Scholarly article on topic 'Endovascular repair of acute traumatic injury of thoracic aorta'

Endovascular repair of acute traumatic injury of thoracic aorta Academic research paper on "Clinical medicine"

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Abstract of research paper on Clinical medicine, author of scientific article — Ahmed H. Abou-Issa, Wael Abdulghaffar, Fady Elganayni, Mohammad Bafaraj, Hesham Fathy Soliman

Abstract Blunt thoracic aortic injury is associated with a high mortality rate. It is the second leading cause of death after head injury from vehicle accidents. Surgical repair with graft interposition was the traditional treatment of blunt aortic injury however; the introduction of endovascular stent graft has revolutionized the definitive treatment of these injuries. Objectives To review our experience with endovascular repair (EVR) of acute traumatic injury to thoracic aorta regarding technique, device, complications and outcome. Patients and methods This series included 14 patients subjected to EVR for acute traumatic aortic injury (ATAI) to the thoracic aorta between January 2010 and August 2011. The diagnosis was suspected in 11 patients based on plain X-ray and the mechanism of trauma and was confirmed on CT scan. The other 3 cases were diagnosed incidentally during CT scan for other indications. Gore TAG device was used in all patients. Results EVR was well tolerated with no peri-procedural mortality, conversion to open surgery, post-intervention paraplegia or significant blood loss. Complications encountered are: inadvertent stent jump (1), endoleak type 1 (1), endoleak type 3 (1), and left common iliac artery thrombosis (1). Conclusion Endovascular repair of acute traumatic injury to thoracic aorta can be performed with less risk than emergency surgical treatment. It is a less invasive therapeutic option even in young and low risk patients. It can be performed rapidly with minimal blood loss and subsequent shorter convalescent periods.

Academic research paper on topic "Endovascular repair of acute traumatic injury of thoracic aorta"

The Egyptian Journal of Radiology and Nuclear Medicine (2012) 43, 193-201

Egyptian Society of Radiology and Nuclear Medicine The Egyptian Journal of Radiology and Nuclear Medicine

www.elsevier.com/locate/ejrnm www.sciencedirect.com

ORIGINAL ARTICLE

Endovascular repair of acute traumatic injury of thoracic aorta

Ahmed H. Abou-Issa a'*, Wael Abdulghaffar a, Fady Elganayni a, Mohammad Bafaraj b, Hesham Fathy Soliman c

a Diagnostic Radiology Department, Faculty of Medicine, Mansoura University, Egypt b Vascular Surgery Department, Alnoor Specialist Hospital, Holy Makkah, Saudi Arabia c Anesthesiology Department, Faculty of Medicine, Ain Shams University, Egypt

Received 12 August 2011; accepted 14 January 2012 Available online 8 February 2012

KEYWORDS

Endovascular; Repair; Traumatic; Thoracic aorta; Injury

Abstract Blunt thoracic aortic injury is associated with a high mortality rate. It is the second leading cause of death after head injury from vehicle accidents. Surgical repair with graft interposition was the traditional treatment of blunt aortic injury however; the introduction of endovascular stent graft has revolutionized the definitive treatment of these injuries.

Objectives: To review our experience with endovascular repair (EVR) of acute traumatic injury to thoracic aorta regarding technique, device, complications and outcome.

Patients and methods: This series included 14 patients subjected to EVR for acute traumatic aortic injury (ATAI) to the thoracic aorta between January 2010 and August 2011. The diagnosis was suspected in 11 patients based on plain X-ray and the mechanism of trauma and was confirmed on CT

Abbreviations: ATAI, acute traumatic aortic injury; CFA, common femoral artery; CTA, computed tomography angiography; DA, descending aorta; EVR, endovascular repair; IA, innominate artery; LCCA, left common carotid artery; LSCA, left subclavian artery; LAO, left anterior oblique; LZ, landing zone; MPCR, multiplanar curved reformat; TAG, thoracic aortic graft; VR, volume rendering * Corresponding author. Tel.: +966 25667623; fax: +966 25664314. E-mail addresses: ahmharon@yahoo.com, ahmharon@gmail.com (A.H. Abou-Issa).

