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Hao F, Genshaft S, Kee ST, Canan T, Yang EH, Moriarty JM. Percutaneous Transthoracic Treatment of Ascending Aortic and Root Pseudoaneurysms: Procedural Aspects and Guidance with the Use of Multimodality Imaging. J Vasc Interv Radiol 2018; 29:628-631. [PMID: 29685660 DOI: 10.1016/j.jvir.2018.01.767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 10/17/2022] Open
Abstract
Open repair of ascending aortic pseudoaneurysms (AAPs) is currently the standard of care, but it is associated with high morbidity and mortality. A single-center retrospective experience of 4 patients after cardiac surgery undergoing 5 percutaneous transthoracic embolization procedures is presented. In 3 of the 4 patients, the primary outcome of complete thrombosis was achieved after the first procedure, with a mean follow-up time of 11.5 months. In all 5 procedures, the patients tolerated the procedure well without associated acute complications. Percutaneous transthoracic embolization of AAPs offers an alternate minimally invasive treatment pathway for prohibitive-risk candidates.
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Affiliation(s)
- Frank Hao
- Vascular and Interventional Radiology, Department of Radiology, University of California, Los Angeles, CA 90095.
| | - Scott Genshaft
- Vascular and Interventional Radiology, Department of Radiology, University of California, Los Angeles, CA 90095
| | - Stephen T Kee
- Vascular and Interventional Radiology, Department of Radiology, University of California, Los Angeles, CA 90095
| | - Timothy Canan
- Department of Cardiology, Department of Medicine, University of California, UCLA Cardiovascular Center, Los Angeles, California
| | - Eric H Yang
- Department of Cardiology, Department of Medicine, University of California, UCLA Cardiovascular Center, Los Angeles, California
| | - John M Moriarty
- Vascular and Interventional Radiology, Department of Radiology, University of California, Los Angeles, CA 90095
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2
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Four-Year Follow-Up of Endograft Repair of Traumatic Aortic Transection in a 10-Year-Old. Vasc Endovascular Surg 2009; 43:597-8. [DOI: 10.1177/1538574409334832] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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3
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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.
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4
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Baldwin Z, Phillips L, Bullard M, Schneider D. Endovascular Stent Graft Repair of a Thoracic Aortic Gunshot Injury. Ann Vasc Surg 2008; 22:692-6. [DOI: 10.1016/j.avsg.2008.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Revised: 11/09/2007] [Accepted: 01/03/2008] [Indexed: 11/24/2022]
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5
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Abstract
Endovascular stent-grafting has found its place in the elective treatment of 60% of abdominal or thoracic aortic lesions. The morbidity and mortality rates are clearly lower than those of classical repair but the results are suboptimal with 9% residual endoleaks at 6 months. Anesthetic management with extensive monitoring even under local anesthesia remains mandatory and tends to reduce the postoperative care requirements. Future development will allow emergent endovascular treatment of ruptured aorta and further improvement will decrease the rate of late endoleaks.
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Affiliation(s)
- M Chollet-Rivier
- Department of Anesthesiology, University Hospital of Lausanne, Switzerland.
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6
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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.
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Affiliation(s)
- T Lettinga-van de Poll
- Department of Vascular Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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7
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Aidinian G, Karnaze M, Russo EP, Mukherjee D. Endograft repair of traumatic aortic transection in a 10-year-old--a case report. Vasc Endovascular Surg 2006; 40:239-42. [PMID: 16703213 DOI: 10.1177/153857440604000310] [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: 11/15/2022]
Abstract
Blunt abdominal aortic injury from trauma is extremely rare. It is generally from motor vehicular crashes resulting in dissection, intramural hematoma, or free rupture. Timely recognition and treatment of this injury are essential for a chance for survival. To the authors knowledge, this is the first reported case of successful management of this injury, with use of an intravascular stent-graft, in a child. Although open aortic repair has been the only modality used in children, intravascular stent-graft can be another available option in these injuries.
