Thoracic Endovascular Aortic Repair for Traumatic Thoracic Aortic Injury: A Single-Center Initial Experience

Thoracic Endovascular Aortic Repair for Traumatic Thoracic Aortic Injury: A Single-Center Initial Experience

Thoracic Endovascular Aortic Repair for Traumatic Thoracic Aortic Injury: A Single-Center Initial Experience Jiang-gui Shan, Xin-ming Zhai, Ji-dong Li...

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Thoracic Endovascular Aortic Repair for Traumatic Thoracic Aortic Injury: A Single-Center Initial Experience Jiang-gui Shan, Xin-ming Zhai, Ji-dong Liu, Wen-gang Yang, and Song Xue, Shanghai, People’s Republic of China

Background: Several publications have documented the technical feasibility and efficacy of stent grafting for aortic injuries. We report short- and mid-term results of thoracic endovascular repair with covered stent grafts for type B blunt thoracic aortic injury. Methods: We performed a retrospective review of patients who had sustained blunt thoracic aortic injuries. From January 2010 to March 2014, 13 patients (12 men and 1 woman) were admitted and treated in our department for type B thoracic aortic injury. The patients’ ages ranged from 19 to 62 years. Traffic accidents were responsible for 10 of the 13 blunt thoracic aortic injuries, and the remainder was caused by blunt trauma from falls. Medical records were examined to identify the clinical outcomes of the procedures, and follow-up computed tomography scans were reviewed to document the efficacy of thoracic endovascular aortic repair. Results: Endovascular stent grafting was technically successful in all cases, and no paraplegia or stroke-like events were reported. No major cardiac, neurologic, or peripheral vascular complications were observed during early or late follow-up. None of the patients died from procedurerelated complications. Conclusions: Our single-center experience demonstrates the feasibility of performing endovascular repair for type B blunt aortic injury. As experience with endovascular surgery accumulates, this method of treatment promises to become the first-choice option for repairing this type of aortic injury, with less associated morbidity and mortality relative to conventional surgical repair.

INTRODUCTION An increasing number of patients with traumatic thoracic aortic injuries are being admitted to hospitals because of the proliferation of traffic accidents. Blunt thoracic aortic injuries are associated with a high mortality rate and have been implicated as

No funding was received from any source. The authors have nothing to disclose. Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China. Correspondence to: Song Xue, MD, PhD, Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, People’s Republic of China; E-mail: [email protected] Ann Vasc Surg 2016; 32: 104–110 http://dx.doi.org/10.1016/j.avsg.2015.09.023 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: April 28, 2015; manuscript accepted: September 18, 2015; published online: January 21, 2016.

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the second most common cause of death in trauma patients, behind intracranial hemorrhage. Moreover, these patients often have multiple coexisting trauma-related injuries. Blunt thoracic aortic injury (BTAI) secondary to blunt chest trauma is a common cause of death following vehicle collisions and other violent decelerations. Most BTAI patients are young and present with severe concomitant injuries. As conventional surgical repair may be dangerous in cases with severe associated injuries, thoracic endovascular aortic repair (TEVAR) has emerged as a promising alternative for treating traumatic thoracic aortic injury. Many studies have proven the safety and efficacy of this technique, particularly among patients at high operative risk. In this report, we evaluate the technical feasibility and early efficacy of performing endovascular treatment for type B blunt aortic injury, drawing on the experience gained by our department in treating both blunt aortic injury and difficult aortic aneurysms.

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METHODS

Stent-Graft Procedure

Patients

TEVAR for exclusion of the BTAIs was elected based on patients’ overall condition and comorbidities. All patients were treated within 7e14 days of diagnosis with BTAI. The aortic neck diameter was measured via CT scan proximal and distal to the zone of trauma. All manipulations were performed in a fully equipped angiography room with the patient under general anesthesia. The common femoral artery was surgically exposed and controlled proximally and distally. Heparin (100 IU/kg) was administered in each case. All patients underwent arch aortography with a marker catheter, which was performed in the angiography room by a cardiovascular surgeon, to determine the distance from the left subclavian artery and the length of the traumatized descending thoracic aorta before endovascular repair. Three different stent-graft devices were used for the procedures: Talent (Medtronic, Minneapolis, MN), Hercules (Microport, Shanghai, China), and Grikin (Grikin, Beijing, China). TEVAR procedures were performed as follows. A hydrophilic guide wire was advanced to track the iliac axis. A guiding catheter was inserted over the wire, up to the ascending aorta. A 22F or 24F EndoFit hydrophilic introducer sheath with a tapered dilator was inserted over the stiff wire up to the deployment site or above it. A series of aortograms was used during deployment to ensure accurate proximal and distal positioning. The proximal bare stent was placed precisely above the orifice of the left subclavian artery to allow free blood flow through the vessel. In 3 patients with dominant right vertebral arteries, the left subclavian artery was covered to ensure adequate graft fixation. During endovascular graft deployment, controlled systemic hypotension (80e100 mm Hg) was induced by administering a fast-acting vasodilator (nitroglycerin). Graft oversizing of 10e15% was applied to secure fixation. If the diameter of the thoracic descending aorta was less than 18 mm, a bare stent was placed in the descending aorta before endovascular grafting to restrict overexpansion of the graft. After the stent graft was released, intraoperative angiography was performed to verify complete exclusion of the transection and correct perfusion through the graft without leakage. The placement system was then removed and the femoral arteriotomy was closed with 5-0 Prolene.

