Endovascular Treatment of Acute and Chronic Thoracic Aortic Injury

Cardiovasc Intervent Radiol (2007) 30:1117–1123 DOI 10.1007/s00270-007-9053-2

CLINICAL INVESTIGATION

Endovascular Treatment of Acute and Chronic Thoracic Aortic Injury Jan Raupach Æ Alexander Ferko Æ Miroslav Lojik Æ Antonin Krajina Æ Jan Harrer Æ Jan Dominik

Received: 21 January 2007 / Accepted: 7 March 2007 / Published online: 13 September 2007 Springer Science+Business Media, LLC 2007

Abstract Our aim is to present midterm results after endovascular repair of acute and chronic blunt aortic injury. Between December 1999 and December 2005, 13 patients were endovascularly treated for blunt aortic injury. Ten patients, 8 men and 2 women, mean age 38.7 years, were treated for acute traumatic injury in the isthmus region of thoracic aorta. Stent-graftings were performed between the fifth hour and the sixth day after injury. Three patients (all males; mean age, 66 years; range, 59–71 years) were treated due to the presence of symptoms of chronic posttraumatic pseudoaneurysm of the thoracic aorta (mean time after injury, 29.4 years, range, 28–32). Fifteen stentgrafts were implanted in 13 patients. In the group with acute aortic injury one patient died due to failure of endovascular technique. Lower leg paraparesis appeared in one patient; the other eight patients were regularly followed up (1–72 months; mean, 35.6 months), without complications. In the group with posttraumatic pseudoaneurysms all three patients are alive. One patient suffered

J. Raupach M. Lojik A. Krajina Department of Radiology, Charles University and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic A. Ferko Department of Field Surgery, Military Medical Faculty in Hradec Kralove, Hradec Kralove, Czech Republic J. Harrer J. Dominik Department of Cardiosurgery, Charles University and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic J. Raupach (&) Department of Radiology, University Hospital, 50005 Hradec Kralove, Czech Republic e-mail: [email protected]

postoperatively from upper arm claudication, which was treated by carotidosubclavian bypass. We conclude that the endoluminal technique can be used successfully in the acute repair of aortic trauma and its consequences. Midterm results are satisfactory, with a low incidence of neurologic complications. Keywords Blunt thoracic aortic injury Interventional radiology Endovascular treatment Stent-graft Antihypertensive therapy Delayed operation

Introduction In 1958, Parmley published a study of autopsies conducted at the Walter Reed Army Medical Center. This study described the natural course of non-treated traumatic laceration of the aorta [1]. Since then, many things have changed. Due to advances in prehospital care, most patients who previously would have died at the scene of an accident today reach a hospital in time for treatment. Despite the major improvement in cardiosurgery brought about by the use of extracorporal circulation, which allows elective operation on the thoracic aorta, the death rate for emergency patients with aortic injury remains high [2, 3]. The recent introduction of endovascular techniques has broadened the range of effective lifesaving treatments for acute aortic injuries [4]. The treatment of aortic aneurysms with endoluminal prostheses, so-called stent-grafts, was introduced in the early 1990s. In the Czech Republic this technique was first used for treatment of traumatic laceration in 1999 [5]. The purpose of this study was to evaluate the results of endoluminal treatment of aortic injuries in the Czech Republic in the subsequent 7 years.

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J. Raupach et al.: Endovascular Treatment of Acute and Chronic Thoracic Aortic Injury

Materials and Methods Patients Between 1999 and 2005, 13 patients with lacerations of the thoracic aorta treated using endovascular techniques were prospectively followed. In addition to the patients treated at the trauma center at University Hospital in Hradec Kralove, two patients treated by our doctors in different hospitals were also included in the study. In 10 of the 13 cases (2 female, 8 males; mean age, 39.6 years; range, 17–54 years), acute injuries in the isthmus region of thoracic aorta were present. Stent-graftings were performed between the fifth hour and the sixth day after injury (mean, 3.2 days posttrauma). All 10 patients suffered from polytrauma and were in severe general condition, with a mean Injury Severity Score (ISS) of 40.5 (range, 15.0–50.1). Three patients (all males; mean age, 66 years; range, 59–71 years) were treated by the endovascular method due to the presence of symptoms of chronic posttraumatic pseudoaneurysm of the thoracic aorta (mean time after injury, 29.4 years; range, 28–32). The size of the pseudoaneurysm varied from 60 to 105 mm (mean, 82 mm). Chronic pseudoaneurysms manifested themselves by oozing (n = 1), dyspnea (n = 3), back pain (n = 3), and vocal cord palsy (n = 2). Altogether 15 stent-grafts in 13 patients were implanted. We used Talent stent-grafts (Medtronic, Minneapolis, MN) 13 times and Ella stent-grafts (Ella— CZ, Hradec Kralove, CZ) two times.

