Ann Thorac Surg 2006;82:2276-2278
© 2006 The Society of Thoracic Surgeons
Case Reports
Endovascular Treatment of an Acute Subdiaphragmatic Aortic Rupture
Sylvain Rubin, MD*,
Olivier N. Pages, MD,
Anne Poncet, MD,
Bernard Baehrel, MD, PhD
CHU Reims, Hôpital Robert Debré, Service de Chirurgie Thoracique et Cardio-Vasculaire, Reims, France
Accepted for publication March 28, 2006.
* Address correspondence to Dr Rubin, Hôpital Robert Debré, Service de chirurgie Cardio-Vasculaire, Avenue du général Koenig, Reims, Cedex 51092, France. (Email: srubin{at}chu-reims.fr).
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Abstract
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We report the case of a 23-year-old man presenting an acute rupture of the subdiaphragmatic aorta in front of a T12 vertebral fracture after a road accident. Because of the location of this lesion, the operative risk and a cardiac instability, we opted for an endovascular treatment with a new and original approach in covering a small part of the aorta using commercial devices. We also describe the probable mechanism of this uncommon aortic rupture. The surgical outcome was uneventful and the 3 month computed tomographic scan confirmed the complete exclusion of the aortic disruption.
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Introduction
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In most aortic ruptures, the surgical treatment still remains the reference technique [1]. However, in our department, patients with multiple-trauma and isthmic aortic ruptures were treated by stent graft placements since 2001. We report the case of a young man who presented with an uncommon subdiaphragmatic aortic rupture with multiple thoracic and abdominal contusions after a road accident without direct trauma.
A 23-year-old man was admitted into our institution after a frontal road accident (70 km/h). The clinical examination found no visible contusions, but he verbally expressed an important thoraco-abdominal pain. The electrocardiogram was normal and on the thoracic and abdominal computed tomographic scan an uncommon subdiaphragmatic aortic rupture was found at the right side of the abdominal aorta near a frontal T12 vertebral fracture located 3 cm above the celiac trunk (Fig 1). Bilateral pulmonary contusions and a moderate peritoneal effusion were also visualized.
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Fig 1. (A, B) Aortic rupture above the celiac trunk. (C) Schematic location of the aortic rupture and the T12 vertebral fracture. (D) Visualization of the acute false aneurysm on the left side of the aorta.
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Initially, surgery was considered for this young patient, but suddenly he presented with an acute hemodynamic instability related to a regressive ventricular tachycardia and fibrillation. On echocardiography a normokinetic but dilated left ventricle without ischemic sequela was found. Because of these severe cardiac and pulmonary contusions, the decision was taken to use an endovascular approach.
Because of the aortic rupture location, between the celiac trunk and the Adamkiewicz artery, commercial aortic endoprosthesis could not be used without risk of paraplegia. Finally, we have used three iliac extension cuffs (endoprosthesis diameter: 24 mm, total length: 60 mm with 30 mm covered by the dacron graft) from Medtronic AVE (Santa Rosa, CA).
The total exclusion of this subdiaphragmatic aortic rupture was achieved using the right femoral access under general anesthesia. In this case, two preoperative angiograms were necessary: the first, frontal, to identify the rupture location, and the second, lateral to locate the celiac trunk. All endoprosthesis deployments were done in the lateral position, essentially to perform the first endoprosthesis deployment just above the celiac trunk. No complications or endoleaks were found in the final angiographic control.
The surgical outcome was uneventful. The postoperative computed tomographic scan confirmed angiographic results.
Because of fracture and contusions, the patient was discharged on postoperative day 14. Preventive low molecular weight heparin and clopidogrel treatment were administered for 8 days and replaced by aspirin for 6 months.
The 3 months follow-up was uneventful and confirmed the total false-aneurysm exclusion. No endoleaks or endoprosthesis displacements were noticed (Fig 2).
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Fig 2. (A) Endovascular exclusion with a total false aneurysm disappearance (frontal). (B) Sagittal view of the endoprosthesis position (just a few mm above the celiac trunk) and the vertebral fracture. (C) Schematic illustration of the deployment of the three extension cuffs.