From January 2010 to March 2014, 13 patients (12 men and 1 woman) were admitted for injuries resulting from traffic accidents or falls and were treated in our department for type B traumatic aortic injury. The patients ranged in age from 19 to 62 years. This study was conducted in accordance with the Declaration of Helsinki as well as relevant policies in China, and it was approved by the Ethics Committee of Shanghai Chest Hospital. Traffic accidents were responsible for 10 of the 13 blunt thoracic aortic injuries; the remaining 3 were caused by blunt trauma from falls. The extent of these patients’ aortic injuries was classified as follows: Grade I (intimal tear), 84.6% (11/13); Grade II (intramural hematoma), 0% (0/13); Grade III (aortic pseudoaneurysm), 15.4% (2/13); and Grade IV (free rupture), 0% (0/13). Patients’ characteristics and features of TEVAR of the BTAIs are summarized in Table I. All patients presented with pleural effusion or severe concomitant injuries, such as thoracic trauma, rib fractures, pubic fractures, pulmonary contusions, and ankle fractures. Contrast-enhanced spiral computed tomography (CT) (64-channel) (GE LightSpeed VCT) with multiplanar reconstruction was used to confirm suspected diagnoses and provided all the data necessary for formulating the treatment plan (Figs. 1e3). Initial Management Upon admission, all patients underwent a physical examination and laboratory testing. For stable patients in whom the diagnosis was suspected (typically based on plain radiographs or CT findings), contrast-enhanced CT was used to obtain a definitive diagnosis. Whole-body CT angiography (CTA) was performed in all cases to define the aortic lesion and detect potential concomitant injuries. Initial management consisted of controlling patients’ blood pressure with analgesics (if hypertension was related to injuries) and hypotensive drugs. The goal has often been stated as ‘‘a systolic blood pressure less than 120 mm Hg.’’1 This control should be maintained until definitive therapy is performed. Clinicians should be mindful that, in the majority of hypertensive BTAI patients, the predominant cause is associated injuries, which should take priority. In this study, patients with concomitant injuries were treated by relevant specialist physicians.

Follow-up Follow-up comprised contrast-enhanced spiral CT scans of the chest, abdomen, and pelvis. Follow-up

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Table I. Thoracic endovascular aortic repair of blunt aortic injury Patient no.

Age (years)

Sex

Mechanism of injury

Associated injury

Time to repair (days)

Device

Complications

Survival on follow-up

1

19

M

Traffic accident

Fracture of pubis

13

Grikin

Occluded left subclavian artery

33 months; alive

2 3

30 44

M M

Traffic accident Traffic accident

8 14

Wallstent Hercules Talent

None None

28 months; alive 41 months; alive

4

36

M

Traffic accident

e

e

Died before repair

e

5

20

M

Traffic accident

Rib fracture Rib fracture Pulmonary contusion Ankle fracture Pulmonary contusion Pleural effusion Rib fracture

10

None

56 months; alive

6 7

37 45

M F

Fall Fall

Fracture of pubis Fracture of pubis

7 10

Grikin Wallstent Hercules Talent

None Occluded left subclavian artery

50 months; alive 22 months; alive

8 9

26 62

M M

Traffic accident Fall

Pulmonary contusion Rib fracture Fracture of pubis

14 12

Grikin Hercules

16 months; alive 18 months; alive

10 11

33 35

M M

Traffic accident Traffic accident

13 14

Hercules Hercules

None Occluded left subclavian artery None None

6 months; alive 20 months; alive

12 13

42 36

M M

Traffic accident Traffic accident

12 10

Talent Hercules

None None

40 months; alive 14 months; alive Annals of Vascular Surgery

M, male.

