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Ann Thorac Surg 2003;75:1803-1807
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Endovascular repair for acute traumatic rupture of the thoracic aorta

^a Service de Chirurgie Thoracique et Vasculaire, Hôpital Arnaud de Villeneuve, Montpellier, France

Accepted for publication December 13, 2002.

^* Address reprint requests to Dr Marty-Ané, Service de Chirurgie Thoracique et Vasculaire, Hôpital Arnaud de Villeneuve, 34295, Montpellier Cedex 5, France
e-mail: ch-marty_ane{at}chu-montpellier.fr

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: We report endovascular treatment of acute traumatic rupture of the thoracic aorta as a potential alternative to open surgery for high-risk patients.

METHODS: Between January 2001 and July 2002, 9 patients with acute traumatic rupture of the thoracic aorta were treated with a stent-graft. In all cases the endovascular management was selected because of age, associated polytrauma, or comorbidities. Preoperative workup included chest computed tomography scan, transoesophageal echography, and angiography. The devices used were the Excluder and the Talent stent-grafts.

RESULTS: Eight patients underwent immediate repair and 1 patient was treated within 5 days of the accident because of delayed diagnosis of aortic rupture after surgical management of spleen rupture. The stent-graft was successfully expanded in all patients through the common femoral artery (n = 7) or the common iliac artery (n = 2). There was no perioperative death, renal failure, or neurologic complication (paraplegia or stroke). In 1 patient the computed tomography scan at 7 days postoperatively showed proximal endoleak requiring placement of a second stent-graft. Follow-up ranged from 4 to 20 months. All spiral computed tomography scans performed during follow-up revealed no evidence of endoleak, migration, or alteration of the stent-graft.

CONCLUSIONS: Endovascular repair in the acute phase of traumatic rupture of the thoracic aorta is technically feasible and safe, and may represent an alternative to open surgery for high-risk patients.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Traumatic ruptures of the thoracic aorta are often fatal in the first hours after injury and surviving patients frequently have associated lesions such as craniocerebral trauma, abdominal trauma, or multiple bone fractures. Standard surgical technique requires left posterolateral thoracotomy, proximal aortic cross-clamping, and use of cardiopulmonary bypass or left atriofemoral shunt for preventing ischemic, neurologic, and visceral complications during aortic cross-clamping. Despite the recent advances in surgical and circulatory assistance techniques, postoperative mortality ranges from 15% to 28% and paraplegia from 2.3% after active augmentation of the distal perfusion to 19.2% after simple aortic cross-clamping [1]. The presence of severe associated injuries precludes massive systemic heparinization required by circulatory assistance and makes conventional surgery very risky. Several reports [2–5] have recently demonstrated the safety and efficacy of endoluminal grafting in thoracic aortic diseases particularly in thoracic aortic aneurysm. The following is the report of the immediate repair of 9 acute traumatic ruptures of the thoracic aorta successfully managed with an endoluminal covered stent.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between January 2001 and July 2002, 9 patients with acute traumatic rupture of the descending thoracic aorta were treated by endovascular placement of a stent-graft. Both the surgical and anesthesiologist teams considered these patients at high operative risk and ineligible for open surgery. Massive trauma with numerous associated injuries precluded invasive surgery that would require a major thoracic approach, systemic heparinization, and circulatory assistance, leading to select endovascular management.

Acute rupture was defined as disruption of the aortic wall with blood flow precariously maintained within the vascular lumen by the adventitia and mediastinal surrounding tissues only (contained rupture). Adequate anatomic criteria for stent-graft placement included rupture located distal to the left subclavian artery with proximal neck of healthy aorta 15 mm or more in length and 38 mm or less in diameter, absence of thrombus in the fixation regions, and absence of marked tortuosity or stenosis of the pelvic vasculature. Preoperative workup included spiral computed tomography (CT) scan of the chest, transoesophageal echography (TEE), and subtraction angiography of the thoracic, abdominal aorta, and iliac arteries.

