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Ten Years of Endovascular Treatment of Traumatic Aortic Transection - A Single Centre Experience
Abstract and Figures
Aim of the study was to present the 10-year results after endovascular repair of acute traumatic rupture of the descending aorta in a single centre.
Forty-eight consecutive patients (35 men and 13 women; mean age 39.8 +/- 18 years) with traumatic lesions of the descending aorta were treated between March 1999 and November 2008. All patients were treated within 24 hours of admission.
Thirty-one Gore TAG, 13 Medtronic Valiant, 6 Cook Zenith TX2 were used. The technical success rate was 100%, the conversion rate was 0%. Thirty-day mortality rate was 8.3%; overall procedure-related mortality was 2.1% due an acute stent graft compression syndrome. Infolding endografts were observed in 3 patients (6.25%). The left subclavian artery was covered in 35 cases (70%), in one patient revascularisation was necessary. No neurological deficit was reported. Mean follow-up was 51.9 months (4-116 months). No late complications occurred.
Endovascular treatment of acute traumatic rupture of the thoracic aorta is a safe method, with a lower morbidity and mortality than open repair.
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... 17 The heterogeneity of the included studies was taken into account and the random effects model was applied to pool the data. 18 The heterogeneity degree among different studies was examined by inspecting both the scatter in the data points and the overlap in their CIs, and by performing I 2 statistics. 19 Secondary outcomes rarely occurring (<3 events globally) were not pooled. ...
Introduction:
to investigate the long-term reinterventions of thoracic endovascular repair (TEVAR) after blunt traumatic aortic injury (BTAI).
Methods:
MEDLINE, EMBASE, and Cochrane databases were interrogated until June 2021.
Inclusion criteria:
BTAI treated with TEVAR and mean follow-up >60 months. A systematic review was conducted and data were pooled using a random-effects model of proportions applying the Freeman-Tukey transformation. Late reintervention was the primary outcome. Secondary outcomes were procedure-related complications (endoleak, in-stent thrombosis, occlusion, infolding/collapse, bird-beak, migration and left arm claudication), overall and aortic-related mortality and aortic diameter changes.
Results:
Eleven studies with a low quality assessment were included. Four-hundred-and-eight patients were collected and 389 surviving >30 days were included. The mean follow-up was 8.2 years (95%CI: 5.7-10.8; I2=40.2%). Late reintervention was 2.1% (95%CI: 0.6-3.9; I2=0.0%; 11/389 cases) with 0.1% (95%CI: 0.0-1.2; I2=0.0%; 3/389) occurring after 5 years. Bird-beak was identified in 38.7% (95%CI:16.4-63.6; I2=86.6%). Left arm claudication occurring after 30-day was 3.1% (95%CI: 0.1-8.6; I2=26.9%; 11/140 cases). In-stent thrombosis was 1.9% (95%CI:0.1-5.2; I2=51.8%; 11/389 cases). Endoleak was 0.5% (95%CI: 0.0-1.9; I2=0.0%; 5/389 cases). Infolding, occlusion, and migration were reported in 2/389, 1/389, and 0/389 patients respectively. Overall late survival was 95.6% (95%CI: 88.1-99.8; I2=84.7%; 358/389 patients) and only one patient accounted for aortic-related mortality. The increase in proximal and distal aortic diameters was estimated at 2.7-mm (95%CI: 1.2-4.3; I2=0.0%) and 2.5-mm (95%CI: 1.1-3.9; I2=0.0%) respectively.
Conclusions:
TEVAR demonstrates remarkably good long-term results and reinterventions are rarely required. Aortic reinterventions tend to occur within the first and after the fifth year.
... Los datos actuales indican que el TEVAR, en anatomías adecuadas, es el tratamiento de elección [98][99][100][101][102][103][104][105][106][107][108][109][110] . En una revisión de 139 estudios (7.768 pacientes), la mayoría de ellos series no comparativas, retrospectivas, y ningún estudio aleatorizado, muestran una mortalidad inferior (9% vs. 19%; p < 0,01) 111 . ...
