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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 42-47

The endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single-center experience


1 School of Medicine, Ningbo University of Medical School, Ningbo, China
2 Department of Vascular Surgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China

Date of Submission11-Oct-2021
Date of Decision21-Feb-2022
Date of Acceptance15-Apr-2022
Date of Web Publication24-Jun-2022

Correspondence Address:
Dr. Qingyun Zhou
Department of Vascular Surgery, Ningbo Medical Center Lihuili Hospital, Ningbo
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2589-9686.348222

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  Abstract 


OBJECTIVE: Blunt thoracic aortic injury is the second most common cause of death in trauma patients. Traumatic aortic injury is an emergency that patients will face death soonly, even there is no enough time to transport the patient to the hospital. In our center, all patients were treated with thoracic endovascular aortic repair (TEVAR). We retrospectively analyze the therapeutic effects of TEVAR of blunt traumatic aortic injury (BTAI) to get some inspiration for the follow-up treatment and provide valuable guidance.
METHODS: We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We have identified 22 patients since 2017. Patients' charts were analyzed for preoperative characteristics and intraoperative variables.
RESULTS: Forty-six patients were included. The median age was 56 years (23–79 years). Sixteen patients were male (73%). Most of them were graded III/IV of aortic injury. All patients were undergone endovascular treatment successfully. Six of 22 patients, showing no chest pain before admission, were presented with classic type B aortic dissection. Moreover, one patient was presented with thoracoabdominal dissection. Emergency surgery (<24 h) was performed in seven patients (32%) who experienced life-threatening injury resulting in hemorrhagic shock and hematoma formation in the mediastinum. All patients were discharged smoothly with no residual symptoms.
CONCLUSIONS: Endovascular treatment of traumatic aortic dissection reduces the mortality rate of these patients who cannot tolerate traditional open surgery. According to our experience, patients who presented with simple pseudoaneurysm in enhanced computed tomography were more stable. Therefore, a postponed operation could be recommended after symptomatically hypotensive management. However, emergency surgery was necessary if patients presented with obviously mediastinal hematoma, especially progressive pleural effusion, which could result in hematoma rupture and death.

Keywords: Blunt aortic injury, thoracic endovascular aortic repair, traumatic aortic injury


How to cite this article:
Ye M, Zhou Q, Wei Y, Wu J, Shen Y, Zheng T, Shao G. The endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single-center experience. Vasc Invest Ther 2022;5:42-7

How to cite this URL:
Ye M, Zhou Q, Wei Y, Wu J, Shen Y, Zheng T, Shao G. The endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single-center experience. Vasc Invest Ther [serial online] 2022 [cited 2022 Aug 19];5:42-7. Available from: https://www.vitonline.org/text.asp?2022/5/2/42/348222




  Introduction Top


Blunt traumatic aortic injury (BTAI) is a life-threatening surgical emergency associated with a high mortality rate.[1],[2] While BTAI only accounts for 1% of trauma, head injury commonly concurs with BTAI which remains the second cause of death in patients with only 10%−15% surviving long enough to reach hospitals.[3],[4],[5] Patients with BTAI are often young and have smaller aortic diameters compared to patients with aneurysms or dissection. BTAI commonly occurs after a sudden deceleration in motor vehicle accidents, falling from a significant height, motorcycle crashes, and crush injuries.[6],[7] Based on severity, BTAI is classified into four grades: Grade I, intimal tear; Grade II, intramural hematoma; Grade III, pseudoaneurysm; and grade IV, free rupture. BTAI can occur along the entire length of the aorta, the predilection site for BTAI is the isthmus of the aorta where existing weaker tensile strength and a transition zone from the unfixed aortic arch to the fixed descending aorta.[8] The major theory that caused the injury mechanism is rapid deceleration which results in increasing shear force of the aortic isthmus.[9],[10] Besides, some supported that the high speed of artery flow generates a “water hammer effect” which may lead to fatal compression of the arterial wall.

