Anterior approach to traumatic mid aortic arch transection

The majority of nonpenetrating traumatic injuries to the thoracic aorta are fatal. Survivors of aortic transection tend to have injuries occurring at the isthmus. We report a rare, blunt traumatic complete transection of the mid aortic arch between the innominate and left common carotid arteries diagnosed by multidetector computed tomography of the chest. The repair was approached anteriorly and required aortic arch replacement.     

Thoracic endovascular aortic repair for traumatic aortic transection

BACKGROUND: Traumatic transection of the thoracic aorta is a highly morbid injury. Treatment may be delayed while attention focuses on concomitant injuries. Thoracic endovascular aortic repair (TEVAR) is effective but remains controversial in these often-young patients. We reviewed our experience in acute and subacute treatment of these injuries with TEVAR. METHODS: A retrospective analysis of five men and five women who underwent TEVAR for aortic transection from 1999 to 2007 was conducted. Procedures were performed with standard endovascular techniques. Follow-up included computed tomography at 1 month and yearly thereafter. RESULTS: Mean age was 44 years (range, 20 to 84 years). Motor vehicle accidents accounted for 7 injuries, a snowmobile accident for 1, skydiving for 1, and balloon angioplasty of a coarctation for 1. Average diameter of the proximal landing zone was 25 mm (range, 23 to 29 mm). Mean external iliac size was 10 mm (range, 7 to 15 mm), and no conduits were required. Immediate technical success was 90%, with no 30-day mortality. Seven patients underwent repair acutely (< or =24 hours) and three patients subacutely (range, 4 days to 2 months) for pseudoaneurysm. Four patients had procedures for concomitant injuries before their transection was repaired (3 laparotomies and a fixation for open fracture). One endoleak was noted, which resolved by the 1-month follow-up. The lone device-related complication was an endograft collapse at 5 months managed by repeat endografting, which was complicated by aortoesophageal fistula requiring esophagectomy and open reconstruction. No iliac injuries occurred. At 20-months of mean follow-up (range, 2 to 70 months), all patients are alive and well. CONCLUSIONS: TEVAR for traumatic aortic transection is feasible, with good initial success. Repair can be delayed in selected cases. Continued surveillance is necessary to ensure good long-term outcomes in these young patients. Care must be taken when performing TEVAR for this off-label indication because these devices are designed for the larger aortic diameters of aneurysm patients.     

Blunt traumatic aortic transection: endoluminal repair with commercially available aortic cuffs

Blunt traumatic aortic transection remains a lethal condition. Treatment requires a high index of suspicion, prompt diagnosis, and expedient operative repair. Even in the best of circumstances, morbidity and mortality associated with open surgical repair are high, particularly because of frequent occurrence of other severe associated injuries. Endoluminal aortic stent-graft repair is an accepted treatment option in patients with aneurysm degeneration, and may be an alternative means of managing contained aortic transection. We describe three cases of blunt traumatic thoracic aortic transection treated with commercially available aortic endoluminal stent grafts.     

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.     

Median sternotomy and extended left anterior thoracotomy for repair of traumatic aortic transection with ruptured right atrium

A 22-year-old man presented with traumatic aortic transtion associated with rupture of the right atrium and underwent urgent median sternotomy to repair the right atrium. A T-shaped extended left anterior thoracotomy was performed, and ruptured descending thoracic aorta was repaired under total bypass. A Y-shaped connector was inserted in the arterial catheter to allow cannulation of both ascending aorta and femoral arteries. A 4-cm long Hemoshield graft was used to repair the aortic transection. The patient made a full recovery and was discharged 13 days after the accident.     

Thoracic aortic emergencies: impact of endovascular surgery

BACKGROUND: Conventional surgery for thoracic aortic emergencies, such as contained or free rupture of thoracic aortic aneurysms, acute type B dissections, and traumatic rupture of the thoracic aorta, is frequently associated with a high rate of mortality and morbidity. To obviate this risk, endovascular surgery is considered to be a valid alternative procedure. METHODS: From March 2001 to July 2002, 15 of 22 patients with acute thoracic aortic syndromes were submitted to endovascular surgery: 3 patients (20%) for traumatic rupture, 4 patients (26.7%) for contained or free rupture of thoracic aortic aneurysm, and 8 patients (53.3%) for acute type B dissection evolving to rupture. Computed tomographic scan was diagnostic in all patients. The stent grafts were introduced through the femoral artery. RESULTS: In the endovascular group there were no perioperative deaths or open conversions. The intraoperative angiography and computed tomographic scan performed on discharge showed no significant endoleaks and successful sealing of the aortic dissection. Average intensive care unit and hospital stay was 1.7 +/- 0.8 and 5.9 +/- 3.0 days. Follow-up ranged between 4 and 23 months and included clinical examinations and serial computed tomographic scan at 3, 6, and 12 months, and every 6 months thereafter. One 84-year-old patient with thoracic aortic aneurysm died of pneumonia 78 days after endovascular surgery. Only one type 1 endoleak was noted in the first patient with traumatic rupture, 3 months after the procedure. CONCLUSIONS: Endovascular surgery is a safe technique, showing encouraging early and midterm results and allowing for prompt treatment of associated lesions in complex multitrauma patients.     

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.     

Continued aortic aneurysmal expansion after thoracic endovascular stent-grafting

We report the successful open repair of a thoracoabdominal aneurysm that had expanded after previous endovascular stenting. Aortic valve-sparing root replacement was performed as an initial step because the patient had significant aortic valve regurgitation caused by root enlargement. Continued aneurysmal dilatation after stenting of the thoracic aorta can lead to repair failure and therefore underscores the need for careful follow-up of patients after endografting.     

Blunt traumatic aortic injury in the elderly population

ObjectiveBlunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database.MethodsPatients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management.ResultsDuring the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group.ConclusionsThis study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.