Resumen
La patología de la aorta supone un reto para la medicina. Tanto a nivel diagnóstico, como terapéutico, el volumen de variables implicado ha hecho que dicha patología sea abordada por una ingente cantidad de especialistas. El manejo quirúrgico de dichas patologías implica un esfuerzo extraordinario por parte de muchos profesionales, dada la complejidad técnica y tecnológica empleada. A lo largo de estos años, dichos esfuerzos están dando sus frutos en forma de mejoras de resultados, gracias a un abordaje sistemático y protocolizado en el seno de un grupo de expertos (Comités de aorta o «Aortic team») en el que se han de implicar cardiólogos, cirujanos cardiacos, cirujanos vasculares, anestesiólogos y radiólogos, principalmente.
En este documento, consensuado entre los grupos de trabajo de aorta de las sociedades españolas de Anestesiología y Cirugía Torácica-Cardiovascular se busca difundir los modos de trabajo más consensuados entre los centros de mayor actividad del país por parte de ambas especialidades, en lo que al tratamiento quirúrgico se refiere de la patología crónica de aorta descendente.
Somos conscientes de la evolución constante de la terapéutica, lo cual sin duda puede hacer cuestionables algunas opiniones aquí expresadas y que sin duda irán modificándose en futuras ediciones.
Este documento aspira a ser una herramienta de trabajo para los diferentes profesionales implicados en el tratamiento de la patología aórtica.
... Los datos actuales indican que el TEVAR, en anatomías adecuadas, es el tratamiento de elección [66][67][68][69][70][71][72][73][74][75][76][77][78][79] . En una revisión de 139 estudios (7.768 pacientes), la mayoría de ellos series no comparativas, retrospectivas, y ningún estudio aleatorizado, muestran una mortalidad inferior (9% vs. 19%; p < 0,01) 80 . ...
Resumen
La patología de la aorta supone un reto para la medicina. Tanto a nivel diagnóstico, como terapéutico, el volumen de variables implicado ha hecho que dicha patología sea abordada por una ingente cantidad de especialistas. El manejo quirúrgico de dichas patologías implica un esfuerzo extraordinario por parte de muchos profesionales, dada la complejidad técnica y tecnológica empleada. A lo largo de estos años, dichos esfuerzos están dando sus frutos en forma de mejoras de resultados, gracias a un abordaje sistemático y protocolizado en el seno de un grupo de expertos (Comités de aorta o «Aortic team») en el que se han de implicar cardiólogos, cirujanos cardiacos, cirujanos vasculares, anestesiólogos y radiólogos, principalmente.
En este documento, consensuado entre los grupos de trabajo de aorta de las sociedades españolas de Anestesiología y Cirugía Torácica-Cardiovascular se busca difundir los modos de trabajo más consensuados entre los centros de mayor actividad del país por parte de ambas especialidades, en lo que al tratamiento quirúrgico se refiere de la patología crónica de aorta descendente.
Somos conscientes de la evolución constante de la terapéutica, lo cual sin duda puede hacer cuestionables algunas opiniones aquí expresadas y que sin duda irán modificándose en futuras ediciones.
Este documento aspira a ser una herramienta de trabajo para los diferentes profesionales implicados en el tratamiento de la patología aórtica.
... [18] The anatomy of the aortic arch vessels dictates that the left vertebral artery stems from the left subclavian artery and its antegrade flow supplies the posterior circulation of the brain. Thus, various studies have associated neurological complications with the total occlusion of the LSA [19][20][21][22][23][24][25] , however this attribution is currently disputed and remains a topic of ongoing debate. [26][27][28][29][30] It is important to note that in most of the studies conducted to look into complications of LSA coverage consisted of a mixed sample of various descending aortic pathologies, including thoracic aortic aneuryms and aortic dissections. ...
Traumatic aortic rupture is usually caused by blunt chest trauma as a result of deceleration trauma. This often occurs in road traffic accidents. Despite significant advances in surgical management, the mortality rate remains high. Immediate imaging should be performed depending on the patient’s cardiopulmonary stability. The diagnostic tool of choice is computed tomography. Depending on the severity of the lesion and taking associated injuries into account, treatment can be initiated immediately or with a delay. Endovascular treatment is the gold standard of care. In order to enlarge the proximal landing zone of the stent graft, overstenting of the left subclavian artery can be necessary.