Diagnostics Polytraumatized patients were admitted to the emergency room, and as a first examination, a chest x-ray in the supine position (anteroposterior projection; tube-film distance = 1 m) was taken. In cases with positive signs of aortic injury, spiral CT examination of the thoracic aorta was performed. All examinations were performed using single-slice CT scanner (Somatom 4 Plus; Siemens, Germany) located at our trauma center. The single-phase CT protocol was as follows: slice thickness, 5 mm; reconstruction increment, 3 mm; table speed, 10 mm/s; and pitch, 2. Scan delay was 25 s after beginning of contrast administration; 110 ml of nonionic iodine contrast material (350 mgI/ml) was administered at a flow rate of 3 ml/s. The thoracic aorta was evaluated on axial images and on multiplanar reconstructions (MPR). Diagnoses were made after CT findings of mediastinal hematoma and clear detection of thoracic aortic injury. Medical antihypertensive therapy with bblockers and vasodilatators was initiated at the same time. In cases of the seriously injured with multiorgan

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involvement, the treatment priorities were established by the interdisciplinary consultation team consisting of a traumatologist, a thoracic surgeon, a cardiologist, an anesthesiologist, and an interventional radiologist.

Endovascular Treatment Endovascular treatment was carried out in the catheterization laboratory under fluoroscopic control (Axiom; Siemens, Germany). Operations were performed in the supine position, under general anesthesia, and under cover of antibiotics. Intravenous administration of 1.2 g of amoxicilin (Amoksiklav; Lek Pharmaceuticals, Slovenia) was used. After surgical preparation of the right common femoral artery, a stiff, 0.035-in. (300-cm-long) guide-wire (Back-up Meier, Boston Scientific Corp., Natick MA, USA ) was inserted by puncture and passed into the aortic arch. From the left femoral or left brachial artery, a calibrating pigtail was passed, which was used for calibration angiography of the aortic arch in the left oblique position (Fig. 1a). Under fluoroscopic control, the stent-graft in the casing was passed from the arteriotomy of the right femoral artery through pelvic arteries into the aortic injury. After a mean blood pressure decrease of 70 mm Hg, the stent-graft was released from the inserting system (Fig. 1b and c). A decrease in blood pressure was achieved pharmacologically by intravenous administration of 25–50 mg urapidil hydrochloridum (Ebrantil; Altana Pharma AG, Germany) The same endovascular approach was used in treatment of chronic pseudoaneurysms (Fig. 2a and b). CT imaging of the thoracic aorta was performed on the fifth day after the treatment at 3 and 6 months, and then every year (Fig. 2c–f).

Results Acute Aortic Injury The length of artificial respiration required by patients ranged from 2 to 25 days (mean, 6.4 days). Stays in the intensive care unit lasted from 3 to 30 days (mean, 8.3 days). The relatively long period of artificial respiration and intensive care was due to severity of concomitant injuries. Mean ISS score in the acute injury group was 40.5. In the group of 10 patients treated for an acute aortic injury, 1 patient died due to complications related to the endovascular treatment. This patient was the polytraumatized man (48 years, ISS = 50.1) with an injury of the aorta in the vicinity of the orifice of the left subclavian artery. At the beginning of our study, in 1999, only custom-made stent-grafts of the Stanford design was available (Ella-CZ). This type of device consisted of a spiral Z-stent covered