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Affiliation(s)
- Gilbert Aidinian
- Department of Surgery, Walter Reed Army Medical Center, Washington, DC, USA
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8
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Dhadwal AK, Abrol S, Zisbrod Z, Cunningham JN. Pseudoaneurysms of the ascending aorta following coronary artery bypass surgery. J Card Surg 2006; 21:221-4. [PMID: 16684045 DOI: 10.1111/j.1540-8191.2006.00220.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Ascending aortic pseudoaneurysms following prior cardiac procedures are a rare entity. We reviewed our institutional experience given the isolated case reports in the literature. METHODS A 10-year retrospective review identified 5 patients who underwent ascending aorta pseudoaneurysm repair. There were 3 women and 2 men with a median age of 70 years (range 63 to 79 years). Median duration from initial CABG to pseudoaneurysm repair was 5 years (range 5 months to 18 years). The clinical presentations included dyspnoea (2 patients), chest pain, fever of unknown origin, and a pulsatile mass. Four patients underwent urgent investigation and surgery. Diagnosis was established via CT scan (3 patients), transesophageal echocardiogram (1 patient), and MRA (1 patient). Two patients had a prior history of sternal wound infection. RESULTS Mortality was 60%. One survivor experienced a stroke. The etiology was prior cannulation site in 4 cases and vein graft anastamotic site in 1. Necrotic aortic tissue was noticed in 2 cases. Aortic tissue cultures were negative in all the patients. Cardiopulmonary bypass was established prior to sternotomy in 4 cases and 1 case was performed off-pump. Inadvertent rupture of the pseudoaneurysm (without exsanguination) occurred in 2 cases following sternotomy. Repair was performed with bovine pericardial patch in 2 cases and plication in 3 cases. CONCLUSION This highlights the varied presentation, necessity for urgent diagnosis and repair with a high operative mortality due to the late presentation. Aggressive diagnosis should be sought and consideration should be given to catheter-based interventions for initial treatment.
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Affiliation(s)
- Ajay K Dhadwal
- Division of Cardiothoracic Surgery, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, New York, USA
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9
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Thompson JK, Reed AB, Giglia JS. Novel Endovascular Treatment of Blunt Thoracic Aortic Trauma with a Self-Expanding Stent Lined with Aortic Extender Cuffs. Ann Vasc Surg 2006; 20:271-3. [PMID: 16550479 DOI: 10.1007/s10016-006-9008-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2005] [Revised: 05/16/2005] [Accepted: 01/24/2006] [Indexed: 10/24/2022]
Abstract
We report the successful treatment of blunt thoracic aortic trauma with a self-expanding stent lined with commercially available aortic extender cuffs. A 24 x 70 mm Wallstent was positioned distal to the left subclavian artery via a left femoral approach. The stent was then lined with three overlapping Gore Excluder aortic extender cuffs. Intravascular ultrasound was performed pre- and post-deployment. The aortic pseudoaneurysm was successfully excluded. The self-expanding stent facilitated placement of the extender cuffs and improved the contact between the multiple cuffs. This technique could still have utility in emergency settings when approved thoracic endografts are available for this indication.
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MESH Headings
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/surgery
- Angioplasty
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/injuries
- Aorta, Thoracic/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/surgery
- Humans
- Male
- Middle Aged
- Prosthesis Design
- Stents
- Suicide, Attempted
- Tomography, X-Ray Computed
- Wounds, Nonpenetrating
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Affiliation(s)
- J Keith Thompson
- Division of Vascular Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA
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10
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Rousseau H, Dambrin C, Marcheix B, Richeux L, Mazerolles M, Cron C, Watkinson A, Mugniot A, Soula P, Chabbert V, Canevet G, Roux D, Massabuau P, Meites G, Tran Van T, Otal P. Acute traumatic aortic rupture: A comparison of surgical and stent-graft repair. J Thorac Cardiovasc Surg 2005; 129:1050-5. [PMID: 15867779 DOI: 10.1016/j.jtcvs.2004.12.023] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.
