Journal of Vascular Surgery
Volume 45, Issue 3 , Pages 487-492, March 2007

Twenty consecutive cases of endograft repair of traumatic aortic disruption: Lessons learned

Presented at the Twentieth Annual Meeting of the Eastern Vascular Society, Washington, DC, Sept 28-30, 2006.

  • David G. Neschis, MD

      Affiliations

    • Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md
    • Corresponding Author InformationReprint requests: David G. Neschis, MD, Assistant Professor of Surgery, Division of Vascular Surgery, University of Maryland Medical Center, 22 S. Greene St, Room N4W66, Baltimore, MD 21201.
    • ,
  • Sina Moaine, MD

      Affiliations

    • Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Md
    • ,
  • Rao Gutta, MD

      Affiliations

    • Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md
    • ,
  • Kirk Charles, MD

      Affiliations

    • Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md
    • ,
  • Thomas M. Scalea, MD

      Affiliations

    • R. Adams Cowley Shock Trauma Center, Baltimore, Md.
    • ,
  • William R. Flinn, MD

      Affiliations

    • Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md
    • ,
  • Bartley P. Griffith, MD

      Affiliations

    • Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Md

Received 9 October 2006; accepted 15 November 2006. published online 26 January 2007.

Article Outline

Objectives

Endograft repair holds considerable promise in the treatment of traumatic disruption of the thoracic aorta because patients often have multiple coexisting injuries further complicating traditional open repair. In addition, patients are often young, with an aortic anatomy dissimilar to those with atherosclerotic aneurysms. As a result, techniques for endograft repair have to be refined accordingly.

Methods

The records of 20 consecutive cases of traumatic aortic disruption treated by endograft repair at a single institution were reviewed.

Results

Mean patient age was 40 years (range, 17 to 88 years), and 17 (85%) of 20 patients were men. All cases were completed. There were no procedure related deaths, but four (20%) patients died of their co-injuries. Only two (10%) of 20 required a graft >28 mm in diameter, and nine (45%) aortas were small enough to require use of 23-mm abdominal cuffs. Six (30%) of 20 cases required complete or partial coverage of the left subclavian artery. Placement of a proximal extension was required in one patient for a type I endoleak. A graft collapse occurred in one patient that required surgical removal and aortic repair.

Conclusions

Endovascular repair of traumatic aortic disruption can be accomplished in most cases. Compared with atherosclerotic aneurysms, the proximal thoracic aorta tends to be smaller and the arch angle tighter in an aorta 19mm in diameter. This frequently necessitates the use of smaller devices and less stiff wires. Surgeons should be prepared to cover the left subclavian artery if needed, have a wide range of device sizes in stock to avoid over-sizing, and show restraint if the anatomy appears unsuitable.

 

The development of endovascular techniques in the treatment of aortic pathology has clearly revolutionized the practice of vascular surgery. Since its first description by Parodi et al1 and others in 1991,2 technologic advances have allowed expansion of indications to beyond simple aneurysms of the infrarenal aorta. Few conditions lend themselves so ideally to endograft repair as traumatic disruption of the aorta. The anatomy is usually favorable, and patients who present with traumatic aortic disruption have usually sustained multiple injuries, including injuries of the chest wall, lungs, abdomen, and brain.3

The current status of traumatic aortic disruption and traditional repair is not ideal. Approximately 80% to 90% of patients die in the field.4, 5, 6 Of those who make it to the hospital, the overall mortality is about 32%, with an operative mortality of 0% to 54% and paraplegia rates of 0% to 36.4%.7

Numerous reports of successful endograft repair have been published.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 The number of cases in each study is relatively low, however, because of the relatively low numbers of annual cases treated by any particular institution. Fabian et al3 estimate that approximately 7500 to 8000 traumatic aortic disruptions occur in the United States annually and that about 1000 to 1500 patients arrive at the hospitals alive. It took 50 centers 2.5 years to generate 274 patients for this prospective report. This averages to just over two patients per year per center.3

The collective results of these preliminary studies are encouraging. Our review of the literature identified 23 reports that included five or more patients with acute traumatic dissection,8, 9, 10, 11, 12, 13, 14, 15, 16, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 35, 37, 38 for a total of 220 cases with 15 deaths (6.8%). However, most of these reports were likely limited by their selective nature and relatively small patient number. The largest series in this review was a multicenter retrospective study of 28 cases with 14% mortality, but it was limited by an unclear selection process and unknown denominator of total patients with traumatic aortic injury seen during the study period. Other studies with a relatively large total patient number were limited by inclusion of patients with chronic injury or other emergency pathology.13, 27, 33, 37 However, regardless of report size or design, to our knowledge, no reports have been made of endograft repair of blunt traumatic aortic injury complicated by postoperative paraplegia.

