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1 Department of Radiology, Cardiovascular Unit, University Hospital S. Orsola,
Via Massarenti, 9, 40138 Bologna, Italy.
2 Department of Cardiac Surgery, University Hospital S. Orsola, 40138 Bologna,
Italy.
Received November 28, 2001;
accepted after revision March 5, 2002.
Address correspondence to R. Fattori.
Abstract
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SUBJECTS AND METHODS. From July 1997 to December 2001, 19 patients with traumatic aortic injury (11 patients with acute and eight with chronic injuries) were selected for endovascular treatment. In all patients, the lesions were sited at the proximal segment of the descending aorta at a distance of 10 ± 17 mm (mean ± SD) from the left subclavian artery. Nine of the patients with acute injuries were treated after clinical stabilization of other severe associated lesions, whereas two patients, in whom hemodynamic and imaging findings suggested an impending rupture, received emergency treatment. Single-detector helical CT or MR imaging was used for patient selection and stent-graft customization before treatment and for evaluation of patients during the follow-up period.
RESULTS. Endovascular stent positioning was successful in all patients. None of the patients developed complications. Aneurysm exclusion and shrinkage were confirmed at followup examinations. A partial covering of the subclavian artery occurred in six patients without interrupting the blood flow. All patients remain asymptomatic after a mean follow-up period of 20 months (range, 1-56 months).
CONCLUSION. Endovascular repair represents an alternative, minimally invasive treatment, particularly suitable for use in patients with traumatic aortic injuries. The decision of whether to provide immediate emergency treatment or to delay treatment should be based on the lesion characteristics on imaging and clinical findings. The durability of treatment seems to be related to the absence of alteration to the aortic wall at the extremities.
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It has long been common practice to consider traumatic aortic rupture a surgical emergency. Nevertheless, the performance of cardiovascular intervention in these severely injured patients has led to an operative mortality rate of 15-45%, the highest mortality rate in cardiovascular surgery [1, 4,5,6]. During the past few years, new strategies have been considered in hopes of modifying this negative prognosis [7,8,9]. Recently, the development of endovascular techniques has provided additional opportunities in the treatment of diseases of the descending aorta [10,11,12,13,14]. Results of clinical studies and case reports have shown the feasibility of endovascular procedures in the treatment of traumatic aortic injury [15, 16].
In this article, we report our experience with endovascular treatment in a consecutive series of traumatic aortic lesions to assess the effectiveness, safety, and long-term reliability of such treatment.
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Among patients with acute traumatic aortic rupture, nine presented with an
isthmic partial lesion and no imaging findings (such as a periaortic hematoma,
hemorrhagic pleural effusion, or discontinuity of the aortic contour) that
suggested impending rupture. Because of the severity of associated injuries,
these patients were scheduled for a delayed treatment of the aortic injury
after the resolution of the other traumatic lesions, in accordance with
previously described protocols
[17]. The patients remained in
the ICU for at least 2 weeks, with continuous monitoring of their ECG results,
respiratory and renal functions, and both arterial and central venous
pressure. A prompt antihypertensive therapy (ß-blockers,
-blockers, and vasodilators) and a controlled fluid replacement regimen
were also established to obtain a systolic blood pressure of less than 100 mm
Hg and a heart rate of less than 60 beats per minute. Five patients developed
acute respiratory distress syndrome that required prolonged assisted
ventilation and a stay in the ICU that ranged from 15 to 45 days. Any injury
that appeared imminently life-threatening (abdominal or intracranial
hemorrhage or pulmonary complications) was treated before endovascular
treatment was performed. Moreover, all orthopedic treatments necessary for a
patient's complete functional recovery were also performed before the aortic
endovascular procedure. Medical antihypertensive therapy was continued until
the aortic repair was performed. The remaining two patients in the acute
segment of our study cohort were admitted to the hospital a few hours after
experiencing trauma. Both had clinical and imaging findings of severe
instability of the aortic tear and received endovascular treatment during the
acute phase (Fig.
1A,1B,1C,1D).