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MESH Headings
- Accidents, Traffic
- Acute Disease
- Analysis of Variance
- Angiography, Digital Subtraction
- Angioplasty, Balloon/adverse effects
- Angioplasty, Balloon/instrumentation
- Angioplasty, Balloon/methods
- Angioplasty, Balloon/mortality
- Aorta, Thoracic/injuries
- Aortic Rupture/diagnosis
- Aortic Rupture/etiology
- Aortic Rupture/therapy
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/methods
- Blood Vessel Prosthesis Implantation/mortality
- Echocardiography, Transesophageal
- Female
- Follow-Up Studies
- Humans
- Injury Severity Score
- Male
- Patient Selection
- Retrospective Studies
- Stents/adverse effects
- Thoracotomy/adverse effects
- Thoracotomy/instrumentation
- Thoracotomy/methods
- Thoracotomy/mortality
- Time Factors
- Tomography, Spiral Computed
- Treatment Outcome
- Wounds, Nonpenetrating/complications
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Affiliation(s)
- H Rousseau
- Department of Radiology, University Hospital Rangueil, 01 av. J Poulhes, 31403 Toulouse, France.
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11
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Abstract
We report three cases of patients with blunt thoracic trauma, who underwent transesophageal echocardiography (TEE) because of high index of clinical suspicion for acute traumatic aortic syndrome. TEE revealed three different locations of aortic injury one of which was not diagnosed with aortography.
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12
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Stahlfeld KR, Mitchell J, Sherman H. Endovascular Repair of Blunt Abdominal Aortic Injury: Case Report. ACTA ACUST UNITED AC 2004; 57:638-41. [PMID: 15454816 DOI: 10.1097/01.ta.0000042018.39379.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kurt R Stahlfeld
- Department of Surgery, Mercy Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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13
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Dunham MB, Zygun D, Petrasek P, Kortbeek JB, Karmy-Jones R, Moore RD. Endovascular stent grafts for acute blunt aortic injury. ACTA ACUST UNITED AC 2004; 56:1173-8. [PMID: 15211121 DOI: 10.1097/01.ta.0000123039.92225.e5] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular stent grafting (EVSG) has emerged as a new treatment for aortic disease and has recently been applied to the treatment of acute blunt aortic injury (BAI). The purpose of this study was to determine the outcome of EVSG for patients with BAI at two tertiary (Level I) trauma centers. METHODS A retrospective review of patients treated between January 1, 1999, and February 1, 2003, at two centers, Calgary Health Region (Calgary, Alberta) and Harborview Medical Center (Seattle, WA), with EVSG for acute BAI is reported. Variables assessed included age, sex, Injury Severity Score, total length of stay (LOS), intensive care unit LOS, operative technique, complications, technical success, mortality, and follow-up data. RESULTS Twenty-eight patients treated with EVSG for BAI were identified during this period. Twelve patients were excluded because injuries occurred more than 30 days before grafting (n = 7) or under a different protocol (n = 4), or the procedure was performed in a different center (n = 1). Sixteen patients with acute BAI were reviewed. The mean Injury Severity Score was 36.9 (SD, 17.0), with a median intensive care unit LOS of 7.5 days (interquartile range, 1-17 days) and total LOS of 24.5 days (interquartile range, 7-41 days). Mean follow-up was 10.7 months (range, 3-30 months). Technical success was achieved in all patients, no graft-related complications have been detected during follow-up, and no patient developed postoperative paraplegia. One postoperative mortality occurred secondary to severe comorbid injury. A single patient with a preoperative traumatic carotid dissection demonstrated a postoperative stroke, and one patient required thoracentesis for a pleural effusion. CONCLUSION Repair of BAI with EVSG can be performed safely in patients with BAI. Mortality, morbidity, and especially paraplegia are reduced. Further long-term studies are required to support the routine use of EVSG technology for BAI.
