Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience

BACKGROUND: Surgical management of acute thoracic aortic ruptures is controversial, especially in patients with preexisting comorbidities; associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome. METHODS: From November 1999 to February 2002 a total of 54 patients, age 28 to 83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated type B dissections, 16 traumatic ruptures). Twenty-eight patients were managed surgically using cardiopulmonary bypass (group 1), and 26 patients were treated acutely with an endovascular stent graft (group 2). The resuscitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes. RESULTS: There were 5 of 28 deaths (17.8%) in the surgical group and 1 of 26 deaths (3.8%) in the endovascular group. In the surgical group 1 of 28 patients (3.6%) exhibited paraplegia; there were no cases of paraplegia in the endovascular group. There were 4 of 28 cases (14.3%) of renal failure in group 1 and 1 of 26 (3.8%) in group 2. In group 1, 8 patients (28.6%) required mechanical ventilation for more than 48 hours; there were 2 of 26 patients (7.7%) in group 2 with this ventilatory requirement. Three patients required a repeat thoracotomy for hemorrhage in the surgical group. There were two access failures in the endovascular group. CONCLUSIONS: In the treatment of acute ruptures of the thoracic aorta, the immediate outcome of patients treated with endovascular stent grafts appears to be better than with management by conventional surgical repair.     

Surgical treatment of traumatic thoracic aorta rupture

Objectives: Traumatic aortic rupture is highly lethal and an ongoing therapeutic challenge. We review our 7-year experience with traumatic aortic disruption. Methods: We treated 12 cases of traumatic rupture of the thoracic aorta (TRTA) from December 1994 to June 2001 at our institution. Of these, 9 were male, and the average age 26 years. Injuries were caused by traffic accidents in 9 cases and falls in 3. Contrast-enhanced helical computed tomography was used to diagnose 10 cases and digital subtraction angiography to diagnose 2 at other hospitals. Six of 12 (50%) disruptions were located in the aortic isthms. All surgery was conducted under cardiopulmonary bypass. A percutaneous cardiopulmonary support system (heparin-bonded artificial lung and centrifugal pump) was used in 6 cases since 1998. Results: Among the 12 patients, 6 had early surgical repair within 2 days after the accident, and all survived free of neurological problems. Six other had repair delayed more than 2 days and all were doing well. Conclusion: Immediate repair of aortic lesions should be the rule because the majority of deaths from TRTA occur within 24 hours. We believe, however, that immediate surgery may not be necessary for some patients with severe, multiple associated lesions who survive initial traumatic aortic disruption of the aorta.     

主动脉腔内修复术救治胸主动脉破裂的临床观察

目的:探讨主动脉腔内修复术(TEVAR)救治胸主动脉破裂的临床适应证及疗效,并总结相关临床经验。方法:回顾性分析2006年1月—2015年9月因胸主动脉破裂急症在广州军区武汉总医院心胸外科就诊的患者临床资料。结果:检索出应用TEVAR救治程序收治的胸主动脉破裂患者51例(胸主动脉夹层动脉瘤破裂15例,胸主动脉创伤32例,主动脉食管瘘4例)。51例患者中,术前死亡4例,47例获TEVAR救治;术后死亡6例(其中主动脉食管瘘3例),其余41例患者均无明显严重并发症,且术后1个月内无死亡。术后3、6、12个月,之后每年复查CT,随访截至2016年5月,36例患者获得了完整的随访,随访6~123个月,平均56.6个月。其中1例随访至术后6个月,4例随访至术后12个月,1例随访至术后24个月。随访患者均健康存活、人工血管旁路通畅,血管支架无内漏。结论:TEVAR是快速、有效的救治胸主动脉破裂的一种措施。     

Surgical treatment of traumatic rupture of the normal aortic valve

The histories of 2 patients who had successful repair of traumatic injury to the aortic valve are reported, and the literature is reviewed. Various types of injury cause this lesion, but violent compression of the chest with high intrathoracic pressure appears to be a common feature. Valvular injuries include avulsion of commissural attachments and tears of the leaflets. Patients present with chest pain and severe congestive heart failure, and an unusually musical murmur of aortic insufficiency is sometimes heard. Attempts at valvuloplasty have not been uniformly successful, and prosthetic valve replacement is recommended.     

