1
|
Mufty H, Maleux G, Houthoofd S, Cornelissen SA, Daenens K, Bonne L, Fourneau I. The effect of TEVAR for blunt traumatic thoracic aortic injury on maximal aortic diameter: Mid- and long-term outcome. Vascular 2019; 27:411-416. [PMID: 30871442 DOI: 10.1177/1708538119836333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Thoracic endovascular aortic repair (TEVAR) has become the standard of care for blunt thoracic aortic injury (BTAI). Long-term effects of TEVAR on the aortic diameter are not well studied. This study evaluates the effect of TEVAR for BTAI on the aortic diameter in mid- and long-term follow-up. Methods All patients treated with TEVAR for BTAI between August 2000 and May 2016 were included. Maximum aortic diameter was measured at four predetermined thoracic aortic levels in the preoperative and first postoperative CT angiography (CTa) and in the last control CTa or MR angiography: 1 cm proximal (D1) and 1 cm distal to the left subclavian artery (D2), 3 cm distal to the left subclavian artery (D3) and 3 cm proximal to the celiac trunk (D4). Results A total of 27 patients (20 men, mean age 40 years (±17.55) were included. Mean follow-up time was 90 months (±48.36)). No re-interventions were needed. Mean growth of aortic diameter at level D1, D2, D3 and D4 was 0.22 mm ± 3.66, 1.79 mm ± 3.82, 0.73 mm ± 4.18 and –1.06 mm ± 2.82, respectively, when comparing last follow-up to the preoperative imaging without any statistical significant differences. When comparing the preoperative diameter with the first postoperative CT, only a statistical significant growth of 2.81 mm ± 2.69 was seen at level of D2 ( p < 0.05) Conclusion During mid- to long-term follow-up, a temporary significant increase of the maximum aortic diameter was seen at level D2 in the direct postoperative phase This increase was not associated with clinical events and suggests long-term efficacy of TEVAR after BTAI.
Collapse
Affiliation(s)
- Hozan Mufty
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- 2 Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Sabrina Houthoofd
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Kim Daenens
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lawrence Bonne
- 2 Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Inge Fourneau
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Pagliariccio G, Salati M, Roncon A, Gironi G, Carbonari L. Endovascular Treatment of Blunt Thoracic Aortic Injury by Fractured Rib. Ann Vasc Surg 2019; 57:272.e15-272.e17. [PMID: 30684606 DOI: 10.1016/j.avsg.2018.10.021] [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: 07/03/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 11/19/2022]
Abstract
We treated an 89-year-old patient affected by a descending thoracic aorta lesion due to a rib fracture with a penetrating costal stump. An urgent combined thoracic and endovascular surgical approach was performed, removing the rib fragment and positioning an aortic endoprosthesis simultaneously. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage.
Collapse
Affiliation(s)
- Gabriele Pagliariccio
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy.
| | - Michele Salati
- Department of Thoracic Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Alberto Roncon
- Department of Thoracic Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Giulia Gironi
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Luciano Carbonari
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| |
Collapse
|
3
|
Tigkiropoulos K, Sigala F, Tsilimigras DI, Moris D, Filis K, Melas N, Karamanos D, Kontogiannis C, Lazaridis I, Saratzis N. Endovascular Repair of Blunt Thoracic Aortic Trauma: Is Postimplant Hypertension an Incidental Finding? Ann Vasc Surg 2018. [PMID: 29524462 DOI: 10.1016/j.avsg.2018.01.100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) is the second most common cause of death in trauma patients. Nowadays, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice because of lower rates of mortality, paraplegia, and stroke. However, concerns have been raised whether graft implantation is related to the development of hypertension in the postoperative period. The aim of this study was to report short- and long-term outcomes of patients undergoing TEVAR for BTAIs at a tertiary hospital and to investigate postimplant hypertension. METHODS Between January 2005 and January 2016, 23 patients with blunt thoracic aortic trauma underwent TEVAR. Median age was 44 years (range, 18-73). Among them, 14 (60.9%) patients were diagnosed with aortic rupture, whereas 9 (39.1%) with pseudoaneurysm. Α single thoracic stent graft was deployed in 21 patients, and the rest 2 patients received 2 stent grafts. RESULTS Complete exclusion of the injury was feasible in all subjects (100% primary success). The left subclavian artery (SCA) was intentionally covered in 6 patients (26%). Intraoperative complications included one nonfatal stroke managed conservatively and one external iliac artery rupture treated with iliofemoral bypass. One patient (4.3%) died on the first postoperative day in the intensive care unit (ICU) because of hemorrhagic shock. The overall 30-day mortality and morbidity were 4.3% and 8.7%, respectively. New-onset postimplantation arterial hypertension was observed in 8 (34.8%) previously nonhypertensive patients. Younger age (P = 0.027) and SCA coverage (P = 0.01) were identified as potential risk factors for the development of postimplant hypertension, whereas the presence of concomitant injuries (P = 0.3) and intraoperative complications (P = 0.1) were not. After a median follow-up of 100 months (range, 18-120), 6 of them still remain on antihypertensive therapy, whereas the other 2 did not require permanent treatment. CONCLUSIONS TEVAR is a safe approach in the treatment of BTAI associated with low short- and long-term morbidity and mortality rates. Lower age and SCA coverage may contribute to the development of postimplant hypertension. Further larger cohort studies are warranted to elucidate the underlying mechanisms of postimplant hypertension.