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Four other patients admitted to our hospital with acute traumatic aortic injury were scheduled for conventional surgery. Two patients requiring urgent repair due to pseudocoarctation syndrome (distal aorta compression by the traumatic tear with severe ischemia and anuria in the low extremities) could not be treated with stent-grafts because the 30-mm diameter of the immediately available stent-grafts was too large for the descending aorta in the patients. In the two remaining patients, the traumatic saccular aneurysm partially extended to the aortic arch, without any proximal aortic fixation.
Imaging Study and Follow-Up
Before treatment was initiated, MR imaging and MR angiography (Signa 1.5-T
scanner; General Electric Medical Systems, Milwaukee, WI) were performed in 17
patients. Single-detector helical CT (Marconi/Elscint MxTwin; Picker
International, Cleveland, OH) was performed in two other patients to assess
the extent of the aneurysm and anatomic details, such as the distance of the
aneurysm from the subclavian artery, the morphology and size of the proximal
and distal necks, and the diameters of the femoral and iliac arteries.
Anatomic conditions that allowed the patient to receive endovascular treatment
were a distance of more than 5 mm between the lesion and the subclavian
artery, an 18- to 42-mm diameter in the proximal and distal necks, and
diameters in the femoral and iliac arteries that exceeded 9 mm. Angiography
was performed in four patients for whom the noninvasive tests had provided
suboptimal information.
Clinical and imaging follow-up examinations using CT were scheduled for 1, 6, and 12 months after the procedure. Patient status and morphologic information on the treated aortic segment were evaluated.
CT was performed first without contrast medium (5-mm sections; pitch, 1.5; and reconstruction interval, 5 mm) from the supraaortic vessels to the diaphragm to define the region of interest for the subsequent contrast-enhanced study. After injecting 120-160 mL of a 200 mg/mL solution of nonionic iodinated contrast medium (Iomeron 200; Bracco, Milano, Italy), we acquired a CT scan (2.7-mm section; pitch, 1.5; reconstruction interval, 1.3 mm; and delay time, 26-35 sec) 5 cm below the distal end of the stent-graft to the thoracic inlet. Postprocessing consisted of multiplanar reconstructions, maximum-intensity-projection images, shaded-surface display reconstructions, and volume-rendering reconstructions. The parameters evaluated were the absence of flow within the aneurysmal sac, the dimensions of the aneurysm, the morphology of the stent-graft, and the diameter and wall morphology of the proximal and distal necks.
Stent-Graft Procedure
The endovascular stent-grafts (in 18 patients: Talent, World Medical,
Sunrise, FL; in one patient: Excluder, W. L. Gore, Flagstaff, AZ) were
custom-designed for 17 patients on the basis of measurements obtained from CT
or MR imaging. In the two patients treated during the acute phase, standard
stent-grafts (28-mm diameter with 102-mm coverage in one patient; 26-mm
diameter with 8-cm coverage in another) were used. Both the Talent and
Excluder grafts consist of a self-expanding springstent in which the spring is
serpentine and is covered by polyester (low-profile Dacron [DuPont,
Wilmington, DE], in the case of the Talent) or polytetrafluoroetylene (in the
case of the Excluder). In the Talent system, the stent-graft is compressed
over a multiple-lumen polyurethane placement catheter that is loaded into a
hollow sheath. The sheath includes a homeostasis valve to prevent excess blood
leakage. In the Excluder system, the stent-graft is compressed over a
placement catheter that requires an introducer with a hemostatic valve for the
insertion through the arteriotomy.
Endovascular stent procedures were performed in the operating theater with the patients under general anesthesia and the cardiopulmonary bypass staff on standby. All the procedures were monitored using a portable C-arm radiographic system equipped with digital subtraction angiography (9800; OEC Medical Systems, Salt Lake City, UT) and by echocardiography (Sonos 2000; Hewlett-Packard, Palo Alto, CA) equipped with a multiplanar transesophageal probe. Using a percutaneous left brachial approach, we inserted a catheter over a guidewire that localized the subclavian artery and was used for pre- and post-procedure aortography. In 17 patients, 5000 U of heparin was injected at the beginning of the procedure; no systemic heparin was administered to the two patients with acute aortic injury. The femoral (18 patients) or external iliac (one patient) artery was exposed, and the endovascular stent system was inserted over a guidewire through a transverse arteriotomy to an area above the aneurysmal site. The systolic pressure was lowered to 50 mm Hg to avoid the displacement of the stent by the force of the systolic flow. Once deployed, the stent-graft expanded and conformed to the shape and size of the aorta. A latex balloon was then used to fix the graft to the aortic wall, mainly at the proximal and distal necks, and to smooth wrinkles in the graft material.