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Affiliation(s)
- M B Dunham
- Departments of Surgery and Critical Care at the Calgary Health Region, Calgary, Alberta, Canada, and Harborview Medical Center, Seattle, Washington, USA
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14
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Minor ME, Morrissey NJ, Peress R, Carroccio A, Ellozy S, Agarwal G, Teodorescu V, Hollier LH, Marin ML. Endovascular treatment of an iatrogenic thoracic aortic injury after spinal instrumentation: case report. J Vasc Surg 2004; 39:893-6. [PMID: 15071460 DOI: 10.1016/j.jvs.2003.10.056] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Iatrogenic aortic injuries after spinal surgery have been described, but are rare. We describe a case of a 77-year-old woman who underwent surgical correction of a debilitating spinal deformity at an outside institution. Postoperative thoracic spine radiographs and computed tomography scans revealed a misplaced pedicle screw at T5, which was impinging on the descending thoracic aortic wall. The patient was brought to the operating room, where a thoracic stent graft was deployed under fluoroscopic guidance as the malpositioned screw was manually retracted. The patient had an uneventful postoperative course, and was discharged within 24 hours. This case represents a rare but potentially morbid vascular complication of spinal instrumentation surgery that was successfully treated without the need for thoracotomy.
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Affiliation(s)
- Michael E Minor
- Department of Surgery, Division of Vascular Surgery, The Mount Sinai School of Medicine, New York, NY 10029, USA
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15
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Abstract
BACKGROUND Thoracic aortic dissections, ruptures, fistulae, and aneurysms pose a unique surgical challenge. Traditional repair of thoracic aortic aneurysms involves thoracotomy with graft interposition. Despite advances in perioperative care and both total and partial cardiopulmonary bypass, conventional surgery carries a significant morbidity and mortality. Principal complications include bleeding, paraplegia, stroke, cardiac events, pulmonary insufficiency, and renal failure. Recent enthusiasm for innovative endovascular therapies to treat aortic disease has spurred many centers to investigate endoluminal grafting of the thoracic aorta. Early reports on endovascular repair using custom made "first generation devices" demonstrated the technique to be feasible with a mortality and morbidity comparable to open repair. METHODS AND RESULTS From February 2000 to February 2001, endovascular stent graft repair of the thoracic aorta was performed in 46 patients (mean age 70; 29 male and 17 female) using the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, fourteen patients (30%) had dissections, three patients (7%) had aortobronochial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcomes, and complications were recorded. All patients were followed with chest CT scans at 1, 3, 6, and 12 months. Mean follow up was 9 months ranging from 1 to 15 months. All procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients left the hospital within 4 days (64%) after endoluminal grafting. Overall morbidity was 23%. Two patients (4%) had endoleaks that required a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 moths post procedure. Both were treated successfully with additional stent grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. The Gore Excluder device was voluntarily recalled on February 26, 2001. Therefore, from June 2000 to January 2001, 37 patients underwent endovascular stent graft repair of the thoracic aorta for various disease entities using our customized thoracic graft (Endomed). Twenty-seven patients (73%) had aneurysms, six (16%) had dissections, two (5%) had pseudoaneurysms, one (2%) had a traumatic transection, and one patient (2%) had an embolizing ulcer. Patients were followed with CT scans at 1, 3, 6, and 12 months. All procedures were technically successful. There were no conversions. The average age was 68 years.(17-87). And the male and female ratio was 24/13. One patient died in the operating room from iliac rupture and one died from embolization/stroke in the immediate postoperative period. Two patients died within 30 days from comorbid factors. The total 30-day mortality was 10%. Two patients had endoleaks. One returned to the operating room and needed an additional cuff. The other had a small leak in a proximal dissection that is being followed. There were no cases of paraplegia. CONCLUSION Thoracic endoluminal grafting is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest that an endoluminal approach to these disease entities maybe favorable to open resection and graft replacement. Technical details of Endoluminal stent grafting of the thoracic aorta for different disease entities have been discussed at length.
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Affiliation(s)
- Venkatesh Ramaiah
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute, 2632 N. 20th Street, Phoenix, AZ 85006, USA.