Collapse
Affiliation(s)
- Konstantinos Tigkiropoulos
- 1st Department of Surgery, Aristotle University Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Fragiska Sigala
- 1st Department of Propaedeutic Surgery, Hippokration University Hospital, University of Athens Medical School, Athens, Greece
| | - Diamantis I Tsilimigras
- 1st Department of Propaedeutic Surgery, Hippokration University Hospital, University of Athens Medical School, Athens, Greece.
| | - Demetrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Konstantinos Filis
- 1st Department of Propaedeutic Surgery, Hippokration University Hospital, University of Athens Medical School, Athens, Greece
| | - Nikolaos Melas
- 1st Department of Surgery, Aristotle University Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Dimitrios Karamanos
- 1st Department of Surgery, Aristotle University Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Christos Kontogiannis
- 1st Department of Propaedeutic Surgery, Hippokration University Hospital, University of Athens Medical School, Athens, Greece
| | - Ioannis Lazaridis
- 1st Department of Surgery, Aristotle University Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nikolaos Saratzis
- 1st Department of Surgery, Aristotle University Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| |
Collapse
|
4
|
Management of the Left Subclavian Artery during Endovascular Stent Grafting for Traumatic Aortic Injury – A Systematic Review. Eur J Vasc Endovasc Surg 2011; 41:758-69. [DOI: 10.1016/j.ejvs.2011.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 01/04/2011] [Indexed: 11/19/2022]
|
5
|
Cindy M, Sabrina H, Kim D, Geert M, Inge F. Traumatic Aortic Rupture: 30 Years of Experience. Ann Vasc Surg 2011; 25:474-80. [DOI: 10.1016/j.avsg.2010.12.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 12/03/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
|
6
|
Urgnani F, Lerut P, Da Rocha M, Adriani D, Leon F, Riambau V. Endovascular treatment of acute traumatic thoracic aortic injuries: A retrospective analysis of 20 cases. J Thorac Cardiovasc Surg 2009; 138:1129-38. [DOI: 10.1016/j.jtcvs.2008.10.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 10/26/2008] [Accepted: 10/26/2008] [Indexed: 10/20/2022]
|
7
|
Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels. ACTA ACUST UNITED AC 2009; 67:660-71. [PMID: 19741416 DOI: 10.1097/ta.0b013e3181b2894c] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times. METHODS A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma. RESULTS In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%. CONCLUSION The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.
Collapse
|
8
|
McDonnell CO, Haider SN, Colgan MP, Shanik GD, Moore DJ, Madhavan P. Endovascular management of thoracic aortic pathology. Surgeon 2009; 7:24-30. [PMID: 19241982 DOI: 10.1016/s1479-666x(09)80063-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endovascular technology has revolutionised the management of abdominal aortic aneurysmal disease but the less frequent occurrence of pathology in the thoracic aorta has meant that evidence demonstrating the primacy of endovascular treatment strategies in this portion of the vessel is less convincing. Herein we summarise the best available evidence to date. METHODS A comprehensive search of the surgical and radiological literature using the search term 'endovascular thoracic aorta' was conducted. FINDINGS AND CONCLUSIONS The vast majority of patients treated by thoracic aortic stent grafting have had their treatment outside the context of a randomised trial. While it would seem that endovascular repair is the treatment of choice for the thoracic aorta, the present evidence is based on single centre case series and is anecdotal at best.
