsed thoracic stent graft by Palmaz stent. Ann Vasc Surg 2010; 24:1137.e13-9. [PMID: 21035713 DOI: 10.1016/j.avsg.2010.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 05/01/2010] [Accepted: 06/16/2010] [Indexed: 11/24/2022]
Abstract
A Gore TAG Excluder stent graft was deployed in a 35-year-old woman for an isthmic saccular aneurysm. At 12-hour follow-up, we diagnosed a proximal collapse. A Palmaz stent was used to reopen the proximal segment. Two months later, she presented with a transient ischemic attack (embolic process) related to a suboptimal apposition of the Palmaz stent in the distal aortic arch. This led to open surgical replacement of the ascending aorta and aortic arch with reimplantation of the supraaortic branches. Reopening of a stent graft collapse with a Palmaz stent might be a short-term solution; however, its presence can lead to embolic complications.
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Affiliation(s)
- Manuel Pirotte
- Department of Thoracic and Cardiovascular Surgery, Saint-Luc Hospital, Brussels, Belgium.
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Abstract
A chronic posttraumatic false aneurysm of descending aorta in a 19-year-old man who had been involved in a car accident 8 months earlier is described. He presented with chronic cough, and on chest roentgenogram, a mass in upper left mediastinum was noticed. Aortography and computed tomography scan revealed a false aneurysm of the descending aorta. The patient underwent aneurysm resection and graft replacement. Cough resolved after surgery and at 5 years follow-up the patient remained well and symptom-free.
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17
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Marcu CB, Nijveldt R, Van Rossum AC. Unsuspected chronic traumatic aortic pseudoaneurysm--what to do about it. Late post-traumatic aortic pseudoaneurysm. Can J Cardiol 2008; 24:143-4. [PMID: 18273489 DOI: 10.1016/s0828-282x(08)70571-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A 59-year-old man with multiple risk factors for coronary artery disease who had been in a motor vehicle accident 30 years earlier presented with new-onset angina pectoris. During cardiac catheterization, an ill-defined dense area was noted in the mediastinum. Chest radiography showed an area of calcification around the proximal descending aorta. Cardiovascular magnetic resonance imaging demonstrated a pseudoaneurysm of the proximal descending thoracic aorta. Due to the typical location (aortic isthmus), the pseudoaneurysm was thought to be the result of deceleration injury sustained by the patient in the previous motor vehicle accident. The present manuscript discusses the natural history and management options of an uncommon consequence of traumatic aortic injury: chronic posttraumatic aortic pseudoaneurysm.
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Affiliation(s)
- Constantin B Marcu
- Department of Cardiology, Vrije University Medical Center, Amsterdam, The Netherlands.
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18
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Yagubian M, Sundt TM. Diseases of the Thoracic Aorta. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Traumatic injury to the aorta and the brachiocephalic branches are potentially lethal injuries. Specialized preoperative imaging and medical management can lead to better outcomes in this group of patients. In addition, improved surgical techniques for spinal cord protection have led to decreased morbidity in surgical candidates. TEVAR remains a promising technique; however, long-term data currently are not available.
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Affiliation(s)
- William T Brinkman
- Division of Cardiovascular Surgery. Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104, USA
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20
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Abstract
BACKGROUND The standard management for patients with blunt aortic injury is surgery; however, a small number of patients have been medically managed. The outcome of these nonoperatively managed patients is unknown. METHODS Seven patients diagnosed as blunt aortic injury were managed without aortic surgery between January 1993 and April 2002, and their outcomes were retrospectively investigated. RESULTS There were three men and four women, with a mean age of 48.7+/-22.7 years and Injury Severity Score of 37.7+/-16.9. The reason for nonoperative management was refusal of surgery (2), do-not-resuscitate order (1), diffuse brain injury (2), small intimal tear (1), and technical difficulty (1). Two patients died resulting from associated injuries. Five patients are alive, and in three patients complete resolution of aortic injury was observed. CONCLUSIONS In selected patients with multiple associated injuries or severe comorbidity, nonoperative management after blunt aortic injury can be a treatment of choice.