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16
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Karmy-Jones R, Hoffer E, Meissner M, Bloch RD. Management of traumatic rupture of the thoracic aorta in pediatric patients. Ann Thorac Surg 2003; 75:1513-7. [PMID: 12735571 DOI: 10.1016/s0003-4975(02)04838-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Traumatic rupture of the thoracic aorta (TRA) in the pediatric population is uncommon. Management of TRA in general has evolved to include selective nonoperative and endovascular stent graft approaches, although operative repair remains the standard. METHODS We conducted a retrospective chart review of patients younger than 16 years of age admitted to a single institution between March 1985 and February 2002. RESULTS Of 160 patients admitted with TRA, 11 were younger than 16 (11.9 +/- 3.5) years of age. Concomitant injuries included closed head injury (5 patients) and acute lung injury (6 patients). All were started on beta-blockers when the diagnosis was suspected. Laparotomy was required in 3 patients and orthopedic procedures in 5 patients. Six underwent operative repair (two primary repairs), with no mortality. Cross-clamp time was 30.4 +/- 2.6 minutes. One patient (operated on without bypass) was partially paralyzed. Two patients were managed nonoperatively, 1 with an intimal arch injury, who on subsequent follow-up has demonstrated healing, and 1 who died of head injury. Three patients were managed by endovascular stent grafts, 2 who died of closed head injury and 1 who at 1-year follow-up has fully recovered. The endovascular stent grafts were placed through the femoral artery in 2 patients and through an iliac conduit in 1 patient. No patient died of rupture. CONCLUSIONS The approach to pediatric TRA should be identical to the adult, with early institution of beta-blockers. Depending on the clinical setting, a spectrum of options should be considered, including operation, non-operation, and endovascular stent graft, although the choice of the latter must be tempered by the lack of long-term follow-up data.
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Affiliation(s)
- Riyad Karmy-Jones
- Division of Cardiothoracic/Trauma, Harborview Medical Center, University of Washington, Seattle, Washington 98104, USA.
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17
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Fabian TC, Croce MA, Minard G, Bee TK, Cagiannos C, Miller PR, Stewart RM, Magnotti LJ, Patton JH. Current issues in trauma. Curr Probl Surg 2002; 39:1160-244. [PMID: 12476229 DOI: 10.1067/msg.2002.128499] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Timothy C Fabian
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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18
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Haulon S, Koussa M, Beregi JP, Decoene C, Lions C, Warembourg H. Stent-graft repair of the thoracic aorta: short-term results. Ann Vasc Surg 2002; 16:700-7. [PMID: 12415485 DOI: 10.1007/s10016-001-0313-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The purpose of this study was to evaluate clinical feasibility and immediate outcome of stent-graft repair of the thoracic aorta. From December 1999 to January 2001, a total of 14 patients underwent stent-graft repair of the thoracic aorta. The underlying etiologies were traumatic rupture of the aortic isthmus in four cases, Stanford type B dissection in four, thoracic aortic aneurysm in three, penetrating atherosclerotic ulcer in two cases, and postoperative aortoesophageal fistula in one case. Stent-graft placement was performed under angiographic control in all cases in association with transesophageal echography in seven cases. The procedure was performed under emergency conditions in five cases. Thirteen patients presented contraindications for surgery. Stent-graft placement was successful in all cases. No further surgery has been performed in any case. Thus we conclude that endovascular treatment of the thoracic aorta using stent grafts is a promising therapeutic modality in patients with contraindications for conventional surgical treatment.
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Affiliation(s)
- S Haulon
- Service de Chirurgie Cardiovasculaire, Hôpital Cardiologique, CHU de Lille Cedex, France.
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19
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Doss M, Martens S, Hemmer W. Emergency endovascular interventions for ruptured thoracic and abdominal aortic aneurysms. Am Heart J 2002; 144:544-8. [PMID: 12228794 DOI: 10.1067/mhj.2002.123578] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The purpose of our study was to show the effectiveness of endovascular stent grafts in the treatment of acutely ruptured abdominal and thoracic aortic aneurysms as an alternative to the conventional surgical approach in an emergency setting. METHODS From October 1996 to October 1998 we deployed 9 emergent endovascular stent grafts--6 in the abdominal aorta and 3 in the thoracic aorta. Aortic rupture was confirmed before surgery with spiral-computed tomographic scan. The average interval from onset of symptoms to treatment was 4.5 hours. We used commercially manufactured stent grafts: 4 Corvita (Corvita Inc/Schneider Corp/Boston Scientific Corp, Natick, Mass), 3 Talent (World Medical Inc, Surise, Fla/Medtronic, Sunnyvale, Calif), and 2 Vanguard (Boston Scientific Corp, Natick, Mass). RESULTS Deployment of the stent grafts was successful in all cases. Two patients died in the follow-up period (120 months) from myocardial infarction. No cases were seen of paraplegia or stent migration. However, 2 endoleaks, 1 in-stent stenosis, 1 temporary renal failure, and 1 brief episode of myocardial ischemia occurred. CONCLUSION Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in selected patients.