Collapse
Affiliation(s)
- C O McDonnell
- Department ofVascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
| | | | | | | | | | | |
Collapse
|
9
|
Alsac JM, Boura B, Desgranges P, Fabiani JN, Becquemin JP, Leseche G. Immediate endovascular repair for acute traumatic injuries of the thoracic aorta: A multicenter analysis of 28 cases. J Vasc Surg 2008; 48:1369-74. [DOI: 10.1016/j.jvs.2008.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 07/08/2008] [Accepted: 07/11/2008] [Indexed: 10/21/2022]
|
10
|
Hussain Q, Maleux G, Heye S, Fourneau I. Endovascular repair of an actively hemorrhaging stab wound injury to the abdominal aorta. Cardiovasc Intervent Radiol 2008; 31:1023-5. [PMID: 18389184 DOI: 10.1007/s00270-008-9327-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 02/13/2008] [Accepted: 03/03/2008] [Indexed: 11/27/2022]
Abstract
Traumatic injury of the abdominal aorta is rare and potentially lethal (Yeh et al., J Vasc Surg 42(5):1007-1009, 2005; Chicos et al., Chirurgia (Bucur) 102(2):237-240, 2007) as it can result in major retroperitoneal hemorrhage, requiring an urgent open surgery. In case of concomitant bowel injury or other conditions of hostile abdomen, endovascular repair can be an alternative treatment. This case report deals with a 50-year-old man presenting at the emergency ward with three stab wounds: two in the abdomen and one in the chest. During explorative laparotomy, liver laceration and bowel perforation were repaired. One day later, abdominal CT-scan revealed an additional retroperitoneal hematoma associated with an aortic pseudoaneurysm, located anteriorly 3 cm above the aortic bifurcation. Because of the risk of graft infection, an endovascular repair of the aortic injury using a Gore excluder stent-graft was performed. Radiological and clinical follow-up revealed a gradual shrinkage of the pseudo-aneurysm and no sign of graft infection at two years' follow-up.
Collapse
Affiliation(s)
- Qasim Hussain
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | | | | |
Collapse
|
11
|
Tang GL, Tehrani HY, Usman A, Katariya K, Otero C, Perez E, Eskandari MK. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: A modern meta-analysis. J Vasc Surg 2008; 47:671-5. [PMID: 17980541 DOI: 10.1016/j.jvs.2007.08.031] [Citation(s) in RCA: 186] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 08/17/2007] [Accepted: 08/18/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Gale L Tang
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | | | | | | | | | | | | |
Collapse
|
12
|
Reddy VS. Minimally Invasive Techniques in Thoracic Trauma. Semin Thorac Cardiovasc Surg 2008; 20:72-7. [DOI: 10.1053/j.semtcvs.2008.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2008] [Indexed: 11/11/2022]
|
13
|
Midgley PI, Mackenzie KS, Corriveau MM, Obrand DI, Abraham CZ, Fata P, Steinmetz OK. Blunt thoracic aortic injury: A single institution comparison of open and endovascular management. J Vasc Surg 2007; 46:662-8. [PMID: 17764869 DOI: 10.1016/j.jvs.2007.05.061] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 05/31/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To review the treatment of blunt thoracic aortic injuries (BAI) at a single institution over the past 12 years and compare pre-, peri-, and postoperative variables and outcomes of both open (OR) and thoracic endovascular (TEVAR) repair of these injuries. METHODS All cases of confirmed BAI from 1994 to present were included in this retrospective review. Data collected included demographic data, injury severity score, Glasgow coma score, arrival hemodynamic variables, and associated injuries. Operative data included: type of procedure (OR or TEVAR), duration of procedure, need for and amount of blood transfused, use of anticoagulation, type of anesthesia, and service performing the procedure. Outcomes evaluated were: death, paraplegia, length of stay, days ventilated, and procedure related complications. Specific to EVAR; access, stent graft type and number, presence of endoleak and long-term clinical and radiologic follow-up were evaluated. RESULTS Thirty cases of blunt thoracic aortic injury were identified. Two patients received no treatment and died, 28 patients were treated (OR 16, TEVAR 12) and included for comparison. There were no significant differences between groups with respect to preoperative variables with the exception of significantly more associated intra-abdominal injuries in the TEVAR group (P = .03). Five patients in the OR group (31.2%) died in the perioperative period. There were no deaths in the TEVAR group (P =.05). One OR patient (6.25%) suffered postoperative paraplegia. No paraplegia occurred in the TEVAR group. Intraoperative variables were similar between groups with the exception of mean units of blood transfused (OR 8.5 units, vs TEVAR 0.2 units, P = .002). Ten patients in the OR group either died or had a procedure related complication compared with none in the TEVAR group (P = .001). There was no difference in length of stay or length of mechanical ventilation between the groups. There were no procedure or device related complications in the TEVAR group during follow-up (mean 15.3 months, range 1 to 53.5 months). CONCLUSIONS Endovascular repair of BAI results in significantly less combined mortality and morbidity when compared to OR. Significantly less blood is needed intraoperatively in the TEVAR group. No complications from stent graft insertion have been observed during follow-up. Endovascular repair is replacing open repair as the treatment of choice for BAI at our institution.