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Fig. 1 A 52-year-old female with paraparesis after ET. Digital subtraction angiogram in left oblique projection reveals a typical acute traumatic pseudoaneurysm in the isthmus region of the thoracic aorta (a). A Talent stent-graft (130-mm total length) was implanted

with the open struts over the left subclavian artery (b). Angiogram after stent-graft placement. The pseudoaneurysm is excluded from circulation (c)

Fig. 2 A 71-year-old male. Angiogram of the large chronic posttraumatic pseudoaneurysm which extends to the origin of the left subclavian artery (a). For complete exclusion of the pseudoaneurysm we had to implant two 130-mm stent-grafts. The distal graft was inserted first and then the proximal graft was placed coaxially, with overlap of the subclavian artery in an effort to minimize the risk of

intersegmental endoleak. Angiogram confirms exclusion of the entire pseudoaneurysm (b). CT follow-up (axial image, saggital MPR) reveals complete pseudoaneurysm thrombosis in 10 days (c, d). CT follow-up (axial image, saggital MPR) confirms marked regression of pseudoaneurysm dimensions in 32 months (e, f)

with polyester prostheses and was dedicated for the straight part of the descending aorta. In an effort to achieve complete sealing of the trauma lesion, we placed the only available stent-graft too high in the aortic arch. The insufficient flexibility of this stent-graft caused soaking of blood between the walls of the tortuous aorta and the stentgraft, which caused its collapse on the third day after the procedure. The obstruction of the aorta thus resulted in hypoperfusion syndrome of the distal part of the body. Because of associated craniocerebral and abdominal trauma, the cardiosurgeon recommended against a chest

operation on the aorta. Stent-in-stent technique was not used due to our lack of experience at that time. Despite an emergency axillofemoral bypass, this patient died on the 15th day after the endovascular procedure. The 30-day mortality rate for our series of urgently treated patients was therefore 10% (1 of 10). During treatment, one 52-year-old female (ISS = 34.2) developed paraparesis of the lower extremities, although no traumatic injury of the thoracic spine or of the spinal cord was subsequently proven. The location of the laceration in this particular case was at the typical site of

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aortic isthmus, close to the left subclavian artery orifice (Fig. 1a). Due to the patient’s state of primary shock (left lung contusion, pneumothorax, craniocerebral injury) as well as the need for an endotracheal intubation, she was not investigated neurologically prior to the operation. Consequently, we do not know if the ischemic damage might have resulted from the covering and blocking of the arterial supply to the spinal cord or whether it was associated with the hemorrhagic shock, hypotension, and mediastinal hematoma. All eight remaining patients are free of complications and are regularly followed-up by CT according to the schedule mentioned above. The clinical condition is followed-up at the cardiological outpatient department (mean follow-up, 35.6 months; range, 1–72 months; Table 1).

Chronic Posttraumatic Pseudoaneurysm In this group of three patients, the 30-day mortality rate was 0. In all patients a marked regression of pseudoaneurysms, from 82 to 46 mm, was proven. In addition, dyspnea and hoarseness improved in three and two patients, respectively. These symptoms were caused by the pseudoaneurysm sac pressure on the pulmonary artery and on the recurrent nerve. In one patient, due to a short proximal neck, the stent-graft was anchored by its covered portion over the entrance to the left subclavian artery. Because of persistent left upper extremity claudications, a carotidosubclavian bypass was performed 6 months later with positive results. All patients were given follow-up examinations between 6 and 38 months (mean, 21.7 months). All patients are free from complications related to endovascular treatment (Table 1).