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Affiliation(s)
- Hitoshi Hirose
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH 44109-1998, USA
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21
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Kieffer E, Leschi JP, Chiche L. Open repair of chronic post-traumatic aneurysms of the aortic isthmus: The value of direct aortoaortic anastomosis. J Vasc Surg 2005; 41:931-5; discussion 935. [PMID: 15944587 DOI: 10.1016/j.jvs.2005.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE This report presents our experience with open repair of post-traumatic aneurysms of the aortic isthmus using recent surgical techniques, including distal aortic perfusion and the preferential use of direct aortoaortic anastomosis without interposition of prosthetic material. METHODS From 1990 to 2004, the senior author (EK) patients (21 men; mean age, 40.3 years) who presented with post-traumatic aneurysms of the aortic isthmus were treated operatively, either with (20 patients) or without (3 patients) distal aortic perfusion, or endovascularly with a stent graft (3 patients). In 15 (75 %) of the 20 patients treated with distal aortic perfusion, the technique consisted of resection followed by direct aortoaortic anastomosis. Eight patients, including the three patients treated with simple clamping, had prosthetic replacement. RESULTS No postoperative deaths or permanent spinal cord complications occurred. One patient required reoperation to control hemorrhage. Aortography or computed tomography angiography was performed on 12 of the 15 patients treated by direct aortoaortic anastomosis, with a mean follow-up of 58.7 +/- 8.9 months. No morphologic abnormality was found. CONCLUSION This study shows that low-risk patients with a chronic post-traumatic aneurysm of the aortic isthmus can be successfully treated with excellent long-term results by resection and direct aortoaortic anastomosis without prosthetic interposition. In our opinion, endovascular repair should only be used in patients who present with absolute contraindications for open surgical repair.
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Affiliation(s)
- Edouard Kieffer
- Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, France.
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22
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Kondo N, Koyama M, Wakayama F, Ji K, Ichinoseki I, Fukuda I. Surgical repair for chronic traumatic thoracic aneurysm after 12-year follow-up. ACTA ACUST UNITED AC 2004; 52:586-8. [PMID: 15651408 DOI: 10.1007/s11748-004-0030-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A 39-year-old man underwent surgical repair of chronic traumatic thoracic aneurysm after 12-year follow-up at our hospital. Eighteen years prior to surgery, he had been involved in a traffic accident, suffering a left hemopneumothorax. Chronic traumatic thoracic aneurysm is extremely rare that few guidelines for surgical intervention exist for this disorder. However, it has been observed that all patients with new symptoms should be operated promptly, and that asymptomatic aneurysm detected over 2 years after the initial trauma can be monitored by careful follow-up pending symptomatic or radiologic change. The present case provides additional support for these strategies.
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Affiliation(s)
- Norihiro Kondo
- First Department of Surgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
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Verbeke SJ, De Waele JJ, Hesse UJ, Vermassen FE, De Roose J. Severe complications after nonoperative treatment of traumatic aortic rupture. THE JOURNAL OF TRAUMA 2002; 53:784-6. [PMID: 12394885 DOI: 10.1097/00005373-200210000-00029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaminishi Y, Saito T, Kato M, Kamisawa O, Misawa Y, Fuse K. Successful surgical treatment of chronic traumatic thoracic aneurysm in two patients. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2002; 50:375-7. [PMID: 12382404 DOI: 10.1007/bf02913187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We successfully treated two patients with chronic traumatic aneurysm of the thoracic aorta. The first, a 40-year-old man involved in an automobile accident 24 years earlier, was treated by thoracic aorta graft replacement via left thoracotomy under femoro-femoral partial bypass. The second, a 57-year-old man with a 3-month history of hoarseness who had suffered blunt chest trauma 17 years earlier, was treated similarly. Both had a calcified pseudoaneurysm at the isthmus of the descending aorta, but neither had atherosclerosis other than at the aneurysm site. They have done well after surgery. We believe chronic traumatic thoracic aneurysm at the aortic isthmus should be treated surgically soon after diagnosis because elective surgery presents low risk of morbidity and mortality.
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Affiliation(s)
- Yuichiro Kaminishi
- Division of Cardiovascular Surgery, Jichi Medical School, 3311-1 Yakushiji, Minami-Kawachi, Tochigi 329-0498, Japan
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Holmes JH, Bloch RD, Hall RA, Carter YM, Karmy-Jones RC. Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis. Ann Thorac Surg 2002; 73:1149-54. [PMID: 11998813 DOI: 10.1016/s0003-4975(01)03585-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear. METHODS A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group. RESULTS One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 +/- 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 +/- 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 +/- 22 versus 36 +/- 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 +/- 9 versus 32 +/- 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms. CONCLUSIONS Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.