Collapse
Affiliation(s)
- Peter I Midgley
- Division of Vascular Surgery, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | | | |
Collapse
|
14
|
Attia C, Villard J, Boussel L, Farhat F, Robin J, Revel D, Douek P. Endovascular Repair of Localized Pathological Lesions of the Descending Thoracic Aorta: Midterm Results. Cardiovasc Intervent Radiol 2007; 30:628-37. [PMID: 17508244 DOI: 10.1007/s00270-007-9030-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The endoluminal stent-graft represents an attractive and a less invasive technique for treatment of various diseases of the descending thoracic aorta. The purpose of this study was to evaluate the Talent endovascular stent-graft for the treatment of various localized diseases of the descending thoracic aorta. Over a 3-year period, Talent thoracic endografts were placed in 40 patients with a high surgical risk, presenting a localized lesion of the descending thoracic aorta: degenerative aneurysm (n = 13), acute traumatic rupture (n = 11), acute Stanford type B aortic dissection (n = 6), false aneurysm (n = 7), and penetrating atherosclerotic ulcer (n = 3). Fifteen patients (37.5%) were treated as emergencies. The feasibility of endovascular treatment and sizing of the aorta and stent-grafts were determined preoperatively by magnetic resonance angiography (MRA) and intraoperative angiography. Immediate and mid-term technical and clinical success was assessed by clinical and MRA follow-up. Endovascular treatment was completed successfully in all 40 patients, with no conversion to open repair or intraoperative mortality. The mean operative time was 37.5 +/- 7 min. The overall 30-day mortality rate was 10% (n = 4), all in emergency cases, for causes not related to the endograft. The primary technical success was 92.5%. The mean follow-up period was 15 +/- 5 months. The survival rate was 95% (n = 35). Diminution of the aneurismal size was observed in 47.5% (n = 19). We conclude that endovascular treatment of the various localized diseases of the descending thoracic aorta is a promising, feasible, alternative technique to open surgery in well-selected patients.
Collapse
Affiliation(s)
- Cherif Attia
- Department of Cardiovascular Surgery, University Hospital Louis Pradel, Lyon, France
| | | | | | | | | | | | | |
Collapse
|
15
|
Lettinga-van de Poll T, Schurink GWH, De Haan MW, Verbruggen JPAM, Jacobs MJ. Endovascular treatment of traumatic rupture of the thoracic aorta. Br J Surg 2007; 94:525-33. [PMID: 17443851 DOI: 10.1002/bjs.5795] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.
Methods
A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.
Results
A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.
Conclusion
Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.
Collapse
Affiliation(s)
- T Lettinga-van de Poll
- Department of Vascular Surgery, University Hospital Maastricht, Maastricht, The Netherlands
| | | | | | | | | |
Collapse
|
16
|
McPhee JT, Asham EH, Rohrer MJ, Singh MJ, Wong G, Vorhies RW, Nelson PR, Cutler BS. The Midterm Results of Stent Graft Treatment of Thoracic Aortic Injuries. J Surg Res 2007; 138:181-8. [PMID: 17292414 DOI: 10.1016/j.jss.2006.09.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 09/27/2006] [Accepted: 09/28/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.
Collapse
MESH Headings
- Accidents, Traffic/mortality
- Adult
- Aged
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/mortality
- Aneurysm, False/surgery
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/injuries
- Aorta, Thoracic/surgery
- Blood Vessel Prosthesis
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Postoperative Complications/mortality
- Retrospective Studies
- Stents
- Tomography, X-Ray Computed
- Treatment Outcome
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/surgery
Collapse
Affiliation(s)
- James T McPhee
- Division of Vascular Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Neschis DG, Moaine S, Gutta R, Charles K, Scalea TM, Flinn WR, Griffith BP. Twenty consecutive cases of endograft repair of traumatic aortic disruption: Lessons learned. J Vasc Surg 2007; 45:487-92. [PMID: 17254737 DOI: 10.1016/j.jvs.2006.11.038] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 11/15/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Endograft repair holds considerable promise in the treatment of traumatic disruption of the thoracic aorta because patients often have multiple coexisting injuries further complicating traditional open repair. In addition, patients are often young, with an aortic anatomy dissimilar to those with atherosclerotic aneurysms. As a result, techniques for endograft repair have to be refined accordingly. METHODS The records of 20 consecutive cases of traumatic aortic disruption treated by endograft repair at a single institution were reviewed. RESULTS Mean patient age was 40 years (range, 17 to 88 years), and 17 (85%) of 20 patients were men. All cases were completed. There were no procedure related deaths, but four (20%) patients died of their co-injuries. Only two (10%) of 20 required a graft >28 mm in diameter, and nine (45%) aortas were small enough to require use of 23-mm abdominal cuffs. Six (30%) of 20 cases required complete or partial coverage of the left subclavian artery. Placement of a proximal extension was required in one patient for a type I endoleak. A graft collapse occurred in one patient that required surgical removal and aortic repair. CONCLUSIONS Endovascular repair of traumatic aortic disruption can be accomplished in most cases. Compared with atherosclerotic aneurysms, the proximal thoracic aorta tends to be smaller and the arch angle tighter in an aorta 19mm in diameter. This frequently necessitates the use of smaller devices and less stiff wires. Surgeons should be prepared to cover the left subclavian artery if needed, have a wide range of device sizes in stock to avoid over-sizing, and show restraint if the anatomy appears unsuitable.