Discussion The diagnoses of traumatic lesions of the aorta are determined by the injury mechanism, clinical signs of a severe thoracic trauma, and imaging. The majority of thoracic aortic injuries are the result of high-impact accidents, occurring most frequently during head-on automobile collisions. Hazukova et al. analyzed autopsy reports from the Department of Forensic Medicine, Hradec Kralove, from the years 1994 to 1997 and found that the rupture of the thoracic aorta was the cause of death in 33% of 298 fatalities resulting from car accidents. The incidence of aortic injuries also correlated significantly with the intensity of head-on collision [6]. Another autopsy study found that not only head-on but also lateral crashes caused aortic injury in 35% of cases [7, 8]. With the availability of multidetector CT scanners, whole-body CT examination is currently performed for a complete diagnostic workup of polytraumatized patients in a single step. Our diagnostic workup was based on the local trauma patient protocol modified by the availability of the single-slice CT scanner; therefore, chest x-ray was used as a screening method at the emergency unit. To identify positive signs of aortic injury on chest x-rays, we mainly search for a widening of the mediastinum of more than 8 cm, an apical cap, and a left-sided hemothorax. The negative predictive value of the x-ray is rather high, 98%, which means that if the x-ray is negative, the probability of aortic injury is minimal. Nevertheless, CT of the chest provided the definitive diagnosis of aortic trauma. Recently, a marked shift has occurred in how these injuries are viewed, mainly due to the introduction of hypertension therapy [11–17]. Antihypertensive drugs enable operations to be postponed, with a minimum,

Table 1 Results of endovascular treatment in group of 13 patients No.

Gender, age (yr)

Treatment delay

Type of stent-graft

Complications

Follow-up (mo)

1

Male, 54

5 days

1 · Ella (34·100 mm)

No

72

2

Female, 52

4 days

1 · Talent (34 · 130 mm)

Paraparesis of lower extremities

67

3

Male, 48

3 days

1 · Ella (26/20 · 73 mm)

Collapse of SG

death in the 15th day

4

Male, 31

6 days

1 · Talent (34 · 130 mm)

No

65

5

Male, 59

28 years

1 · Talent (30 · 130 mm)

No

55

6

Male, 17

5 days

1 · Talent (28 · 130 mm)

No

39

7

Male, 68

32 years

2 · Talent (30 · 130 mm)

Left upper extremities claudications

38

8

Male, 52

8h

1 · Talent (32 · 130 mm)

No

23

9

Male, 71

30 years

2· Talent (30 · 130 mm)

No

23

10

Male, 42

5h

1 · Talent (28 · 130 mm)

No

20

11

Male, 22

6h

1 · Talent (30 · 130 mm)

No

13

12 13

Male, 24 Female, 54

6 days 4h

1 · Talent (24 · 130 mm) 1 · Talent (28 · 130 mm)

No No

11 1

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acceptable risk of aortic rupture. Hemmila has compared the retrospective results of classical early treatment with postponed treatment. In patients in whom early operations were contraindicated, antihypertension therapy was commenced and an operation subsequently performed as a delayed procedure. In this group of 45 delayed-operation patients, only one fatal rupture of the aorta occurred [17]. Similarly positive results for antihypertensive therapy are being reported by other doctors. This result is rather encouraging, especially compared with the postponement of operations without treatment for hypertension [14, 16, 17]. The high mortality rates associated with early operation and the risk of paraplegia are the most significant factors taken into account by a surgeon when deciding whether or not to operate. In his study, Hemmila noted a markedly higher incidence of paraplegia in the group operated on earlier (8 of 33 patients) than in those whose operation had been postponed (0 of 45 patients) [17]. The morphology of each injury is another important factor that may affect the therapeutic approach to thoracic aorta rupture. Parmley, in his 1958 study, described several types of aortic injury, ranging from intima fissures to transmural lesions with discontinuity of the whole aorta circumference [1]. Currently, multislice CT investigation is able to classify changes in the aortic wall and thus Malhotra and coworkers suggested creating a scale of priorities related to the proper treatment of aortic injuries [18]. Minimal aortic injury (MAI) was defined as a minute injury, with an intima separation not longer than 10 mm and only a slight mediastinal hematoma or none at all. Malhotra describes in his study successful conservative treatment of these lesions. More extensive aortic injuries, [10 mm in size with a large mediastinal hematoma, are defined as significant aortic injuries (SAIs) and should be treated accordingly [18]. The newest advance in the treatment of ruptures of the thoracic aorta is endovascular treatment using stent-grafts. Endoluminal treatment (ET) is based on the transfemoral introduction of the stent-graft into the site of aortic injury. This method has some unequivocal advantages. The injured wall is stabilized without need for either a thoracotomy or the use of a thoracic aorta clamp, both of which are linked to a high mortality and morbidity during surgery [4, 19, 20]. Another advantage of ET is the low dose of heparin, reducing the risk of bleeding of concomitant injuries. According to the present experience at our trauma center we have used the decision tree shown in Fig. 3 for treatment of blunt aortic injury. The results for ET at our center have been difficult to assess because of the small sample size and the relatively short length of follow-up care. Nevertheless, even our preliminary data show that ET results are very promising. An interesting finding of our study is the