Open surgical repair has been the standard treatment option for BTAI since it was successfully introduced in 1959.[11] In the past decade, thoracic endovascular aortic repair (TEVAR) has become the primary line of treatment of BTAI, being associated with increased survival, decreased neurological deficit, and spinal cord injury compared to open surgery and nonoperative management.[12],[13],[14] On this basis, the society for vascular surgery guidelines recommend TEVAR over the open repair or nonoperative management.[2],[15] Some studies have shown that delayed TEVAR (≥24 h) was associated with significantly reduced mortality in stable BTAI patients. In keeping with the recommendation, when patients shown no sign of impending rupture, delayed TEVAR for BTAI within 1–2 weeks was applied in our center. Emergency surgery (<24 h) was performed in patients who experienced multiple trauma resulting in hematoma formation in the mediastinum. The purpose of this study aims to report our 5-year experience using TEVAR to treat BTAI.


  Materials and Methods Top


Study design

We retrospectively reviewed 22 patients treated with TEVAR for traumatic lesions of the aortic isthmus were identified from 2017 to July 2021. Patients' charts were analyzed for preoperative characteristics and intraoperative variables. A trained radiologist and vascular surgeon reviewed all available computed tomography (CT) angiography imaging which has become by far the imaging modality of choice, to ensure agreement on BTAI grading. The specific measurements including the diameter and length of the lesion (for pseudoaneurysms), proximal landing zone and blood loss. Computed tomography angiography (CTA) could help detect multiorgan damage and hemorrhagic shock in multiple trauma patients.

Therapeutic protocol and surgical technique

Patients suffering from severe trauma routinely underwent CTA to evaluate the whole-body condition and initial stabilization. All patients were treated with TEVAR in our center. Given the severity of clinical status, the timing of the operation was different. When patients of BTAI combined with any imminently life-threatening lesion such as mediastinum hematoma and hemorrhagic shock, TEVAR was considered the first-line treatment. Once radiological or clinical findings suggested impending rupture, emergency surgery (<24 h) was performed in patients who experienced multiple trauma, especially the hematoma formation in the mediastinum. Delayed TEVAR (>24 h) for BTAI within 1–2 weeks was applied in our center when patients showed no sign of impending rupture was present. Those patients were treated with adequate clinical stabilization, fluid management, and treatment of other lesions. All procedures performing in a cardiac surgery operating room by a group of cardiac surgeons and interventional radiologists. Patients all underwent general anesthesia and the femoral artery access was a commonly used approach. Heparin was administered before the stent-graft was implanted except for severe hemorrhagic disease. The left subclavian artery (LSA) was intentionally completely covered when the distance from the LSA to the aortic lesion was within 2 cm. Endograft oversizing was maintained in the 10%–20% range. Although applying minimum stent in patients with smaller and straight aortic arch, we found that oversizing could reach 30% which may have injuries proximal aorta due to high radical force or compression of the stent. However, the complications of inappropriate sizing were not seen in our center as migration, pseudo-coarctation, graft occlusion, and endoleak. Infection, access site complications, stroke, and paraplegia/paraparesis were either not found.


  Results Top


Patient characteristics and intraoperative variables

A total of 22 patients have been identified with a diagnosis of BTAI since 2017. Of these patients, all patients were treated with TEVAR and no patients with BTAI have undergone open surgical repair. Baseline characteristics are listed in [Table 1]. The median age was 55 years (23–79 years) and 73% (n = 16) were males. Six patients (27%) were found to have a history of smoking or drinking, and 4 (18%) patients had hypertension. Emergency surgery (<24 h) was performed in seven patients (32%) who experienced poly-trauma resulting in mediastinal hematoma and hemorrhagic shock. One of two patients with hemorrhagic shock for pseudoaneurysm of the isthmus of aorta was successfully carried out procedure [Figure 1]. The median time from diagnosis to treatment was 24 h (range 2–552 h). Concomitant injury as cerebral, lung, bone, visceral, and vascular was observed in all patients. One patient was diagnosed with “Bovine” configuration by CTA. Grade III/IV lesion (Pseudoaneurysm/free rupture) accounted for 19 (87%) cases; Grade II injury was treated in three (13%) cases only. The average diameter of traumatic aortic injury was 27 mm (±9). The mean injury severity score was 40 (±9).
Figure 1: (a) Computed tomography angiography showing the pseudoaneurysm of the isthmus of aorta, compression of the right lung, and accompanied by mediastinal hematoma. (b) A three-dimensional reconstruction showing the distal edge of the stent graft: note the similar diameters between the stent graft (Lifetech 200 mm × 36 mm × 28 mm) and the healthy aorta distal to the stent graft itself