Rib fracture Rib fracture Fracture of pubis Pulmonary contusion Femoral fracture Pulmonary contusion Pleural effusion

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Fig. 1. Blunt thoracic aortic injury before repair (cross section).

Fig. 2. Blunt thoracic aortic injury before repair (vertical plane).

CTA scans were obtained 3, 6, and 12 months after the procedures and were scheduled annually thereafter, with the goal of monitoring changes in the aorta and stent graft. Early mortality and morbidity included events occurring within 30 days after stent-graft deployment. Patientrelated information was obtained by contacting patients. Adherence to follow-up (range 6e 56 months) was 100%.

RESULTS Treatment using endovascular stent grafting was technically successful in all cases of BTAI. One of the 13 patients with concomitant thoracic injuries died before TEVAR from aortic rupture. None of the procedures were performed emergently, thereby allowing time for appropriate measurement of the endovascular stents. The time until

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Fig. 3. Blunt thoracic aortic injury before repair (three-dimensional reconstruction).

intervention ranged from 7 to 14 days (median 10 days). During this period, all patients were maintained on hypotensive drugs to maintain systolic blood pressure below 120 mm Hg. All patients remained hemodynamically stable from the time of injury until stent-graft intervention. Thirtythree percent (4/12) of the BTAI patients underwent orthopedic surgeries after endovascular stent repair without obvious influence on the injured aorta. The left subclavian artery had to be occluded in 3 cases to ensure adequate graft fixation. No intraoperative strokes or other major complications occurred. None of the procedures were converted to open repair. Three patients received a Talent stent graft, 6 patients a Hercules, and 3 patients a Grikin. Device selection was based on patients’ vascular anatomy and course, anddin some casesdthe type of aortic lesion. In 3 patients with descending aortas less than 18 mm in diameter, a Wallstent (Boston Scientific; Marlborough, MA) bare stent was used as scaffolding, followed by placement of a covered endovascular stent. All patients remained hospitalized in the cardiovascular surgery ward until TEVAR was completed and their general condition was stable. The patients were assessed for the first time 3 months postprocedure by CTA scans of the entire aorta. At this time, the lesions had been successfully excluded without signs of endoleak or other graft-related complications (such as stent-graft collapse) in all patients; the para-aortic hematomas had reduced in size. The median follow-up duration was 24 months (range 6e56 months). No paraplegia or stroke-like

events were reported. No major cardiac, neurologic, or peripheral vascular complications were observed during early or late follow-up. None of the patients died as a result of procedure-related complications (Figs. 4 and 5).

DISCUSSION BTAI proves fatal in the vast majority of patients before they reach the hospital. It has been reported that up to 40% of survivors die within the first 24 hr because most BTAIs rupture.2 Mortality rates are reported to be as high as 90% if these injuries are left untreated.3 Therefore, diagnosis should be rapid (typically based on a high index of suspicion) in cases with major deceleration injuries. The primary etiology of BTAI is rapid acceleration and deceleration. Described trauma mechanisms include shear forces applied at the ligamentum arteriosum, acute compression by the diaphragm, torsion of the aorta, acute intravascular hypertension, and compression of the aorta between the sternum and the spine.4 Because of the nature of the original shearing force and the aortic anatomy, BTAI mainly occurs in the aortic isthmus (as in our patients). This injury has traditionally been treated with early open surgical repair,5 which may be limited by the fact that most patients present with multiple comorbidities. For example, lung contusions make single-lung ventilation intolerable. Endovascular repair, which was first used for treating thoracic

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Fig. 4. Blunt thoracic aortic injury after repair (three-dimensional reconstruction).

Fig. 5. Blunt thoracic aortic injury after repair (cross section).

aortic aneurysms by the Stanford group,6 can now be applied to other pathologic conditions of the thoracic aorta.7 Several reports describing the successful endovascular treatment of BTAI have been published.8e10 Endovascular repair is particularly attractive for managing patients whose associated injuries or comorbidities put them at greater risk for open repair.11 Its main advantages are a shorter procedure time and lower operative risk. It should also be noted that treatment with endovascular grafts

need not be definitive and can be used as a bridge to subsequent procedures. In patients not affected by other life-threatening injuries that take precedence, endovascular repair should be performed before other surgical treatments to eliminate the risk of sudden aortic rupture. Results of a metaanalysis comparing 30-day outcomes between 278 aortic ruptures managed surgically and 355 managed by endovascular means showed no significant differences in injury severity or age between the groups.12 The endovascular group showed