0378-603X © 2012 Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V. All rights reserved.

Peer review under responsibility of Egyptian Society of Radiology and

Nuclear Medicine.

doi:10.1016/j.ejrnm.2012.01.005

scan. The other 3 cases were diagnosed incidentally during CT scan for other indications. Gore TAG device was used in all patients.

Results: EVR was well tolerated with no peri-procedural mortality, conversion to open surgery, post-intervention paraplegia or significant blood loss. Complications encountered are: inadvertent stent jump (1), endoleak type 1 (1), endoleak type 3 (1), and left common iliac artery thrombosis (1). Conclusion: Endovascular repair of acute traumatic injury to thoracic aorta can be performed with less risk than emergency surgical treatment. It is a less invasive therapeutic option even in young and low risk patients. It can be performed rapidly with minimal blood loss and subsequent shorter convalescent periods.

© 2012 Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V.

All rights reserved.

1. Introduction

Blunt thoracic aortic injury is associated with a high mortality rate. It is a devastating consequence of deceleration trauma. Aortic injury is second only to head injury as the leading cause of death from vehicle accidents. More than 80% of patients die at the scene, and most of those who survive the initial injury will die without definitive treatment (1-3).

The force that causes the aorta to tear often leads to other organ injuries. Up to 25% of patients with blunt aorta injury require a major operation before aortic repair (4,5). Therefore, definitive treatment is often delayed due to these multiple concomitant injuries, an aspect that accounts for an in-hospital rupture rate of 10-13%, usually within a few hours after admission (3,6,7). The aortic tear occurs most often at the aortic isthmus, and, in order of frequency, affects the proximal descending aorta, the ascending aorta, the aortic arch, distal descending aorta, and the abdominal aorta (4,8).

Traditional treatment of blunt aortic injury has been early open surgical repair with graft interposition, with or without adjuncts to maintain distal perfusion. Open repair carries a 2.9-7% risk of paraplegia and an operative mortality rate ranging from 15% to 23.5%. Nevertheless, the introduction of endovascular stent grafts is revolutionizing the definitive treatment of these injuries. Although endovascular management of aortic rupture was initially restricted to high-risk patients with multiple injuries, in many centers it has now become the preferred first treatment even in young or low-risk patients. The potential benefits of thoracic endovascular aortic repair (TEVAR) over open repair include no need for thora-cotomy or single lung ventilation, avoidance of aortic cross-clamping, decreased use of systemic anticoagulation, less blood loss, less procedure time, can be done with local anesthesia, less postoperative pain and lower paraplegia rate. These factors can improve overall survival as documented by several meta-analyses (2-4,9-12).

2. Aim of study

To review our experience with endovascular repair of acute traumatic aortic injury to thoracic aorta regarding technique, device used, complications and outcome in 14 patients.

3. Patients and methods

This study included 14 patients subjected to EVR for thoracic ATAI between January 2010 and August 2011. Before the starting date, surgical repair was the treatment option for these

cases. The diagnosis was suspected in 11 patients based on plain X-ray and mechanism of trauma and was confirmed on CT scan. The other 3 cases were diagnosed incidentally during CT scan for other indications.

All cases were done in Angio Suite (Siemens Axiom Artis) with interdisciplinary cooperation between interventional radiologists, vascular surgeons, anesthesiologists and intensive care teams. Standby operative room was ready for surgical conversion if required.

Pre-intervention planning was based on CT scan which was reviewed for the following points: (1) Length of injured segment and pattern of injury; (2) length and diameter of proximal landing zone (LZ); (3) diameter of distal LZ; (4) relation to LSCA; (5) measure C-arm angle required during intervention; (6) diameter of common femoral and iliac arteries to choose larger access; (7) aorta distal to injured segment for any injury or abnormality and (8) any associated organ injuries or hematoma as heparin would be avoided with these injuries.