Collapse
Affiliation(s)
- David G Neschis
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | | | | | | | | | | | | |
Collapse
|
18
|
Saratzis NA, Saratzis AN, Melas N, Ginis G, Lioupis A, Lykopoulos D, Lazaridis J, Dimitrios K. Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience. Cardiovasc Intervent Radiol 2007; 30:370-5. [PMID: 17295078 DOI: 10.1007/s00270-006-0186-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. METHODS Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosed with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. RESULTS Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8-16 months) follow-up. CONCLUSIONS This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.
Collapse
Affiliation(s)
- Nikolaos A Saratzis
- 1st Department of Surgery, Aristotle University, Papageorgiou General Hospital, Thessaloniki, Greece.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Steingruber IE, Czermak BV, Chemelli A, Glodny B, Bonatti J, Jaschke W, Waldenberger P, Rieger M, Neuhauser B. Placement of endovascular stent-grafts for emergency repair of acute traumatic aortic rupture: a single-centre experience. Eur Radiol 2006; 17:1727-37. [PMID: 17115167 DOI: 10.1007/s00330-006-0451-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 08/09/2006] [Accepted: 08/18/2006] [Indexed: 11/27/2022]
Abstract
The aim of this retrospective study was to evaluate mid- and long-term results of endovascular stent-graft placement for emergency repair of acute traumatic thoracic aortic rupture. From 1996 through 2005, 22 consecutive patients (mean age: 38.7 years) underwent endovascular repair of acute traumatic thoracic aortic rupture located at the aortic isthmus in most cases. All patients were at high surgical risk due to severe associated injuries. The endografts were inserted via femoral or iliac artery access under fluoroscopic guidance. Follow-up was performed postinterventionally, at 6 and 12 months and yearly thereafter, and included clinical examination and computed tomography (CT) scans. Technical and clinical success rates were 86.3%. Mean follow-up was 31.7 months. Three patients developed early type I endoleak due to the inability of the rigid graft to adapt to the curved aortic contour. In two of them conversion to open surgery was necessary. One patient had late type I endoleak and died. No other complications were observed. The outcome was successful in most patients. The mid- and long-term results of our current study are promising. However, early type I endoleak represents a problem, especially in adolescent patients with a marked curvature of the aortic arch.
Collapse
Affiliation(s)
- I E Steingruber
- Department of Radiology, University Hospital Innsbruck, Austria.
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Hoornweg LL, Dinkelman MK, Goslings JC, Reekers JA, Verhagen HJM, Verhoeven EL, Schurink GWH, Balm R. Endovascular management of traumatic ruptures of the thoracic aorta: A retrospective multicenter analysis of 28 cases in The Netherlands. J Vasc Surg 2006; 43:1096-102; discussion 1102. [PMID: 16765221 DOI: 10.1016/j.jvs.2006.01.034] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2005] [Accepted: 01/11/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Minimally invasive endovascular treatment of a traumatic rupture of the thoracic aorta is a new strategy in the care of multitrauma patients. We report the experience in The Netherlands with endovascular management of patients with acute traumatic ruptures of the thoracic aorta. METHODS We reviewed 28 patients with a traumatic thoracic aortic rupture treated with a thoracic aortic endograft between June 2000 and April 2004. All patients underwent treatment at one of the four participating level 1 trauma centers. Data collected included age, sex, injury severity score, type of endovascular graft, endovascular operation time, length of stay, length of stay in the intensive care unit, and mortality. Follow-up data consisted of computed tomographic angiography and plain chest radiographs at regular intervals. RESULTS All patients (mean age, 40.9 years; SD, 18.5 years) experienced severe traumatic injury, and the mean injury severity score was 37.1 (SD, 7.8). All endovascular procedures were technically successful, and the median operating time for the endovascular procedure was 58 minutes (interquartile range, 47-88 minutes). The overall hospital mortality was 14.3% (n = 4), and all deaths were unrelated to the aortic rupture or stent placement. There was no intervention-related mortality during a median follow-up of 26.5 months (interquartile range, 10-34.6 months). Postoperative data showed no severe endovascular graft- or procedure-related morbidity, except for one patient with an asymptomatic collapse of the endovascular graft during regular follow-up. This was corrected by placing a second graft. CONCLUSIONS This study shows that the results of immediate endovascular repair of a traumatic aortic rupture are at least equal to those of conventional open surgical repair. Especially in these multitrauma patients with traumatic ruptures of the thoracic aorta, endovascular therapy seems to be preferable to conventional open surgical repair.