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Affiliation(s)
- Mirko Doss
- Department of Thoracic and Cardiovascular Surgery, J. W. Goethe University, Frankfurt am Main, Germany.
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Thompson CS, Gaxotte VD, Rodriguez JA, Ramaiah VG, Vranic M, Ravi R, DiMugno L, Shafique S, Olsen D, Diethrich EB. Endoluminal stent grafting of the thoracic aorta: initial experience with the Gore Excluder. J Vasc Surg 2002; 35:1163-70. [PMID: 12042726 DOI: 10.1067/mva.2002.122885] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to describe our experience with endoluminal graft repair of a variety of thoracic aorta pathologies with a commercially developed device currently under investigation. Our patient population included patients eligible for open surgical repair and those with prohibitive surgical risk. METHODS From February 2000 to February 2001, endovascular stent-graft repair of the thoracic aorta was performed in 46 patients (mean age, 70 years; 29 male and 17 female patients) with the Gore Excluder. Twenty-three patients (50%) had atherosclerotic aneurysms, 14 patients (30%) had dissections, three patients (7%) had aortobronchial fistulas, three patients (7%) had pseudoaneurysms, two patients (4%) had traumatic ruptures, and one patient (2%) had a ruptured aortic ulcer. Patient characteristics, procedural variables, outcome, and complications were recorded. All patients were followed with chest computed tomographic scans at 1, 3, 6, and 12 months. Follow-up period ranged from 1 month to 15 months, with a mean of 8.5 months. RESULTS All the procedures were technically successful. There were no conversions. Average duration of the procedure was 120 minutes. Average length of stay was 6 days, but most patients (64%) left the hospital within 4 days after endoluminal grafting. The overall morbidity rate was 23%. Two patients (4%) had endoleaks that necessitated a second procedure for successful repair. Two patients (4%) died in the immediate postoperative period. There were no cases of paraplegia. At follow-up examination, one patient had an endoleak found the day after the procedure and another patient had an endoleak 6 months after the procedure. Both cases were treated successfully with additional stent-grafts. There were no cases of migration. One patient died of a myocardial infarction 6 months after graft placement. In patients treated for aneurysm (n = 23), the aneurysm diameter ranged from 5.0 to 9.5 cm (mean, 6.8 cm). Residual sac measurements were obtained at 1, 6, and 12 months, with mean sac reductions of 0.59 cm, 0.77 cm, and 0.85 cm, respectively. In three cases, the sac remained unchanged, without evidence of endoleak. CONCLUSION Thoracic endoluminal grafting with the Gore Excluder is a safe and feasible alternative to open graft repair and can be performed successfully with good results. Early data suggest an endoluminal approach to these disease entities may be favorable over classical resection and graft replacement.
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Affiliation(s)
- Charles S Thompson
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Hospital, 2632 N 20th Street, Phoenix, AZ 85006, USA
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21
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Abstract
Vascular injury poses a small but significant challenge in Australian trauma care. Opportunities such as better practice guidelines and minimum standards will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. Training in the management of vascular trauma surgery with integration of vascular and general surgery in trauma care should optimize outcomes. The authors' vision is that all vascular and general surgery trainees would eventually undertake the Definitive Surgical Trauma Care Course and improve vascular trauma outcomes and reduce mortality.
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Affiliation(s)
- Michael Sugrue
- Trauma Department, Liverpool Hospital, University of New South Wales, Sydney, Australia.