Under general anesthesia and strict sterilization, diagnostic aortography in LAO projection was done with 5F pigtail catheter through RT CFA in 12 cases. Rt brachial access was done in 2 cases due to RT hip injury in one patient and severe aortic injury in the second one to minimize negotiation with the guide wire (Fig. 1, Table 1). The LAO angle ranged from 60° to 75° and was predefined on CT scan. This angle is very important to have a clear view of the landing zone, LSCA and LCCA. IV heparin 5000 IU used regularly except in 1 case with cerebral hematoma.

Exposure of left common femoral artery and arteriotomy then performed, 0.035 Amplatz super stiff J-shaped wire, 260 cm (Boston Scientific) introduced into ascending aorta. An introducer sheath (18-22Fr) was advanced; sheath size depends on the stent diameter. Stent is then advanced through the sheath to cover the injured segment. Proper positioning of the wire and stent is confirmed before release. After stent release, trilobed balloon used to touch the distal and proximal landing zones respectively to fix the stent. Finally, completion aortography is done to confirm stent position, relation to great vessels and to exclude endoleak (Fig. 2).

The Gore TAG endoprosthesis was used in 13 patients. The stent diameter ranged from 26 to 34 mm and was pre-defined depending on diameter of proximal LZ on CT scan. This device is composed of a symmetric expanded polytetrafluoroeth-ylene (ePTFE) graft with an outer self-expanding nitinol support structure to combine both device flexibility and material durability. The function of the endoprosthesis is to internally reline the thoracic aorta and isolate the diseased segment from blood circulation. Two radiopaque gold bands

Figure 1 32 YOM, RTA victim with ATAI of proximal DA. (A) Aortography via RT brachial access confirmed the diagnosis. (B) Completion angiography shows exclusion of the injured segment. (C) Follow up CTA after 1 month: no endoleak or other complications.

Table 1 shows age, sex, access site, stent diameter and complications in 14 patients subjected to EVR in our series.

Case Age Sex Access LZ diameter (mm) Stent size (mm)b LSCA coveragec Complications

Diagnostic Therapeutic

1 31 M RT CFA LT CFA 20 26 x 100 Total -

2 32 M RT brachial A LT CFA 26 31 x 150 Non -

3 25 M RT CFA LT CFA 23 26 x 100 Partial -

4 28 F RT CFA LT CFA 27 31 x 100 Total Stent jump

5 55 M RT CFA LT CFA 30 34 x 150 Total Endoleak type 3

6 42 M RT brachial A LT CFA 26 31 x 100 Total -

7 22 M RT CFA LT CFA 25 28 x 100 Total LT CFA thrombosis

8 34 M RT CFA LT CFA 24 28 x 100 Total -

9 29 M RT CFA LT CFA 23 28 x 100 Total -

10 35 M RT CFA LT CFA 25 28 x 100 Non Endoleak type 1a

11 33 M RT CFA LT CFA 27 31 x 100 Total -

12 26 M RT CFA LT CFA 22 26 x 100 Total -

13 45 M RT CFA LT CFA 26 31 x 100 Non -

14 16 M RT CFA LT CFA 17 21 x 100 Partial -

a This patient is subjected to re-intervention with overlapping stent (Fig. 6). b Stent size was 10-20% larger than diameter of proximal landing zone. c Left SCA was totally covered in 9 cases with evidence of refilling in all cases.

are attached to the base of the flares, serving as a guide during deployment and in graft surveillance. A trilobed balloon is used to inflate the aortic stent graft while allowing continuous antegrade blood flow during balloon inflation (Fig. 3) (13,14). The last patient in this series was 16 years old in whom a 21 mm C-Tag endoprosthesis (C = Conformable) was used (Fig. 4).