Collapse
Affiliation(s)
- Liselot L Hoornweg
- Department of Vascular Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Iyer VS, Mackenzie KS, Tse LW, Abraham CZ, Corriveau MM, Obrand DI, Steinmetz OK. Early outcomes after elective and emergent endovascular repair of the thoracic aorta. J Vasc Surg 2006; 43:677-83. [PMID: 16616219 DOI: 10.1016/j.jvs.2005.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Accepted: 12/01/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endovascular treatment of thoracic aortic pathology has emerged as a viable alternative to open surgical repair in both the elective and emergent settings. The aim of this study was to evaluate preoperative work-up, intra-operative strategy, and outcomes of endovascular stent-grafting of the thoracic aorta in patients undergoing elective repair and those undergoing emergent repair. METHODS All patient information was obtained by a retrospective review of an established clinical database for all endovascular thoracic stent-graft cases. From October 1999 to August 2005, 70 patients were treated with endovascular stent-grafts for lesions of the thoracic aorta. Thirty-five patients had an elective endovascular procedure, and 35 patients had an emergent procedure. RESULTS Thirty-five patients in the endovascular (EL) group were treated for aneurysm (n = 34) and type B dissection (n = 1). Thirty-five patients in the emergent (EM) group were treated for aneurysm (n = 10), intramural hematoma (n = 10), type B dissection (n = 7), traumatic rupture (n = 7), and aortoesophageal fistula (n = 1). Preoperative angiography was performed in 94.3% (33/35) of EL patients but in only 45.7% (16/35) EM patients (P < .005). The EM procedures had significantly shorter operative times, used lower contrast volumes, used fewer stent-graft components (mode 2, range 1 to 5 vs mode 1, range 1 to 3; P = .02), and spinal cerebrospinal fluid drains were used significantly less often (82.9% vs 57.1%, P = .04). Both groups had similar 30-day morbidity, mortality (0/35 EL vs 1/35 [2.9%] EM, P = .99), postoperative endoleak (9/35 [25.7%] EL vs 7/35 [20.0%] EM, P = .78), endovascular failure (3/35 [8.6%] EL vs 5/35 [14.3%] EM, P = .71), and patient survival. CONCLUSION There are significant differences in the underlying pathology, preoperative evaluation, and operative course between elective and emergency treatment endovascular procedures for lesions of the thoracic aorta. Endovascular repair of thoracic aortic lesions can be accomplished with low perioperative mortality and morbidity rates, as well as acceptable endoleak and endovascular failure rates for both elective and emergency procedures.
Collapse
Affiliation(s)
- Vikram S Iyer
- Division of Vascular Surgery, McGill University, Montréal, Québec, Canada
| | | | | | | | | | | | | |
Collapse
|
22
|
Fang TD, Peterson DA, Kirilcuk NN, Dicker RA, Spain DA, Brundage SI. Endovascular management of a gunshot wound to the thoracic aorta. ACTA ACUST UNITED AC 2006; 60:204-8. [PMID: 16456457 DOI: 10.1097/01.ta.0000196318.23409.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Tony D Fang
- Division of Trauma and Surgical Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | | | | | | | | | | |
Collapse
|
23
|
Criado FJ, Abul-Khoudoud OR, Domer GS, McKendrick C, Zuzga M, Clark NS, Monaghan K, Barnatan MF. Endovascular Repair of the Thoracic Aorta: Lessons Learned. Ann Thorac Surg 2005; 80:857-63; discussion 863. [PMID: 16122443 DOI: 10.1016/j.athoracsur.2005.03.110] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2004] [Revised: 03/06/2005] [Accepted: 03/16/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND Available information on outcome and best strategies for thoracic endovascular repair is somewhat limited and unclear. We sought to gain a better understanding of these issues through a retrospective review of our 8-year clinical experience in the treatment of thoracic aortic aneurysms and dissections. METHODS A retrospective chart review of 186 patients undergoing stent-graft repair of thoracic aortic lesions at our institution during the 92-month period ending on December 31, 2004 was performed. Patients were divided into two groups based on the indication for treatment; group A had thoracic aortic aneurysms (TAA) and group B had type B aortic dissections (TBAD). Both groups were analyzed for outcome variables including technical success, mortality, major morbidity, endoleak rate and type, secondary endovascular interventions, and long-term survival. Mean follow-up was 40 months (range, 1 to 92 months). RESULTS Compared to group B, group A patients were older and had a higher incidence of peripheral vascular disease and chronic obstructive pulmonary disease. Sixty percent of all patients were American Society of Anesthesiologists class III and the remainder were class IV (38.3%) and V (1.7%). The procedure was completed in 180 patients (96.7%), with all 6 failures being access-related. The average procedure time was 149 minutes (range, 72 to 405). The 30-day mortality was 4.7% (9 patients), and serious morbidity was 19.9% (37 patients). Eight patients (4.3%) developed spinal cord ischemia, 4 immediately after the procedure and 4 delayed (1 to 3 days). Total hospital length of stay averaged 6.7 days. Secondary endovascular interventions were successful in 17 patients with angiographically confirmed endoleaks (type I and III). At an average follow-up of 40 months, freedom from all-cause mortality was 62.5% in group A and 58.1% in group B. CONCLUSIONS Stent-graft repair for TAA and TBAD can be achieved with high technical success and comparatively low rates of morbidity and mortality. Midterm survival appears to be favorable. Further refinements in device technology and procedural techniques are needed.