Stent-graft placement
All endovascular procedures were performed in an operating room. Patients were draped sterilely for emergency left thoracotomy; a cell salvage system and cardiopulmonary bypass were available if surgical conversion was needed. The thorax, abdomen, and groin were prepared sterilely for potential iliac artery or retroperitoneal aortic approach. For stent-graft placement we used peroperative TEE and not intravascular ultrasonography imaging, which was not available. The stent-graft was delivered under general anesthesia through the common femoral or iliac artery, which was surgically exposed. A Terumo 0.035 guide (Terumo Medical Corporation, Tokyo, Japan) was placed in the ascending aorta through a hemostatic sheath inserted by means of the Seldinger technique under fluoroscopic control. When the iliofemoral diameter was less than 8 mm a retroperitoneal approach was achieved and an end-to-side implantation of a 10-mm Dacron graft was used to insert the stent-graft. Intraoperative imaging was delivered by a portable C-arm fluoroscope (Siremobil 2000; Siemens, Erlanger, Germany) equipped with digital subtraction capabilities. A 5F calibrated angiographic pigtail catheter (Cordis Europe, Roden, the Netherlands) was then placed in the aortic cross through the right brachial or the contralateral femoral artery, allowing perioperative digital subtraction angiography to precisely indicate the target site for stent-graft placement. After intravenous administration of 5,000 IU of heparin sodium, the 21F to 24F sheath (William Cook Europe, Denmark) was introduced over a 0.035 superstiff guidewire (Amplatz Superstiff; Medi-Tech/Boston Scientific, Watertown, Massachusetts). Sheath progression was sometimes facilitated by application of a small amount of mineral oil. The stent-graft was delivered through the sheath and placed in the thoracic aorta under fluoroscopic and TEE controls. The mean arterial pressure was temporarily lowered to 60 to 70 mm Hg using nicarpidine during deployment. After the stent-graft was expanded, postdeployment angiography was performed to confirm the adequate position of the device and exclusion of the rupture. Oversizing of the endoprosthesis relative to aortic diameter ranged from 10% to 15%. The arteriotomy was repaired by a series of 6-0 polypropylene interrupted sutures. The follow-up consisted of angiogram and spiral CT scan before hospital discharge, and then spiral CT at 1, 3, and 6 months and yearly thereafter.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
This series included 3 women and 6 men with a mean age of 52.3 years (range, 23 to 78). All patients were involved in a car accident with strong deceleration resulting in polytrauma with blunt thoracic trauma. They presented with multiple rib fractures with mild hemothorax in 7 cases and massive hemothorax (2000 mL) in 2 cases requiring emergency chest drainage. Five patients presented with flail chest requiring in 1 bilateral case emergency intubation for respiratory distress. Hemodynamic instability related to splenic injury required emergency splenectomy in 1 patient. In the other patients the initial hemodynamic instability was reversible after fluid perfusion and blood transfusion. Associated lesions and comorbidities are reported in Table 1.

View larger version (94K): [in this window] [in a new window]   Fig 1. Computed tomography scan (left) showing contained rupture of the aorta with mediastinal hematoma around the proximal descending aorta and digital angiography (right) showing an irregular bulbus deformity that represents a classic image of aortic isthmus rupture.

View larger version (88K): [in this window] [in a new window]   Fig 2. Computed tomography scan (left) and angiographic control scan (right) after endovascular procedure showing complete exclusion of the aortic rupture without endoleak.

	Comment

Top Abstract Introduction Material and methods Results Comment References

Endovascular treatment is a less invasive strategy and represents an attractive alternative to conventional surgery, requiring a minimal vascular approach, avoiding proximal aortic cross-clamping, circulatory assistance, heparinization, and leading to potential reduction of operative risk, hospital stay, and cost. Semba and associates [8] reported endovascular management of acute thoracic aortic rupture in 11 patients—including three acute traumatic ruptures—with an overall survival of 82% and a paraplegia rate of 0%. Lobato and associates [9] reported the successfull immediate repair of a thoracic aortic tear secondary to blunt trauma with a Gianturco Z stent-graft. The endoluminal procedure decreases the morbidity associated with posterolateral thoracotomy and one-lung ventilation in these patients who often have multiple ribs fractures, flail chest, or pulmonary contusions. The absence of proximal aortic cross-clamping theoretically decreases the risk of cardiac failure and visceral or medullar ischemia and avoids the rise of intracranial pressure in case of severe cranial injury. There is a general agreement that the incidence of paraplegia increases significantly if the aortic cross-clamping duration is higher than 30 minutes. A potential disadvantage of endovascular treatment is that stent-graft placement precludes the reimplantation of intercostal arteries—as it is possible during open surgery—and may increase the risk of paraplegia. The short length of covered aorta (100 mm) and the rarity of a spinal artery originating from the intercostal arteries at the level of the aortic isthmus makes this consideration very hypothetical. Nevertheless although the absence of postoperative paraplegia in this experience and in other reports [8–11] is probably related to the absence of aortic cross-clamping, it must be considered with caution because of the small size of these series compared with the large previous surgical series. The stent-grafting technique is a promising alternative particularly for high-risk patients with acute rupture of the thoracic aorta.