Objectives:
To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU.
Data sources and study selection:
A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord.
Data extraction and data synthesis:
The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries.
Conclusions:
The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.
Traumatic aortic injury (TAI) is an uncommon condition that can result from penetrating or more often blunt trauma. Blunt traumatic aortic injury (BTAI) occurs in 0.3% of polytrauma victims transported to hospital and, despite its relative rarity, is a life-threatening event representing the second leading cause of death, after head injury, in polytrauma patients.
Beim stumpfen Thoraxtrauma stehen Verletzungen des knöchernen Thorax im Vordergrund. Bei begleitendem Hämato- oder Pneumothorax besteht die Initialbehandlung in der Anlage einer Thoraxdrainage mittels Minithorakotomie. Je nach Ausmaß des Traumas werden die betroffenen Patienten ggf. auf der Intensivstation überwacht, da sich eine Dynamik im Sinne einer pulmonalen Insuffizienz oder auch persistierenden Blutung entwickeln kann. Verletzungen der großen Gefäße und des Herzens erfordern die Versorgung an spezialisierten Zentren. Penetrierende Verletzungen werden immer operativ revidiert, wobei das Corpus alienum erst im Operationssaal entfernt wird. Lebensbedrohliche Situationen wie ein Spannungspneumothorax werden unmittelbar bereits präklinisch durch eine Thoraxdrainage behandelt.
Surgery of the aortic arch is arguably one of the most complex areas of cardiac surgery. Despite that, studies and guidelines have not sufficiently addressed the aortic arch specifically. In general, indications for aortic arch intervention parallel those of the ascending aorta. Herein we review indications for aortic arch intervention in various aortic pathologies based on the scant evidence available combined with surgical expertise and expert opinion.
Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years.
This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma.
There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia.
Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.
Since March 1999, 52 thoracic endovascular aortic repair (TEVAR) procedures have been done acutely as part of primary polytrauma repair in 48 patients after thoracic aortic rupture. In the presence of aortic diameters of 12–30 mm, only the smallest thoracic stent graft systems available from Gore, Medtronic, and Cook—in one instance, an iliac extension limb—were used. The primary success rate (sealing of the aorta) was 100%. Three patients died from serious concomitant injuries unrelated to the aorta. Of three cases of acute stent compression syndrome, one proved to be lethal. Contemporary stent graft systems show conformability deficits at the narrow curvature of the juvenile aortic arch, with consequent disattachment phenomena and disattachment angles at the inner aortic curvature of up to 63° end-systolic. Nevertheless, the conversion rate up to 10 years was 0%, and no stent corrections were necessary after 30 days. Two additional patients died during the long-term observation period (after 3 and 5 years, respectively) after non-aorta-related trauma. All other patients are under supervision in a special magnetic resonance imaging assessment program; the majority are back to their normal activities and are seen regularly once a year. Ten years of follow-up is a long time, but not long enough in these young patients. Therefore, the definite role of TEVAR can be determined only after another 20 years.
To evaluate the available data on stent-graft repair of acute blunt traumatic thoracic aortic injury with regard to safety and efficacy compared with conventional open surgical repair.
The literature on endovascular repair of acute traumatic aortic injury since 1990 was systematically reviewed. Metaanalysis of publications with open and stent-graft repair cohorts was performed to evaluate whether there was a difference in treatment effect with regard to mortality and paraplegia. Case series were included to obtain an adequate population to assess the incidence of stent-graft procedure-related complications.
There were no prospective randomized studies. Nineteen publications that compared the outcomes of 262 endograft repairs and 376 open surgical repairs were identified. The odds ratio for mortality after endovascular versus open repair was 0.43 (95% CI, 0.26-0.70; P = .001). The odds ratio for paraplegia after endovascular versus open repair was 0.30 (95% CI, 0.12-0.76; P = .01). In the pooled group of 667 endovascular repair survivors from 50 reports, the incidence of early endoleak was 4.2%, and late endoleak occurred in 0.9%. Stroke or transient ischemic attack was reported in 1.2%. Access site complications that required intervention occurred in 4.1%.