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Table 1: Preoperative patient characteristics

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The endovascular procedure was successfully carried out in all patients. The operative variables are listed in [Table 2]. All patients had femoral artery to gain endovascular access. One patient with a “Bovine” configuration was having brachial artery access to place chimney stents into an aortic endograft. An endovascular stent was used in all 22 patients: Medtronic talent was used in 2, Gore Tag was used in 4, Microport and Lifetech were used in 8, respectively. The average stent graft diameter was 30 mm (±4), and the average length was 160 mm (±21). Coverage of LSA was accounted for 81% (n = 18). Perfusion in the left arm was slightly delayed. Landing zones were measured as the distance from the LSA to the start of the injury including the only uninvolved aorta. Over 90% had a landing zone ranging from 2 to 3. The amount of intraoperative bleeding was controlled within 30 ml. In 12 patients (55%) who were accompanied by severe concomitant injuries were treated with additional surgery: Debridement and fixation for traumatic fracture in seven patients, visceral repaired in three patients, vascular repaired in one patient, cerebral hematoma evacuation in one patient, and tracheotomy in one patient. One patient with multiple fractures caused a life-threatening rupture of vascular was performed followed by left common carotid artery – ascending aorta bypass. Three patients were treated with small intestine repair and splenic artery embolization, respectively.
Table 2: Intraoperative variables

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  Discussion Top


TEVAR was originally used for treating artery aneurysms. Over the past 20 decades, endovascular surgery has been enthusiastically embraced by several vascular surgeons, leading to increased experience with endovascular interventions. Endovascular treatment of blunt thoracic aortic injury (BTAI) has been widely discussed, and several studies have confirmed the endovascular therapy for BTAI.

The purpose of this study aims to share our 5-year experience using TEVAR to treat BTAI. All 22 patients who had been successfully carried out the endovascular procedure were discharged smoothly with no residual symptoms. As we all know, patients with BTAI are often young and have smaller aortic diameters compared to patients with aneurysms or dissection. However, in our center, the median age in our patients was 55 years (23–79) which was older than that of patients in previous studies. The incidence of BTAI in patients aged 65 years or older is approximately 32%. We considered two reasons below. On the one hand, with the rapidly aging population in China, the elderly may be vulnerable to injury and falls that can produce serious injuries in this group. On the other hand, increased age is associated with the formation and rupture of an aneurysm.[16] As compared to young adults, older adults who get chest injury are more easily resulting in thoracic aortic injury. Any trivial trauma increases the incidence of BTAI in elderly individuals.

Controversy about the timing of surgical intervention for traumatic blunt aortic injury is under-discussed. BTAI is a life-threatening lesion that is commonly combined with multiple other life-threatening injuries. A prospective randomized controlled study of BTAI would be difficult to undertake, which causes the prognosis of patients to varying widely. Currently, most scholars insist that emergency surgery should be performed in patients with traumatic aortic injury when there are no special contraindications. It is recommended that surgical treatment be performed as soon as possible within 24 h. However, there is also some literature shown that delayed repair could improve overall survival.[17],[18],[19] Delayed TEVAR(>24 h) for BTAI within 1–2 weeks was recommended in stable BTAI patients. Immediate operation for aortic surgery is prohibitive due to the polytrauma that would carry a significantly high risk of mortality and complications. The meta-analysis of comparative studies published by the American Association for the Surgery of Trauma in 2008 showed that delayed repair had 65% lower mortality compared to open repair (P < 0.01).[20] When the average time from admission to aortic repair from 15 to 55 h in their original trial in 1997.[20],[21] Whereas patients who are successfully admitted to the hospital are mostly in a stable phase and usually able to survive in the early trauma. In our series, patients who presented with pseudoaneurysm in enhanced computed tomography were a sign of stable, delayed repair that could be applied after symptomatically blood pressure reduction. On contrary, emergency surgery will be required if CTA shows pronounced mediastinal hematoma and increasing pleural effusion during observation, which could readily result in hematoma rupture even death.