Collapse
Affiliation(s)
- Frank J Criado
- Center for Vascular Intervention, Division of Vascular Surgery, Union Memorial Hospital, MedStar Health, Baltimore, Maryland, USA.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
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.
Collapse
Affiliation(s)
- Edouard Kieffer
- Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, France.
| | | | | |
Collapse
|
25
|
Wellons ED, Milner R, Solis M, Levitt A, Rosenthal D. Stent-graft repair of traumatic thoracic aortic disruptions. J Vasc Surg 2005; 40:1095-100. [PMID: 15622361 DOI: 10.1016/j.jvs.2004.09.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Blunt traumatic thoracic aortic disruption results in pre-hospital death in 80% to 90% of patients. Because of the significant surgical morbidity and mortality associated with open operative repair, endovascular stent-graft repair has been investigated. The objective of this study was to evaluate the efficacy of thoracic aortic disruptions treated with commercially available proximal aortic extension cuffs. METHODS Nine patients with multiple system trauma (age range, 16-42 years) were seen after motor vehicle accidents between January 1, 2003, and April 1, 2004. Chest x-ray findings warranted thoracic computed tomography scans, which revealed disruptions of the thoracic aorta. Aortograms delineated the extent of the aortic injuries and identified a "landing zone" (neck length range, 1.5-2.0 cm) distal to the subclavian artery but proximal to the tear. The repairs were performed with AneuRx (n= 8) and Excluder (n = 1) proximal aortic extension cuffs. A left femoral artery approach was used in 6 patients, a suprainguinal retroperitoneal approach with an iliac conduit in 2 patients, and direct tunnel in 1 patient. An Amplatz super-stiff wire was placed in the right axillary artery to enable easy tracking of the endografts, and left brachial artery access was used for arch arteriography. RESULTS In each patient the stent-graft cuff was deployed adjacent to the left subclavian artery, with successful exclusion of traumatic disruptions verified at intraoperative arteriography and on computed tomographic scans obtained within 48 hours of initial repair. One patient required a second cuff for exclusion of a type I endoleak at the distal attachment site 1 month after the initial endograft repair. There were no procedure-related deaths; 1 patient, however, died of other injuries. CONCLUSIONS Stent-graft repair of traumatic thoracic aortic disruptions is technically feasible. Placement of a stiff wire in the right axillary artery and percutaneous left brachial artery access for arteriography are useful adjuncts during endograft deployment. Endovascular stent grafts may enable definitive repair or serve as a bridge until the patient is stable enough to undergo an operation, if necessary. This technique warrants further investigation.
Collapse
Affiliation(s)
- Eric D Wellons
- Department of Vascular Surgery, Atlanta Medical Center, GA, USA.
| | | | | | | | | |
Collapse
|
26
|
Rousseau H, Bolduc JP, Dambrin C, Marcheix B, Canevet G, Otal P. Stent-Graft Repair of Thoracic Aortic Aneurysms. Tech Vasc Interv Radiol 2005; 8:61-72. [PMID: 16098939 DOI: 10.1053/j.tvir.2005.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular treatment of aortic disease has emerged as an alternative mode of treatment that is particularly attractive for patients with severe comorbidities who would not be ideal candidates for open surgery. Actually, short-term morbidity and mortality rates, of large series, compare favorably with those from surgery, and stent-graft placement is proving to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases. However, although endoluminal interventions are minimally invasive, they are associated with complications, as are surgical methods. In this article, indications, technical aspects, and results of endovascular TAA repairs will be reviewed. We will also examine the advantages and limitations of stent-graft treatment. Finally, we will discuss the management of complications following aortic stent-graft implantation. We intentionally do not cover the topic of thoracic dissection, as it is being covered in another article in this volume.
Collapse
Affiliation(s)
- H Rousseau
- Department of Radiology, University Hospital Rangueil, Toulouse, France.