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possibility of treating every case of acute aortic injury with one short stent-graft (length, 73–130 mm). Even with the short length of stented aorta, one serious neurological complication occurred. Treatment of complicated large, chronic posttraumatic pseudoaneurysms required a longer stent-graft. In two of three patients in this group we needed two 130 mm stent-grafts to cover whole lesions. A longer one-piece stent-graft was not commercially available at the time of our study. However, we did not notice any neurological complications in this group, probably due to the slow progressive growth of the pseudoaneurysm and development of collaterals for spinal cord supply. Dunham et al. summarized the results of published works from 1996 to 2003 [21]. They studied a group of 84 endovascularly treated patients in which the mortality rate was 4.8% and no postoperative paraplegia was observed. These results differed from those of a prospective study from the United States in which 207 patients (operated on an average of 16.5 hours after injury) treated classically had a 31% mortality rate and an 8.7% incidence of paraplegia [22]. The results were markedly better with ET. Also, studies comparing ET with classical treatment confirm the reduced mortality and morbidity with the endovascular approach [23–26]. With respect to the delay between the trauma and surgery, again, stent-grafts show a considerable advantage. This can be performed urgently before or after treatment of other life-threatening injuries . We now have a complete range of stent-grafts in stock, to reduce delay in management of ruptured thoracic aorta [27–29]. ET has unequivocal benefits when used in the stabilization of thoracic aortic injuries, with little physiologic effect of a short procedure. Questions regarding long-term side effects and durability of the repair remain to be answered. In two of our young patients we detected transient severe hypertension after ET of acute aortic injury. This was explained by pressure of the oversized stent-graft on baroreceptors in the aortic wall. This problem could be

Blunt Aortic Injury

MAI (minimum aortic injury)

SAI (significant aortic injury)

antihypertensive therapy

if possible

CT (MRI) folow-up stent-graft

regression

x

conservative Tx

progression stent-graft

Fig. 3 Decision tree for treatment of blunt aortic injury

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1122


solved with a small-diameter, flexible stent-graft, which is so far not commercially available. Further endovascular prostheses may migrate or perforate the aortic wall, as is known from the experience with ET in the treatment of thoracic aorta aneurysms. ET has its limitations as well. Technical success, the proper placement of the stent-graft, is not achieved in 1% to 2% of patients [21]. However, technical failure may occur in open surgery as well. In 8 of the 207 patients described by Fabian et al., control over the proximal neck of the aneurysm could not be achieved, and these patients died by exsanguination on the operating table [22]. Other technical problems associated with ET include difficulties with stent-graft introduction when considerable sclerosis is present in the pelvic arteries. In the case of gracile pelvic arteries, an alternative approach via the iliac artery or distal abdominal aorta from a small laparotomy may be used. In cases of short proximal necks, it is possible to extend the anchor zone by overlapping the entrance to the left subclavian artery with an already covered portion of the stent-graft. Although the risk of left upper extremity ischemia is rather low, patients must be closely followed for the possibility of subclavian steal syndrome or left upper extremity ischemia. When complications occur, the patency of the subclavian artery may be re-established by the endovascular procedure [30] or by a carotido-axillary bypass [31]. On the basis of the literature as well as our own experience, we conclude that trauma patients with laceration of the aorta who make it to the hospital have a good chance of survival. Even patients in unstable condition with signs of continuing bleeding from the thoracic aorta can benefit from immediate endovascular repair. Therefore, the permanent availability of different-sized stent-grafts and 24-h on-call service are necessary. The durability of ET has to be proved in larger studies because the majority of injured patients are young people with a good long-life prognosis.

7. 8.

9.

10.

11.

12.

13. 14.

15.

16.

17.

18.

19.

20.

21. 22.

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