Finally, digital subtraction angiography and transesophageal echocardiography with color-flow Doppler sonography were performed to verify the correct positioning of the stent and to detect any primary leakage (Fig. 2A,2B,2C,2D). The placement system was then removed, and the arteriotomy was sutured.
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After one month, follow-up examinations confirmed aneurysm exclusion in 18 patients. In the remaining patient, a perigraft leak was visualized in a large fusiform aneurysm at the junction of the two stent-graft segments (type III endoleak). CT performed at the 3-month follow-up examination showed a spontaneous thrombosis of the leak and an initial reduction in the aneurysm.
Clinical and Imaging Follow-Up
All patients were alive and well at the last follow-up examination. The
follow-up period ranged from 1 to 56 months after stent-graft placement (mean,
20 months). A limited functional recovery from the major bone fractures in one
patient is the only sequelae that has required a referral. On CT, occlusion of
the left subclavian artery with retrograde reperfusion was detected in one of
the six patients in whom the artery was partially covered. However, none of
the patients developed any symptoms attributable to a stealing effect from the
left subclavian artery. Complete thrombosis of the aneurysmal sac and
progressive fibrosis of the thrombosed aneurysms with reduction in size (mean,
8 ± 7 mm) were observed in all patients at the 6-month follow-up
examination (Fig. 3). Total
aneurysmal shrinkage was complete 12 months after stent-graft placement in 12
of the 13 other patients (Figs.
4A,4B,4C
and
5A,5B,5C).
We did not observe alteration of the graft material or secondary endoleaks
during the follow-up period.
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The premise for using immediate surgery was primarily based on the historical study performed by Parmley et al. in 1958 [22], who reported autopsy findings in 296 people killed by nonpenetrating traumatic aortic rupture in the Korean War. Those authors estimated that a remarkable 85% of the victims died on the scene from free aortic rupture. Of those who survived for at least 1 hr, 30% died within 6 hr, 49% died within 24 hr, and 90% died within 4 months. However, a clear relationship between the occurrence of free aorta rupture and death was not reported, nor was an estimate made of how much other potentially fatal injuries—which were found in more than half of the patients—may have contributed toward death. The 1958 Armed Forces Institute of Pathology series is a cohort that probably does not apply to the current clinical reality.
In the past few years, several studies have reported a reduction in mortality rates when patients received medical therapy during the acute phase of aortic injury and had the surgical repair of the aortic tear postponed until after stabilization of patients with multiple traumas [19, 20, 23,24,25]. Delayed surgery of the posttraumatic aneurysm has a low operative mortality rate (range, 0-10%) and a low risk of spontaneous aortic rupture in the interval between the trauma and surgery. This delayed surgery policy has been in place at our center since 1993, and we have seen excellent results [23, 24]. This strategy may be considered an important advance in the difficult management of patients with multiple traumas. However, surgery cannot be delayed in every case. Even if most traumatic aortic ruptures are stable lesions, approximately 5% of them carry a high risk of rupture during the acute phase. Signs of impending rupture, such as periaortic hematoma, repeated hemothorax, and uncontrolled blood pressure, are considered signs of instability [20]. Sometimes the aortic tear, acting with a valve mechanism, may cause pseudocoarctation syndrome, reducing blood flow in the descending aorta and causing lower extremity ischemia. This complication, which represents a surgical emergency, was found in 10% of cases in one study [26].
In 1996, the introduction into clinical practice of endovascular techniques for the thoracic aorta opened up the option of a less invasive procedure for patients in whom emergency treatment is necessary. Because the less invasive technique does not require thoracotomy or the use of heparin, this procedure can be used during the acute phase without the risk of destabilizing patients with pulmonary, head, or abdominal traumatic lesions. Standard sizes of thoracic stent-grafts are available, allowing use of the stent-graft in emergencies. However, the range of standard sizes available is limited (from 26 to 46 mm). Two patients admitted to our hospital with traumatic aortic ruptures complicated by pseudocoarctation syndrome could not be considered for endovascular treatment because the aortic diameter was too small (< 20 mm) for the standardized stent-grafts.