| | | | | | | | | | | |
Collapse
|
27
|
Tse LW, MacKenzie KS, Montreuil B, Obrand DI, Steinmetz OK. The proximal landing zone in endovascular repair of the thoracic aorta. Ann Vasc Surg 2004; 18:178-85. [PMID: 15253253 DOI: 10.1007/s10016-004-0008-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In this study we evaluated the relationship between the site of the proximal landing zone during endovascular repair of thoracic aortic pathology and treatment outcomes. We reviewed all cases of endovascular repair of thoracic aortic lesions at our institution in the past 42 months. Thirty-seven Talent thoracic endografts were used to treat 20 thoracic aneurysms, 8 intramural hematomas, 6 aortic dissections, and 3 post-traumatic aneurysms. The proximal edge of the covered endograft was situated proximal to the left common carotid artery (zone 1) in 3 patients, between the left common carotid and subclavian arteries (zone 2) in 4 patients, <2 cm distal to the left subclavian artery (zone 3) in 9 patients, and >2 cm distal to the left subclavian (zone 4) in 21 patients. Five patients had extraanatomic bypass to revascularize one or more covered aortic branches. For zones 1, 2, 3, and 4 the endoleak rates were 100%, 0%, 11%, and 0%, respectively; the secondary procedure rates were 33%, 0%, 11%, and 5% respectively; and the treatment failure rates were 67%, 0%, 11%, and 0%, respectively (p < 0.05, for endoleak rates, using Fisher's exact test to compare zone 1 to zones 2, 3, and 4 individually, and as a group). All three endovascular failures were due to proximal type 1 endoleaks. In conclusion, despite the use of great-vessel ligation and extraanatomic bypass to extend the proximal landing zone into the aortic arch, we have been unable to reliably exclude thoracic aortic pathology through use of endografts when the proximal landing zone is proximal to the left common carotid artery.
Collapse
MESH Headings
- Aged
- Aged, 80 and over
- Aortic Dissection/diagnostic imaging
- Aortic Dissection/mortality
- Aortic Dissection/therapy
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/mortality
- Aneurysm, Ruptured/therapy
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/pathology
- Aorta, Thoracic/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/therapy
- Canada
- Embolization, Therapeutic
- Female
- Follow-Up Studies
- Heart Arrest, Induced
- Humans
- Hypothermia, Induced
- Male
- Middle Aged
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/etiology
- Postoperative Complications/mortality
- Survival Analysis
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular Surgical Procedures
Collapse
Affiliation(s)
- Leonard W Tse
- Division of Vascular Surgery, McGill University, Royal Victoria Hospital, Montreal, Quebec, Canada
| | | | | | | | | |
Collapse
|
28
|
Amabile P, Collart F, Gariboldi V, Rollet G, Bartoli JM, Piquet P. Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004; 40:873-9. [PMID: 15557899 DOI: 10.1016/j.jvs.2004.08.053] [Citation(s) in RCA: 158] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Blunt traumatic thoracic aortic rupture is a life-threatening surgical emergency associated with high mortality and morbidity. The recent development of endovascular stent-graft prostheses offers a potentially less invasive alternative to open chest surgery, especially in patients with associated injuries. We sought to compare the results of conventional surgical repair and endovascular treatment of traumatic aortic rupture in a single center. METHODS From July 1998 to January 2004, 20 patients with acute blunt traumatic aortic rupture underwent treatment at our institution. All patients had a lesion limited to the isthmus, and associated injuries. Initial management included fluid resuscitation, treatment of other severe associated lesions, and strict monitoring of blood pressure. Eleven patients (9 men, 2 women; mean age, 32 years) underwent surgical repair, including direct suturing in 6 patients and graft interposition in 5 patients. Ten patients were operated on with cardiopulmonary support (left bypass with centrifugal pump, n = 2; extracorporeal circulation, n = 8). The delay between trauma and surgery was 2.6 days (range, 0-21 days). Nine patients (8 men, 1 woman; mean age, 32 years) underwent endovascular treatment with commercially available devices (Excluder, n = 2; Talent, n = 7). In all patients 1 stent graft was deployed. In 2 patients the left subclavian artery was intentionally covered with the device. The delay between trauma and endovascular treatment was 17.8 days (range, 1-68 days). RESULTS One patient in the surgical group (9.1%) died during the intervention. Three surgical complications occurred in 3 patients (27%), including left phrenic nerve palsy (n = 1), left-sided recurrent nerve palsy (n = 1), and hemopericardium 16 days after surgery that required a repeat intervention (n = 1). No patient in this group had paraplegia. In the endovascular group successful stent-graft deployment was achieved in all patients, with no conversion to open repair. No patient died, and no procedure-related complications, including paraplegia, occurred in this group. Control computed tomography scans obtained within 7 days after endovascular treatment showed exclusion of pseudoaneurysm in all cases. Length of follow-up for endovascular treatment ranged from 3 to 41 months (mean, 15.1 months). Computed tomography scans obtained 3 months after endovascular treatment showed complete disappearance of pseudoaneurysm in all patients. CONCLUSION In the treatment of blunt traumatic thoracic aortic rupture, the immediate outcome in patients who receive endovascular stent grafts appears to be at least as good as observed after conventional surgical repair. Long-term follow-up is necessary to assess long-term effectiveness of such management.
Collapse
Affiliation(s)
- Philippe Amabile
- Department of Vascular Surgery, Hôpital Sainte Marguerite, 13009 Marseille, France
| | | | | | | | | | | |
Collapse
|