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significantly lower mortality (7.6% vs. 15.2% for surgical repairs, P ¼ 0.008) and rates of paraplegia (0% vs. 5.5%, P < 0.0001) and stroke (0.81% vs. 5.1%, P ¼ 0.003) compared with the open surgical repair cohort. However, there are some difficulties associated with TEVAR that may limit the feasibility of this technique. The size of the devices remains large (a 22e24F delivery sheath), and access other than the common femoral artery is often required. A short proximal landing zone is also a common problem. In our series, detailed CT evaluation was performed to determine the distance between the left subclavian artery and the beginning of the aortic transection as well as the size of the normal aorta. If it was determined that a secure landing zone for the stent graft was present, the patient was scheduled for endovascular repair. Nevertheless, in 3 of the patients it was necessary for the installed stent graft to obstruct the left subclavian artery to achieve a more secure landing zone. Careful patient and device selection, as well as experience with this technique, may substantially improve the outcome of stent-graft treatment. Preoperative evaluation of the anatomy and diameter of the bilateral iliac and femoral arteries is also critical in planning for access and graft progression. During the procedure, a stent graft 10e15% larger than the diameter of the normal aortic segment should be selected. Although great successes have been achieved with endovascular stent grafting and no complications resulted from TEVAR in our study, potential complications include endoleak, stent collapse, stroke, retrograde dissection, migration, and paralysis.4 According to several reports in the literature, delay or complete avoidance of repair is indicated in patients with severe head or pulmonary injuries, among others.13 Careful blood pressure control plays a central role in the nonoperative management of stable patients with BTAI. Indeed, the use of antihypertensive and rate-controlling agents to prevent transection extension during treatment delays in stable BTAI patients is considered by some to represent the standard of care.14 In our series, all patients were treated within 7e14 days of BTAI diagnosis. Our study is limited by its retrospective nature and the small number of patients. In general, selection bias undoubtedly occurs in the patient population that survives while hospitalized, which typically represents the group of patients able to wait many days for BTAI repair.

Annals of Vascular Surgery

CONCLUSION Our single-center experience demonstrates the feasibility of performing endovascular repair for type B blunt aortic injury. We believe that as experience with endovascular surgery accumulates, this method of treatment will become the first-choice option for repairing this type of thoracic aortic injury, with less associated morbidity and mortality relative to conventional surgical repair.

REFERENCES 1. Karmy-Jones R, Jackson N, Long W, et al. Current management of traumatic rupture of the descending thoracic aorta. Curr Cardiol Rev 2009;5:187e95. 2. Lettinga-van de Poll T, Schurink GW, De Haan MW, et al. Endovascular treatment of traumatic rupture of the thoracic aorta. Br J Surg 2007;94:525e33. 3. Cardarelli MG, McLaughlin JS, Downing SW, et al. Management of traumatic aortic rupture: a 30-year experience. Ann Surg 2002;236:465e9. discussion 469e70. 4. Nishimoto M, Fukumoto H, Nishimoto Y, et al. Surgical treatment of traumatic thoracic aorta rupture: a 7-year experience. Jpn J Thorac Cardiovasc Surg 2003;51:138e43. 5. Xenos ES, Abedi NN, Davenport DL, et al. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008;48:1343e51. 6. Kato N, Hirano T, Shimono T, et al. Treatment of chronic aortic dissection by transluminal endovascular stent-graft placement: preliminary results. J Vasc Interv Radiol 2001;12:835e40. 7. Dake MD. Endovascular stent-graft management of thoracic aortic diseases. Eur J Radiol 2001;39:42e9. 8. Reed AB, Thompson JK, Crafton CJ, et al. Timing of endovascular repair of blunt traumatic thoracic aortic transections. J Vasc Surg 2006;43:684e8. 9. Bortone AS, Schena S, D’Agostino D, et al. Immediate versus delayed endovascular treatment of post-traumatic aortic pseudoaneurysms and type B dissections: retrospective analysis and premises to the upcoming European trial. Circulation 2002;106:I234e40. 10. Jang MO, Kim JH, Oh SK, et al. Endovascular stent in traumatic thoracic aortic dissection. Korean Circ J 2012;42: 341e4. 11. Kasirajan K, Heffernan D, Langsfeld M. Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management. Ann Vasc Surg 2003;17:589e95. 12. Tang GL, Tehrani HY, Usman A, et al. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. J Vasc Surg 2008;47: 671e5. 13. Duwayri Y, Abbas J, Cerilli G, et al. Outcome after thoracic aortic injury: experience in a level-1 trauma center. Ann Vasc Surg 2008;22:309e13. 14. Nienaber CA, Divchev D, Palisch H, et al. Early and late management of type B aortic dissection. Heart 2014;100: 1491e7.