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Orend KH, Kotsis T, Scharrer-Pamler R, Kapfer X, Liewald F, Görich J, Sunder-Plassmann L. Endovascular repair of aortic rupture due to trauma and aneurysm. Eur J Vasc Endovasc Surg 2002; 23:61-7. [PMID: 11748950 DOI: 10.1053/ejvs.2001.1546] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to report a single centre experience with endovascular repair of the ruptured descending thoracic and abdominal aorta. DESIGN prospective non-randomised study in a university hospital. MATERIAL AND METHODS between 1995 and 2000, endovascular treatment was utilised for 231 aortic repairs; in 37 cases (16%) endografting was conducted on an emergency basis for 21 ruptured infrarenal aortic aneurysms, 15 ruptured descending thoracic aortic lesions, and 1 ruptured thoracoabdominal aortic aneurysm. The feasibility of endovascular treatment and the prostheses' size were determined, based on preoperative spiral CT and intraoperative angiography, both obtained in each patient. RESULTS endografting was successfully completed in 35 patients (95%). Primary conversion to open repair was necessary in 2 patients (5%). Postoperative 30-day mortality rate was 11% (4 deaths). No patient developed postoperative temporary or permanent paraplegia. In 2 patients (5%) primary endoleaks required overstenting and in 6 patients (16%) secondary surgical interventions were required. Mean follow-up was 19 months (1-70 months); three deaths occurred within three months postoperatively (1-year survival rate 81+/-6%). In one case, secondary conversion to open repair was necessary 14 months postoperatively. CONCLUSION the feasibility of endoluminal repair of the ruptured aorta has been demonstrated. Endoluminal treatment may reduce morbidity and mortality, and may in time become the procedure of choice in certain centres. However, further follow-up is required to determine the long-term efficacy.
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Affiliation(s)
- K H Orend
- Department of Thoracic and Vascular Surgery, University of Ulm, Ulm, Sweden
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23
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24
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Lin PH, Bush RL, Tong FC, Chaikof E, Martin LG, Lumsden AB. Intra-arterial thrombin injection of an ascending aortic pseudoaneurysm complicated by transient ischemic attack and rescued with systemic abciximab. J Vasc Surg 2001; 34:939-42. [PMID: 11700498 DOI: 10.1067/mva.2001.116968] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Thrombin injection as a means of inducing thrombus formation has recently received wide attention as an alternative treatment for pseudoaneurysm. We present a case of a 67-year-old man in whom a large mycotic pseudoaneurysm developed in the ascending aorta because of sternal osteomyelitis and mediastinitis after coronary artery bypass grafting. Transcatheter intra-arterial thrombin injection was performed, and it successfully induced pseudoaneurysm thrombosis. However, the procedure was complicated by a sudden transient ischemic attack caused by thrombus propagation into the cerebral circulation. Complete thrombus dissolution in the cerebral circulation with the resolution of neurologic symptoms was achieved by means of intravenous abciximab.
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Affiliation(s)
- P H Lin
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.
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25
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Milner R, Bavaria JE, Baum RA, Carpenter JP, Velazquez OC, Brinster D, Fairman RM. Thoracic aortic stent grafts. Semin Roentgenol 2001; 36:340-50. [PMID: 11715329 DOI: 10.1053/sroe.2001.29163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- R Milner
- Department of Surgery, Division of Vascular Surgery, University of Pennsylvania Medical Center, 3400 Spruce St, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA
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26
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Mattison R, Hamilton IN, Ciraulo DL, Richart CM. Stent-graft repair of acute traumatic thoracic aortic transection with intentional occlusion of the left subclavian artery: case report. THE JOURNAL OF TRAUMA 2001; 51:326-8. [PMID: 11493793 DOI: 10.1097/00005373-200108000-00016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R Mattison
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, Tennessee 37403, USA
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27
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Taylor PR, Gaines PA, McGuinness CL, Cleveland TJ, Beard JD, Cooper G, Reidy JF. Thoracic aortic stent grafts--early experience from two centres using commercially available devices. Eur J Vasc Endovasc Surg 2001; 22:70-6. [PMID: 11461107 DOI: 10.1053/ejvs.2001.1407] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES open surgical intervention for aneurysms of the distal arch and descending thoracic aorta is associated with high morbidity and mortality. Stent grafts offer an attractive alternative treatment for these aneurysms. The aim of this study was to assess the morbidity and mortality of endovascular treatment for these aneurysms with stent grafts. DESIGN, PATIENTS AND METHODS a prospective observational study was performed of 37 consecutive patients treated from July 1997 to October 2000 (30 at Guy's and St. Thomas' and 7 at Sheffield). Indications