The available cohort and case series data support stent-graft repair as a highly successful technique that may reduce mortality and paraplegia rates by half compared with open surgery. These data support endograft repair as first-line therapy for blunt thoracic aortic trauma.
Traumatic thoracic aortic injuries are associated with high mortality and morbidity. These patients often have multiple injuries, and delayed aortic repair is frequently used. Endoluminal grafts offer an alternative to open surgical repair. We performed a meta-analysis of comparative studies evaluating endovascular vs open repair of these injuries.
A systematic search of studies reporting treatment of traumatic aortic injury was performed using the following databases: Medline/PubMed, CINAHL, Proquest, Up to Date, Database of Abstracts of Reviews of Effects (DARE), ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Search terms were thoracic aortic trauma, traumatic thoracic aortic injury, traumatic aortic rupture, stent graft repair, and endovascular repair. Outcomes analyzed were procedure-related mortality, overall 30-day mortality, and paraplegia/paraparesis rate using odds ratios (OR) and 95% confidence intervals (CI). Publication bias was investigated using funnel plots. Assessment of homogeneity was performed using the Q test; statistical heterogeneity was considered present at P < .05. Weighted averages of age, interval to repair, and injury severity score were compared with the Welch t test; P < .05 was considered statistically significant.
Seventeen retrospective cohort studies from 2003 to 2007 were included. All were nonrandomized; no prospective randomized trials were found. These studies reported on 589 patients; 369 were treated with open repair, and 220 underwent thoracic stent graft placement. There was no significant difference in age (mean 38.8 years for both) or interval to repair (mean 1.5 days for endoluminal repair; 1 day for open repair). Injury severity score was higher for patients undergoing endoluminal repair (mean, 42.4 vs 37.4 for open repair, P < .001). Procedure-related mortality was significantly lower with endoluminal repair (OR, 0.31; 95% CI, 0.15-0.66; P = .002). Overall 30-day mortality was also lower after endoluminal repair (OR, 0.44; 95% CI, 0.25-0.78; P = .005). Sixteen studies reported data for postoperative paraplegia; 215 patients were treated with endograft placement and 333 with open repair. The risk of postoperative paraplegia was significantly less with endoluminal repair (OR, 0.32; 95% CI, 0.1-0.93; P = .037). The Q test did not indicate significant heterogeneity for the outcomes of interest; publication bias was limited.
Meta-analysis of retrospective cohort studies indicates that endovascular treatment of descending thoracic aortic trauma is an alternative to open repair and is associated with lower postoperative mortality and ischemic spinal cord complication rates.
Despite a lack of level I evidence, endovascular stent grafting is frequently used for the treatment of blunt thoracic aortic injury. The purpose of this study is to compare the outcomes between open and endovascular repair of traumatic rupture of the thoracic aorta.
This article is based on a single-institution review of all consecutive patients treated for blunt aortic injury at the University of Wisconsin Hospital and Clinics between October 1999 and May 2007. This study was reviewed and approved by the institutional review board. Patients were identified from our Level 1 trauma registry. Inclusion criteria for this study was based on computed tomographic or angiographic evidence of thoracic aortic injury distal to the left subclavian artery. Two groups were identified: patients who underwent open repair (OR) and, patients who underwent endovascular repair (ER). Patient demographics, mechanism of injury, Injury Severity Score, associated injuries, comorbid conditions, intraoperative findings, postoperative complications, and duration of hospital stay were analyzed. Data regarding these patients and their injuries were retrieved from our trauma registry as well as chart review and outpatient records. The outcomes from OR and ER were compared using the Fisher exact test. P values less than 0.05 were considered statistically significant.