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Comment
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Acute abdominal aortic rupture is uncommon after road accidents [2]. Today the multi-slice tomography is the most powerful investigation to search for aortic diseases [3]. However, the aortography can be used to appreciate the dynamic aspect of aortic lesions.
In our case, the thoracic and abdominal computed tomographic scan analysis explains the possible mechanism of this rupture. The T12 vertebral fracture was related to an anterior flexion and an axial compression of the rachis. Furthermore, the abdominal aorta was fixed at different levels; at the top by the diaphragm, and below by renal arteries, and it was free in the small intermediate area (Fig 1). These aortic flexion and compression associated to the anterior displacement of abdominal organs have induced an aortic mobilization possibly responsible for this aortic rupture.
However, the endovascular treatment of acute aortic lesions is controversial [1]. Even if we have been doing endovascular treatments since 1999, we can only consider the endovascular approach for selected patients with high surgical risks. Patients with poly trauma, high risk of bleeding, clinical instability, or visceral dysfunctions are good candidates to perform an endovascular repair [3]. The rupture location must also be considered [4]. On the other hand, the surgical approach needs large thoracic and abdominal accesses and induces an more important risk of paraplegia [5, 6]. In our case, because of severe pulmonary and cardiac contusions, we have considered the endovascular option as a good mini-invasive treatment despite the age of our patient. Besides, several authors have reported endovascular or hybrid approaches of aortic lesions with positive results [7, 8].
To minimize the risk of paraplegia, due to the short sub-diaphragmatic aortic part between the celiac trunk and the medullar vascularization, the area to be covered should not exceed 8 cm.
In our case, we performed an original endovascular treatment using 3 endoprosthesis segments. The first was placed above the celiac trunk, the second above the aortic rupture and the last between them. The perioperative and the 3 months postoperative investigations found no endoleak or endoprosthesis mobilization. After bibliographic review, to date, no author has reported this approach with a composite endovascular treatment of short aortic segments.
To conclude, we report an uncommon case successfully treated by an original technique. However, we think that endovascular treatment is an effective option for instable patients with high surgical risk. This endovascular approach is feasible and can be achieved with minimal risks. However, a strict follow-up is mandatory to evaluate the long-term durability of endovascular repair of such traumatic aortic transections.
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References
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- Doss M, Balzer J, Martens S, et al. Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience Ann Thorac Surg 2003;76:1465-1470.[Abstract/Free Full Text]
- Vasquez J, Poultsides GA, Lorenzo AC, Foster JE, Drezner AD, Gallagher J. Endovascular stent-graft placement for nonaneurysmal infrarenal aortic rupture: a case report and review of the literature J Vasc Surg 2003;38:836-839.[Medline]
- Downing SW, Sperling JS, Mirvis SE, et al. Experience with spiral computed tomography as the sole diagnostic method for traumatic aortic rupture Ann Thorac Surg 2001;72:495-502.[Abstract/Free Full Text]
- Rizoli SB, Brenneman FD, Boulanger BR, Maggisano R. Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex Ann Thorac Surg 1994;58:1404-1408.[Abstract]
- Griepp RB, Ergin MA, Galla JD. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta J Thorac Cardiovasc Surg 1996;112:1202-1215.[Abstract/Free Full Text]
- Iannelli G, Piscione F, Di Tommaso L, Monaco M, Chiariello M, Spampinato N. Thoracic aortic emergencies: impact of endovascular surgery Ann Thorac Surg 2004;77:591-596.[Abstract/Free Full Text]
- Naude GP, Back M, Perry MO, Bongard FS. Blunt disruption of the abdominal aorta: report of a case and review of the literature J Vasc Surg 1997;25:931-935.[Medline]
- Lindblad B, Brunkwall J, Lindh M, Nyman U, Malina M, Ivancev K. Traumatic aortic rupture and retroperitoneal haematoma—treatment including combined operative and endovascular approach Eur J Vasc Endovasc Surg 1999;17:451-455.[Medline]
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Abstract
Introduction