Surgical treatment of traumatic rupture of the normal aortic valve

Blunt trauma followed by aortic valvular insufficiency is a rare occurence. In one case, a male high-school student who had sustained a non-penetrative chest injury suffered from aortic regurgitation resulting from the rupture of the normal aortic valve. A sizable tear in the non-coronary cusp caused aortic insufficiency. The case was treated successfully by surgical replacement of the aortic valve with a No. 21 SJM prosthesis.     

Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury

BACKGROUND: Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented for open surgical or endovascular repair. METHODS: Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n = 48, 77%), or endovascular repair (n = 14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open surgical and endovascular groups. RESULTS: Age, gender, race, and mechanism of injury did not differ between open surgical and endovascular groups. Additionally, RTS, ISS, and NISS values were not significantly different. The proportion of patients with sternal fractures (14% vs 0%), or unstable spinal fractures (36% vs 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n = 13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic endografts (n = 6; 43%) and abdominal aortic endograft components (n = 8; 57%). Forty-one interposition grafts were placed in the open surgical group. Renal complications (32% vs 7%), and urinary tract infections (35% vs 7%) approached significance between surgical and endovascular groups (P = .082 and P = .077, respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0%, respectively (P = .056). Endovascular repair was associated with significant reductions in operative time (118 vs 209 minutes), estimated blood loss (77 vs 3180 ml), and intraoperative blood transfusions (0.9 vs 6.1 units). No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group. CONCLUSION: Endovascular repair of blunt descending thoracic aortic injuries utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short term and associated with a lower intraoperative mortality (P = .056). Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions.     

Conventional surgical repair and endovascular treatment of acute traumatic aortic rupture.

OBJECTIVE: Endoluminal aortic stent grafting offers a potentially less invasive alternative to open chest surgery, especially in patients with polytrauma. We compare the results of conventional surgical repair and endovascular treatment of traumatic aortic rupture. METHODS: Retrospectively, 74 patients with acute traumatic aortic rupture were analyzed. Most of the patients had a rupture limited to the isthmus, and severe associated injuries. Thirty-five patients (6 female, 29 male, mean age 36 years) underwent surgical repair. Two patients were operated upon without cardiopulmonary bypass. In 39 patients (5 female, 34 male, mean age 36 years) thoracic endografts were implanted. The delay between trauma and treatment was comparable in the two groups. RESULTS: Hospital mortality was 20% (7 of 35 patients) in the surgical group and 7.7% (3 of 39 patients) in the endovascular group. The most common cause of death in the surgical group was brain death in severe traumatic patients. Ten surgical complications occurred in 5 patients: respiratory insufficiency (n=3), pulmonary infection (n=2), recurrent nerve palsy (n=2), repeat thoracotomy (n=2), and compartment syndrome (n=1). No patient in this group had paraplegia. Except for one case, which required conversion to conventional surgery, stent-graft implantation was successful in all cases, without peri-interventional complications or procedure-induced paraplegia. In 9 patients the left subclavian artery was covered with the device. Two patients underwent surgical repair 15 days and 4 months after endografting because of injury of the aortic wall by the stent and development of a spurious aneurysm, respectively. CONCLUSIONS: In the treatment of traumatic thoracic aortic rupture, the early outcome of patients treated with endovascular stent grafts appears to be better than that with conventional surgical repair. The new technique allows safe and successful repair of this life-threatening injury in the early phase of trauma management. How far this potential benefit is sustained in the long term remains unclear at present.     