During the 8-year period, 26 consecutive patients were treated for blunt aortic injury (OR = 12 and ER = 14). There were 20 men, and the mean age was 36 years. There were no differences between the groups in the mechanism of injury, Injury Severity Score, or number of associated injuries on initial presentation. On an intent-to-treat basis, the endovascular therapy was technically successful 100% of the time. There was no procedure-related mortality. There was 1 patient, however, in the OR group with presumed recurrent laryngeal nerve palsy. There was no incident of treatment-related paraplegia in either group. The 1-year survival for OR and ER patients was 93% and 92%, respectively. At 1 year, 25% of patients in the OR group and 18% of patients in the ER group required reinterventions. Mean operating room time was 309 minutes for the ERs and 383 minutes for the patients who underwent OR. Intraoperative blood product administration was greater in the OR group (P = .055); there was no difference between the groups, however, in the total blood products administered for a given hospital stay. The mean duration of hospital stay was 13 days for the OR group and 13.9 days for the ER group.
There were no significant differences with respect to morbidity or mortality between these 2 groups. These data suggest that ER is at least as safe as OR for blunt aortic injury.
The isthmic aortic rupture represents the main cause of death in car crash accidents, because of closed chest trauma. Early medical and surgical care and endovascular prosthesis treatment with semi-invasive method can improve short and mid term survival. Nine patients with traumatic isthmic aortic rupture underwent endoprosthesis aortic implantation. All the patients were male, mean age 42.48 +/- 17.66 years. Operations included 5 acute cases and 4 chronic cases (chance diagnosis). In all cases the diagnosis was performed by tomodensitometric exam. Cloth prostheses were used (self-expansible Goretex- or Dacron-stent). Three years after the endoprosthesis implantation, we obtained the complete thrombosis of the false aortic lumen in all patients, both acute and chronic, as well as the levelling of the false aneurysms without complications of any kind.
The appropriate management of traumatic aortic rupture is often difficult to determine, particularly if the rupture is associated with severe additional lesions. Between 1986 and 1991, ten consecutive patients with acute traumatic rupture of the thoracic aorta (ATRTA) and concomitant injuries were initially treated medically and submitted to delayed aortic repair. Within the same period no other patient had emergency reconstruction of the thoracic aorta. Diagnosis of ATRTA was established immediately after admission in eight patients. Five patients underwent emergency surgery for severe concomitant injuries. With regard to the aortic lesion, all patients were managed medically and submitted to pharmacological treatment in an attempt to reduce cardiac shear forces. None of the patients developed clinical signs of imminent free rupture while waiting for aortic surgery. In the absence of a significant hemothorax and when no coarctation syndrome is evident, the risk of free aortic rupture is considered to be rather low if the patient reaches the hospital in a stable circulatory condition. Postponement of aortic reconstruction is particularly indicated when severe concomitant lesions preclude safe immediate repair of the aortic tear. Following the patient's recovery from associated major injury, aortic surgery can be performed as a low risk procedure using cardiopulmonary bypass which is recognised as the most effective technique to prevent spinal cord ischemia and to reduce the risk of paraplegia.
Stent grafting is emerging as a new treatment for several pathological conditions involving the thoracic aorta. We studied the feasibility and safety of this technique for delayed treatment of ruptures of the aortic isthmus.
Nine patients (14 to 76 years old; mean, 37 years; male/female ratio, 8/1) underwent stent grafting of the aortic isthmus in subacute (n=5) or chronic (n=4) aortic traumatic rupture after a motor accident. In subacute ruptures, this treatment was delayed (1 to 8 months; mean, 5.4 months) because of the severity of other associated injuries. Stent grafting was technically successful (defined as complete exclusion of the pseudoaneurysmal sac) in all patients. Short-term fever and biological inflammatory syndrome occurred in 3 patients. Two major complications occurred: in 1 patient, an early occlusion of the left subclavian artery was treated by placement of 2 Palmaz stents. In another patient, an atelectasis related to an increase of preexisting compression of the left main bronchus by the pseudoaneurysmal sac was successfully treated by temporary placement of an endobronchial silicone stent. Mean follow-up was 11.6 months (range, 3 to 21 months). Thrombosis of the pseudoaneurysmal sac was found in all patients.
In the absence of available extended follow-up about the safety and effectiveness of endovascular grafting, this approach seems to be a viable therapeutic option for traumatic rupture of the aortic isthmus, but appropriately controlled prospective studies are needed before we can recommend its widespread use.