For patients with severe traumatic aortic injury, especially when the threatened rupture of mediastinal hematoma and large pleural effusion has appeared in a CT scan, interventional surgery is needed as soon as possible.[22] Mediastinal hematoma is an uncommon finding in blunt chest trauma, associated with 1 st rib, 2nd rib, scapular or sternal fracture and the chest hitting the steering wheel during road traffic accidents.[22] Mediastinal hematoma increases the risk of cardiac tamponade which is more insidious when compared to pericardial tamponade mainly due to the large space of mediastinum. Moreover, a huge mediastinal hematoma can result in extrapericardial cardiac tamponade by compressing the adjacent organs.[23] It is urgent surgery to evacuate the hematoma for patients with mediastinal hematoma.[24] In our series, emergency surgery (<24 h) was performed in seven patients (32%) who experienced polytrauma resulting in mediastinal hematoma and hemorrhagic shock, and the median time from diagnosis to treatment was 24 h (range 2–552 h). Two of the patients had developed posttraumatic rupture of aortic causing hemorrhagic shock, in whom stents were rapidly placed and completely sealing of aortic lesions stabilized hemodynamics status when blood pressure had dropped to about 60 mmHg during operation. Thoracentesis and drainage were performed on the 3rd day after operation in our center. Massive pleural effusion affects closure of aortic rupture is a major reason we considered, although which could cause significant respiratory depression. We recommend the volume of drainage not exceeding 500 ml each time and 1000 ml per day. Researches showed that early drainage of the pleural cavity can deteriorate a patient's status by increasing the bleeding from the ruptured aorta.[25]

It is a technical challenge in traumatic aortic injury for young patients with special anatomical structures. Most patients (68%) were under 65 years old. The dilatation of aortic was rare in those young patients who had no history of hypertension. The femoral artery access was significantly thinner affected by hypovolemia and stress stimulation after injury, especially the section of the external iliac artery where the diameter of a local artery within 5 mm was not uncommon in the CT measurement. Moreover, a good surgical plan before operation attempts to prevent rupture of the local external iliac artery. First, puncture technique and placed sheath were used to avoid the occurrence of local vessel vasospasm by an incision which could lead to further reduction of the vessel lumen. At the same time, a larger sheath core for stepwise expansion and small-caliber stents were applied such as a domestic minimally invasive 18F system aortic stent. In our center, no patients were found access-related complications. However, access-related issues comprise a major reason for failure or conversion to open repair and can contribute to a significant amount of morbidity and mortality.[26] Currently, large devices and nonsteerable delivery systems can cause iliofemoral injuries during insertion of the device at a rate of 5% to 17%.[27],[28] Lambrechts et al.[29] reported that access artery complications with rupture of the iliac artery occurred in two patients and were successfully managed by iliac-femoral bypass. Besides, it is well known that patients with BTAI could have other concomitant arterial diseases that may complicate or even exclude them from receiving endovascular stent-graft therapy.[30],[31] Several modalities were used including balloon angioplasty, endarterectomies, and the construction of extraluminal and endoluminal conduits to facilitate device navigation.[32] Moreover, the oversize rate of stent can exceeds 30% even with the smallest diameter in those young patients who often has increased tortuosity and smaller diameter of aortic arch increases the risk of the bird-beak configuration with a subsequent increased risk of endoleak and stent-graft collapse or migration, which lead to excessive radial force compression on the proximal normal aortic wall and limit stent release. In our series, no related complications were found in the treatment of our cases.


  Conclusions Top


Endovascular treatment of traumatic aortic dissection reduces the mortality rate of these patients who cannot tolerate traditional open surgery. According to our experience, patients who presented with simple pseudoaneurysm in enhanced computed tomography were more stable. Therefore, a postponed operation could be recommended after symptomatically hypotensive management. However, emergency surgery was necessary if patients presented with obviously mediastinal hematoma, especially progressive pleural effusion, which could result in hematoma rupture and death.

Limitations

Our retrospective and single-center study has important limitations that must be acknowledged. The main limitation of this study is the loss of follow-up, a large number of patients had gone aortic imaging in other centers. The relatively small number of patients and nonrandomized treatment are the other important shortcoming.

Ethics statement

The research reported has adhered to the relevant ethical guidelines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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