included degenerative aneurysms (n=18), false aneurysm (5), acute dissection (4), aortic transection (4), aneurysm related to previous surgery for coarctation (3), chronic dissection (2) and traumatic dissection (1). Nineteen were performed as elective and 18 as non-elective procedures. RESULTS three non-elective patients died in hospital (in-hospital and 30-day mortality 8%) and one suffered a stroke with spontaneous full recovery. No elective patient died. One patient with a persistent proximal endoleak required conversion to open repair at 6 weeks. Two patients with persistent flow into the sac at 24 h spontaneously thrombosed at subsequent 3 month follow-up. Two further patients developed new distal endoleaks at 3 months and required distal extension cuffs. One patient died at 28 months of aortic rupture. Serial CT scans had shown prolapse of the stent graft into the aneurysm sac and the patient died just before planned endovascular repair. No patient suffered paraplegia or renal failure. Intensive care facilities were only required for patients who needed them preoperatively. CONCLUSIONS thoracic stent grafts can be performed with low morbidity and mortality. They offer a realistic alternative to open surgery. Long term follow up is required to assess their durability.
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Affiliation(s)
- P R Taylor
- Department of Surgery, Guy's Hospital, London, SE1 9RT, U.K
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28
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Abstract
A review is given of endovascular treatment for AAA, thoracic aortic aneurysms, dissections as well as complications following previous aortic surgery. In several of these conditions endovascular treatment has advantages like a reduced operative trauma, shorter stay in hospital, and the possibility of treating patients who would have been unfit for open surgery. On the other hand, problems like endoleak, deformation of the endoprosthesis, retrograde filling of the aneurysmal sack, and graft limb occlusion need to be solved before the place of endovascular treatment can be defined. It is possible that the steadily improving quality of the implants as well as the introducer systems will widen the indications for endovascular surgery, but randomised clinical trials are warranted and a longer follow-up period is necessary to draw final conclusions.
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Abstract
With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade or hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using beta-blocker-induced relative hypotension, is rapidly becoming the standard of care throughout the United States.
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Affiliation(s)
- D V Feliciano
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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30
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Abstract
The endovascular management of hemodynamically stable patients with traumatic vascular lesions is an appealing concept. In principle, many of the injuries detected at the time of diagnostic angiography can be treated at the same setting. Moreover, lesions that occur at the base of the skull or at infraclavicular and pelvic locations pose far less difficulty when managed by transcatheter techniques than by traditional surgical exposure. Even among more accessible injuries, standard surgical dissection is often complicated by the presence of hematoma or pseudoaneurysm, which causes obliteration of natural tissue planes, or arteriovenous fistulas that may complicate dissection because of associated regional venous hypertension. Thus, endovascular approaches may provide easier access to the target lesion, limit the morbidity often associated with surgical exploration, and reduce transfusion requirements. Nonetheless, the long-term consequence of placing an intravascular foreign body in a young patient is undefined, and the potential risk for a device infection cannot be ignored. Definitive answers to these issues await the outcome of longitudinal follow-up studies. Until that time, a prudent approach in the use of this new technology is appropriate.
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Affiliation(s)
- V J Weiss
- Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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31
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Gavant ML. Helical CT grading of traumatic aortic injuries. Impact on clinical guidelines for medical and surgical management. Radiol Clin North Am 1999; 37:553-74, vi. [PMID: 10361546 DOI: 10.1016/s0033-8389(05)70111-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Helical CT is a reliable method for screening patients with blunt chest trauma for vascular and visceral injuries. Thoracic aortic injuries detected by CT examination affect the immediate clinical management and patient triage. This article describes the clinical indications and imaging protocols for helical CT of the chest used to detect aortic injuries, provides a grading system of the range of aortic injuries demonstrated by CT, and discusses the clinical management decisions that should be considered based on the CT grade of the aortic injury.
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Affiliation(s)
- M L Gavant
- Department of Radiology, University of Tennessee, Memphis, USA.
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