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Affiliation(s)
- James H Holmes
- Virginia Mason Medical Center and Harborview Medical Center, University of Washington, Seattle 98195-6310, USA
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Diseases of the Thoracic Aorta and Great Vessels. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
BACKGROUND Coarctation occurring within the aortic arch is rare and may present difficulties during surgical repair. We describe the operative technique and outcome in 6 patients with this unusual anomaly. METHODS Five patients had antegrade perfusion with circulatory arrest. Three patients with presubclavian narrowing (one presenting with type B dissection) were operated through extended left thoracotomy. Two precarotid and paracarotid lesions were approached through a median sternotomy. All patients were perfused antegradely from the ascending aorta and operated with hypothermic circulatory arrest. One patient who had a complex presubclavian coarctation after two previous repairs received an ascending aorta to abdominal aorta bypass graft without cardiopulmonary bypass. RESULTS All patients survived operation and are well at a mean follow-up of 3.3 years after the procedure. None had cerebral problems or spinal cord injury. Renal function was unchanged. The mean (+/- standard error of the mean) resting gradient across the coarctation decreased from 42+/-4.0 mm Hg to 6+/-1.2 mm Hg (p = 0.0004). CONCLUSIONS Hypothermic circulatory arrest using antegrade ascending aortic perfusion allows safe and effective repair of mid-arch coarctation. Complicated reoperations can be managed safely using ascending-to-abdominal aortic bypass.
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Affiliation(s)
- T Katsumata
- Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, England.
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Katsumata T, Westaby S. Proximal aortic perfusion with passive cerebral flow: a method to prevent cerebral embolism in the arch and descending aortic operation. J Card Surg 1999; 14:194-6. [PMID: 10789708 DOI: 10.1111/j.1540-8191.1999.tb00978.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Antegrade aortic perfusion is preferable in arch and descending aortic operations. We describe a left lateral approach using an ascending aortic cannula, temporarily relocated within the distal aorta to maintain hypothermic cardiopulmonary bypass of the lower torso. This modification provides continual antegrade systemic perfusion and passive retrograde cerebral flow during arch repair. It minimizes the risk of embolization into the brachiocephalic arteries of debris and malperfusion of the dissected aorta.
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Affiliation(s)
- T Katsumata
- Department of Cardiac Surgery, Oxford Heart Centre, The John Radcliffe Hospital, Headington, England.
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Westaby S, Katsumata T, Vaccari G. Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome. Eur J Cardiothorac Surg 1999; 15:180-5. [PMID: 10219551 DOI: 10.1016/s1010-7940(98)00310-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Although cannulation of the femoral artery is used routinely for thoracic aortic operations with hypothermic circulatory arrest, retrograde perfusion through the descending aorta carries the risk of cerebral malperfusion or embolism. We have, therefore, routinely used a central cannulation technique for distal arch and descending aortic operations since 1995. In this study, we compared neurological outcome in consecutive patients undergoing femoral versus ascending aortic perfusion for these aneurysms. METHODS Between 1987 and 1998, 61 patients underwent aortic resection with circulatory arrest, but without retrograde cerebral perfusion, for lesions of the aortic arch and descending aorta. Thirty-one patients had fusiform true aneurysms, 19 had aortic dissection and 11 had extensive saccular or false aneurysms. Thirty-two patients (52%) were perfused via the femoral artery (group A), and 29 patients (48%) from the ascending aorta (group B). Operative mortality and morbidity, and neurological outcome, were reviewed. RESULTS There were no differences between the groups in mean age, pathology, abdominal and peripheral vascular disease, net perfusion time, or circulatory arrest time. There were four hospital deaths (three in group A and one in group B; P = 0.61), including one neurological death in group A, group A suffered a higher incidence of neurological events (nine patients: 28%) than group B (two patients: 7%; P = 0.03). Temporary focal neurological deficits occurred in both groups (two patients in group A, 6% and two patients in group B, 7%; P > 0.99), but permanent injury occurred exclusively in group A (seven patients: four with monoplegia, one with hemiplegia, and two with diffuse cerebral injury with one death; P = 0.01). CONCLUSIONS Anterograde perfusion using a proximal aortic cannula provides a low risk of cerebral embolism and allows extensive aortic resection with low morbidity.
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Affiliation(s)
- S Westaby
- Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Headington, UK
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Katsumata T, Westaby S. Proximal Aortic Perfusion with Passive Cerebral Flow: A Method to Prevent Cerebral Embolism in the Arch and Descending Aortic Operation. Echocardiography 1985. [DOI: 10.1111/j.1540-8175.1985.tb01275.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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