For the patient with chronic posttraumatic aneurysm, endovascular treatment represents a good alternative treatment for this asymptomatic disease, which is frequently discovered several years after the causative trauma. Chronic posttraumatic aneurysms potentially are evolving lesions. Death from rupture may occur many years after injury, sometimes without any onset of signs or symptoms [27]. Because it is impossible to predict which aneurysm will remain quiescent, elective repair is always recommended for both symptomatic and asymptomatic aortic tears [28]. Over the years, advances in surgical techniques and spinal cord protection have significantly reduced the operative mortality rate and the occurrence of paraplegia in patients undergoing elective surgical repair of the thoracic aorta. In the largest surgical series, operative mortality for patients with chronic posttraumatic aneurysms ranged from 0% to 10% and paraplegia occurred in 5% of the patients [28,29,30]. The risk of paraplegia in patients undergoing surgery for chronic posttraumatic aneurysm is low compared with such a risk in patients undergoing surgery for atherosclerosis [28, 31], because the pseudoaneurysm usually does not extend beyond the first pair of intercostal arteries. However, patients with a chronic asymptomatic aneurysm are not always willing to accept a major thoracotomy and the risk of serious complications. Endovascular treatment may play an important role in chronic posttraumatic aneurysm management. In an early clinical series [10], patients undergoing endovascular treatment were found to have lower morbidity and mortality rates than did patients undergoing open surgical repair, even high-risk patients. Use of heparin is not required, and the blood loss is minimal. The risk of paraplegia seems to be low even in patients with extensive atherosclerotic aneurysms in which the coverage of the stent-graft extends from the left subclavian artery to the celiac axis. To the best of our knowledge, no case of paraparesis or paraplegia resulting from endovascular treatment of traumatic aortic lesion has been reported in the literature.
Because endovascular treatment requires that specific anatomic conditions be present, not all the patients with aortic tears are candidates for endovascular repair. An adequate peripheral vascular access is required. Especially important if the Talent devise is to be used is the angle between the transverse arch and the descending aorta. The angle should be more than 90° because having to twist the delivery system hinders the deployment of the stent-graft. Hence, the most important anatomic characteristic for endovascular treatment of a posttraumatic lesion is the presence of an adequate proximal neck or a distance from the aortic tear to the subclavian artery of more than 5 mm and the absence of mural thrombus, calcifications, or hemorrhage in the aortic wall at the neck site.
Other studies have described a procedure in which an artificial aortic neck is created and the left subclavian artery is covered with the stent-graft, either with or without previous carotid artery—to—subclavian artery transposition [11, 13]. We did not perform this procedure for several reasons: the curved anatomy of the aortic arch does not seem favorable for long-term efficacy of the stent-graft; in addition, the flow from the left subclavian artery may impede aneurysm sealing. The uncovered part of the stent-graft extending to the left carotid artery is a potential source of emboli. Moreover, if symptoms from the closure of the left subclavian artery occur and a carotid—subclavian bypass becomes necessary, the benefit of the minimal invasiveness of the procedure is partially diminished.
Preoperative imaging studies are essential to determining whether endovascular treatment is indicated and to customizing the stent-graft. The accuracy of measurements then becomes essential to verifying the efficacy of the procedure during the follow-up period. Both helical CT and MR imaging are excellent modalities with which to evaluate traumatic aortic lesions. Both modalities display the extent of the disease without partial volume errors and provide accurate details of the aortic wall structure [32,33,34]. Angiography can provide only luminal information on the aortic vessel and should be reserved for use in the few patients in whom the necessary details have not been ascertained through noninvasive methods [35].
For many years, traumatic aortic injury has been considered a highly lethal lesion and a potential cause of death in patients who have sustained blunt chest trauma. Despite evidence in the literature of lower morbidity and mortality rates, initial medical management of the uncomplicated aortic injury and subsequent delayed surgery have not been easily accepted in clinical practice. The development of endovascular techniques represents a viable, low-risk alternative and has limited potential for trauma destabilization. However, long-term follow-up care is required to assess the durability and effectiveness of this novel, less invasive therapy.
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