Plain X-ray chest was done on the second day to confirm stent position and contour. Follow up CT scan was done at 1 month after procedure unless it is indicated earlier e.g. if endoleak is noted at time of intervention (Fig. 7) or for other reasons e.g. to exclude pulmonary embolism.

4. Results

Study included 14 patients, they were RTA victims, 13 males and 1 female, age ranged from 16 to 55 years. ATAI was confirmed on CT scan, patterns of injury included deformities of the aortic contour, intimal flaps, transection, thrombus or debris into the aortic lumen, adventitial hematoma, pseudoan-eurysm and periaortic hematoma.

EVR was done in all cases with no peri-procedural mortality. There was no conversion to open surgery, post-intervention paraplegia or significant blood loss. Complications encountered are: inadvertent stent jump (1 case, Fig. 5),

Figure 2 Summarizes the steps of EVR in a 25YOM, RTA victim with ATAI. (A) CTA MPCR shows location of aortic injury and relation to LSCA. (B) Aortography through 5F pigtail catheter in 55° LAO projection, confirmed aortic injury. The C-arm angle was predefined on CT scan. (C) Confirms stent position before deployment, the stent and wire should follow the outer curve of aorta. (D&E) After release of stent; a trilobe balloon is inflated to touch the distal and proximal landing zone respectively. (E) Completion angiogram to confirm stent position, coverage of injured segment and absence of endoleak. The LSCA was partially covered with stent flares.

endoleak type 1 (1 case, Fig. 6), endoleak type 3 (1 case, Fig. 7), and left common iliac artery thrombosis for which thrombectomy was done (Table 1).

5. Discussion

Despite significant advances in critical care medicine and refinement in surgical techniques; morbidity and mortality rates of

open surgical repair of ATAI are still high. Postoperative paraplegia is of major concern with an incidence up to 25.5% and 30-day mortality ranging from 8% to 30% (15). Some authors have advocated that open repair remains the first line therapy for blunt aortic injury in patients <18 years of age and those with an outer wall aortic diameter <18 mm for reasons of oversizing but in many centers it has now become the initial procedure of choice, even in young or low-risk patients.

Figure 3 (A) Diagram shows components of Gore TAG endoprosthesis, (B) Trilobe balloon (13,14).

As for the timing of repair, in the case of aorta-related hemodynamic instability (massive mediastinal hematoma, active bleeding, or left hemothorax), emergency endovascular treatment must be performed. In the case of non-aorta-related hemodynamic instability, the other life-threatening injuries should be treated first, and endovascular treatment of the aortic injury can be performed within 24 h (16). In our institution, EVR is now the treatment option for patients with acute injury of the thoracic aorta. Surgery was performed before the introduction of this technique. EVR is associated with clear reduction in peri-operative mortality and morbidity. No paraplegia was encountered in all (14) cases. Due to the introduction of

new C-TAG device (C = Conformable) we were able to do EVR for a 16 year old patient whose aorta was 17 mm in diameter (Fig. 4). Although we did not have immediate complications yet, long term follow up and use in more cases will show the future of these devices in small aorta and young ages.

Graft was oversized by 10-20% based on the inner diameter of the landing zone except in the first case where a 26 mm stent used in 20 mm aorta (30% oversizing) because C-TAG was not available at that time. However, no endoleak or collapse was encountered in this case. The minimum length of landing zone required for EVR was 1 cm from the origin of

Figure 5 28YOF, RTA victim, referred for EVR. (A) 3DVR CTA, (B) Conventional angiography confirmed complex aortic injury distal to LSCA. Common trunk for LCCA and IA noted. Note the short distance between LSCA and the common trunk and the short landing zone as well.(C) Angio after stent release shows inadvertent proximal jump of the stent so it partially covers the common trunk and encroaches on LCCA. (D) Follow up CTA shows encroachment on the common trunk and retrograde filling of LSCA. Patient recovered without ischemic or neurologic complications. Comment: RT brachial access would be preferred in such cases, if bailout stenting is required.