The main potential limitations to endovascular treatment of ruptured thoracic aorta are the site of the rupture, the vascular access, and the availability of a stent-graft in emergency. The success of the endovascular procedure greatly depends on the rigorous respect for precise anatomic criteria, mainly at the level of the proximal neck, which must be 15 mm or more beneath the origin of the left subclavian artery. In case of insufficient proximal neck, the ostium of the left subclavian artery can be covered by the stent-graft and a transposition of this vessel in the left common carotid artery can be carried out in a second step in the event of vertebrobasilar insufficiency or upper limb ischemia. In case of nonacute aortic thoracic pathology (nonruptured aneurysm, chronic rupture) with the proximal neck near the origin of the left subclavian artery, surgical transposition of the left subclavian artery will be performed before the elective endovascular procedure. Although the best candidates for the endovascular technique are patients with limited disease in a quite straight portion of the thoracic aorta, all stent-grafts in this series were implanted proximally at the end of the aortic cross (site of the rupture) without any difficulty. That probably resulted from the increased malleability of the new devices, which better accomodate the curved anatomy of the distal aortic arch than did the semirigid stent-grafts of the first generation [2–4]. We observed a proximal type I endoleak in only 1 patient that required placement of a second stent-graft 1 week later, covering the ostium of the left subclavian artery.

Vascular access is another determinant in the technical success of the endovascular procedure and it is sometimes difficult in emergency situations to precisely assess the arterial vascularization of the lower limb. Stenosis, tortuosity, calcifications, or an iliofemoral axis less than 8 mm in diameter can make the progression of a 21F to 24F sheath very hazardous. In this series femoral vascular access was not possible in 2 patients and required common iliac artery access through a retroperitoneal approach.

Because we do not use a "home made" [8] stent-graft there is no excessive delay before stent-graft insertion due to fabrication or gas sterilization of the device. We have only a few stent-grafts of various diameters and lengths ready and when the available stent-grafts were not adequate in size, the delay for getting the appropriate one varied from 6 to 12 hours.

Controversy continues concerning the timing of surgical repair of acute traumatic ruptures of the thoracic aorta. In general, immediate repair is warranted unless the patient has multiple and severe injuries because some authors have reported that in the natural course of the disease 40% of the patients who survive the initial trauma die within 24 hours and 72% die within the first week [12, 13]. On the other hand the increasing mortality of emergency repair of aortic traumatic ruptures has led some authors to delay surgical treatment when coexisting injuries made the surgical risk unacceptably high in order to operate under optimal conditions after the management of these associated lesions (fluid resuscitation, visceral injury repair, cerebral decompression, fracture reduction) [13–16]. Others have reported the possibility of delayed endovascular treatment of traumatic ruptures of the thoracic aorta several months after the accident, at the chronic phase of pseudoaneurysm [10, 11]. These authors recommend selectivity in the timing of aortic repair and delayed operation (several weeks or months) for hemodynamically stable patients with severe comorbidities. Monitoring vital signs and sequential CT scan or MRI allow detection of clinical deterioration such as rapid increase of the mediastinal hematoma or hemothorax or extravasation of contrast media requiring emergency operation [17]. One of the major determinants of aortic rupture is left ventricular systolic ejection dynamics, suggesting that the use of ß-blockers is even more essential than simple antihypertensive therapy [10]. A substantial advantage of endovascular treatment is that it may be performed soon after prior management of another life-threatening lesion. That is in contrast with invasive open surgery, which requires a substantial delay for recovery from a prior major intervention, as explained in a previous published report about acute ruptures of the descending thoracic aorta including the first 3 patients of this series [18].

This experience demonstrated the feasibility and safety of immediate endovascular treatment of acute traumatic ruptures of the thoracic aorta with a covered stent. Further study is required to detemine the role and long-term results of endovascular treatment of aortic injuries. The long-term results with stent-grafts have yet to be determined with special reference to the migration, infection, or unknown durability of the stent-graft. Although open surgery remains the reference standard in treating these potentially lethal aortic ruptures, endoluminal management represents a promising alternative particularly for high operative risk patients.

	References

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