Descending thoracic aortic rupture: role of endovascular stent-grafting

Background

The mortality of patients with descending thoracic aortic rupture who are treated by conventional surgery is high. Our current strategy for the management of descending thoracic aortic rupture is to treat seriously ill patients with endovascular stent-grafting using handmade grafts, and to treat other patients with traditional open repair. The aim of this study was to assess the early results of our strategy.

Methods

Twenty-nine consecutive patients with descending thoracic aortic rupture were referred to Sapporo Medical University Hospital from June 2001 to January 2004. Eighteen of these 29 patients were selected for endovascular stent-grafting because of polytrauma (n = 7), comorbidities (n = 6), advanced age (n = 2), past history of left thoracotomy (n = 2), and patient's preference (n = 1). The remaining 11 patients underwent traditional graft replacement of the diseased aorta. Their outcomes and follow-up data were collected and analyzed retrospectively.

Results

The in-hospital mortality rate was 14% (4/29). The mortality rate for surgical patients and stent-grafting patients was 9% (1/11) and 17% (3/18), respectively. The survival rate of patients at 2 years was 63% ± 10%. In the follow-up period, 2 of the 18 patients who underwent endovascular stent-grafting required open repair, and 1 patient underwent a redo endovascular stent-grafting procedure because of stent failure. One of these 3 patients died of an intraoperative retrograde type A aortic dissection.

Conclusions

The early results of endovascular stent-grafting for the treatment of high-risk patients with descending thoracic aortic rupture are promising. Early results of open repair can also be improved by the selection of stabilized patients. However, the requirement of reintervention indicates that detailed follow-up examinations in patients who have undergone endovascular stent-grafting with handmade stent-grafts should be performed.     

Surgical correction of failed thoracic endovascular aortic repair

OBJECTIVE: The number of thoracic aortic endovascular procedures is increasing rapidly, and the clinical outcome largely depends on the underlying aortic pathology. When primary stent grafting is unsuccessful, secondary endovascular solutions are most often feasible. However, in recurrent endovascular failure without further minimally invasive options, conservative treatments or conversion to open surgery are the only remaining therapeutic strategies. METHODS: In our experience, 106 patients received thoracic aortic endovascular treatment. Five of these patients and three from other centers underwent conversion to open repair because of 4 type Ia endoleaks (3 thoracic aortic aneurysms, 1 traumatic rupture), 2 retrograde type A dissections, 1 type Ib endoleak with contained rupture, and 1 secondary false aneurysm rupture due to stent graft migration. The latter four were surgical emergencies; the other four were urgent or elective procedures. Three patients underwent supracoronary arch replacement through sternotomy. One patient had arch and proximal descending aortic replacement, three had hemiarch and descending aortic replacement, and one had descending aortic replacement through left thoracotomy. Five stent grafts were totally removed, and three endografts were left in situ. All conversions were performed according to a protocol including total extracorporeal circulation (n = 7) or left heart bypass (n = 1), cerebrospinal fluid drainage and monitoring motor-evoked potentials, transcranial Doppler, and electroencephalography. RESULTS: All patients survived the surgical procedure. Six patients had an uneventful postoperative course, whereas necrotic cholecystitis developed in one patient who required cholecystectomy and prolonged intensive care stay. One polytrauma patient died from secondary rupture due to prosthesis infection 24 days after stent graft explantation. No stroke, paraplegia, renal failure, or other major complication occurred. With a mean follow-up of 14 months (range, 4-71 months), seven patients are alive without any sign of recurrent aortic problems. CONCLUSION: Failure of thoracic endovascular aortic repair comprises a new aortic pathology. Secondary endovascular treatment is feasible in most patients; however, some patients will require open surgery to repair failures of thoracic endovascular aortic treatment. These procedures constitute a large surgical trauma and require an extensive protocol, including extracorporeal circulation, neuromonitoring, and adjunctive modalities to provide organ protection. We recommend that these procedures be performed in centers with experience and the infrastructure to offer these protective measures.