LSCA otherwise; the LSCA will be covered. The LSCA was covered totally in 9 and partially in 2 patients. This decision was based on CT measures and reviewed during angiography. Sizing catheters was used in 3 patients to allow more accurate assessment before deployment.

Intentional covering of LSA may lead to higher incidence of extremity ischemia and stroke. The evidence in the literature

is sparse with a low number of events and the outcomes are poorly described in many cases although it needs to be weighed against many factors, such as urgency of repair or patient anatomy (17,18). In our study, LSCA covering was well tolerated without signs or symptoms of peripheral limb ischemia or neurological manifestations. All cases showed refilling of LSCA on follow up CTA (Figs. 2,4-7).

Figure 6 35YOM, RTA victim with ATAI. (A) 3DVR CTA shows injury distal to LSCA. (B) Completion angiogram after stent deployment shows bird peak sign (arrow) however, no endoleak noted. The LSCA was not covered. (C&D) follow up after 1 month shows endoleak type I with collapsed stent. (E) Re-intervention with insertion of a larger stent proximally. (F) Follow up CTA shows complete exclusion of the injured segment with no endoleak however, the LSCA is totally covered now.

Complications after endograft repair can manifest immediately or in a delayed fashion. The most commonly reported complications (many of which are rare) include endoleak, graft collapse, branch vessel complications including stroke and left upper extremity ischemia, endograft infection, graft material failure, missed injury or stent migration, paraplegia, and complications related to the access site (19).

Endoleak is the most common complication after endo-vascular repair with a prevalence ranging from 3.2% to 14.4% (9,11). Endoleaks are important to recognize because they result in exposure of the excluded pseudoaneurysm to systemic arterial pressure. Small endoleaks are sometimes managed conservatively with imaging follow-up, but most require rapid intervention with either additional overlapping stent placement or conversion to open surgical repair (20,21).

In our series, we reported 1 case with inadvertent jump during deployment (Fig. 5). Immediately after stent release, the patient developed a sudden drop of blood pressure and circulatory collapse but was successfully resuscitated. Although the

graft encroaches on LCCA yet, there were no neurological or ischemic manifestations on follow up. Endoleak was reported in 2 cases. The first one was type 1 and resulted in collapse of the graft and refilling of the pseudoaneurysm (Fig. 6). Endo-leak was expected in this patient due to presence of bird beak sign on completion angiogram. This sign was due to lack of apposition between the stent and inner surface of the aorta which allows passage of blood between them with eventual collapse of the stent. Re-intervention with overlapping larger stent was performed. The second patient had type 3 endoleak (Fig. 7); there was immediate filling of the aneurysm on completion angiogram. CTA showed contrast filling of the aneu-rysm at inner curve of the stent in relation to focal contour irregularity of the stent suggesting fracture or disruption of the stent. Access complications in our series included 1 patient in whom thrombosis of the left iliac and common femoral arteries occurred. Thrombectomy was done and antegrade flow regained. Due to new trend toward EVR of ATAI, we prepare for total percutaneous repair with the use of closure devices to minimize surgical access complication and shorten the overall procedure time.

Figure 7 55YOM, RTA victim subjected to EVR for ATAI. (A) Catheter angiography shows injured segment distal to LSCA. There is a common trunk for IA & LCCA. (B) Completion angiography shows endoleak (arrow). (C,D&E) CTA after 1 week shows endoleak (type 3) related to small defect in the graft.

6. Conclusion

Endovascular repair of acute traumatic injury to the thoracic aorta can be performed with less risk than emergency surgical treatment. It is a less invasive therapeutic option that can be performed even in young and low risk patients. This procedure is well tolerated, can be performed rapidly with minimal blood loss with subsequent shorter convalescent periods. However, close follow up is important to exclude risks of late complications.

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