The current report describes our experience with 20 consecutive endograft procedures for repair of traumatic aortic injury. We believe it represents the largest single-center experience of endograft repair of acute traumatic aortic disruption published to date.

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Patients and methods 

All patients were initially admitted to the R. Adams Cowley Shock Trauma Hospital trauma resuscitation unit where initial treatment and diagnostic imaging were performed. With the exception of the first patient, treated in December 2004, all patients were treated consecutively between July 2005 and September 2006, and almost all patients who underwent intervention for blunt traumatic aortic injury during that time were included. Two patients underwent open repair primarily: one patient was unstable and the other had near complete lateral separation of the thoracic aorta. Both were discharged from the hospital alive.

All procedures were performed at the University of Maryland Medical Center, usually in our angiographic operating room suite with fixed imaging equipment (Toshiba Medical Systems, Tustin, Calif). One exception required treatment on a standard operating room table with a portable C-arm (OEC 9800, GE OEC Medical Systems, Salt Lake City, Utah). After the first case (D. G. N.), all procedures were performed by the same team, which consisted of a vascular surgeon (D. G. N.) and cardiac surgeon (B. P. G).

Preoperative computed tomography (CT) was available in all cases and used for device selection. Devices used included proximal and distal extension cuffs of the Zenith TX2 thoracic endograft device (Cook Inc, Bloomington, Ind) in one case and Gore abdominal aortic extension cuffs or TAG thoracic endograft devices (W.L. Gore and Associates, Flagstaff, Ariz) in the remaining cases, depending on the size of the native aorta proximal to the injury.

All cases were performed under general endotracheal anesthesia after life-threatening injuries were treated. The patients’ abdomen and groins were prepared in the supine position. A perfusion team was on standby, and the nursing staff was capable of assisting in both the endovascular procedure, or should the need arise, open aortic repair with mechanical perfusion.

The standard operative approach involved open cutdown of one common femoral artery, chosen on the basis of preoperative imaging and the extent and location of concomitant injuries. Percutaneous access was usually obtained through the contralateral common femoral artery for placement of a pigtail catheter for intraoperative imaging.

In one case involving a disruption at the level of the transverse aortic arch, the left common carotid artery was bypassed by using a graft off the ascending aorta performed through a median sternotomy. No other adjuvant access procedures, bypasses, or conduits were required in this series. No patient had a vascular injury that required extensive repair.

Before device insertion, all patients were systemically heparinized, usually with 5000 IU of heparin. If not available preoperatively, initial angiography was performed of the target and access vessels. On the planned access side, the initial access wire was exchanged to a stiff wire—either an Amplatz (Boston Scientific, Miami, Fla) or Lunderquist (Cook Inc)—for guidance of the selected device. The goal in planning device placement was to preserve the left subclavian artery origin whenever possible.

At the time of device deployment, the patient’s blood pressure was maintained at a mean of 70 mm Hg. Adenosine was used to produce temporary cardiac arrest during device deployment in eight patients in the later portion of our experience. The average dose was 18 mg, although doses as high as 30 mg were occasionally needed. The rational for the use of adenosine was somewhat arbitrary and included reasons such as hyperdynamic state and need for extra precision in device deployment. We have no standard protocol for adenosine use at this time.

After device deployment, balloon expansion was used on all 10 TAG cases, but not the other cases. Completion arteriograms were performed in all cases to confirm satisfactory device positioning and resolution of the pseudoaneurysm. In procedures in which abdominal cuffs were used, multiple cuffs were used in all cases. Introducer systems and sheaths were removed upon completion of device deployment, and access sites were repaired in standard fashion.

Postoperative CT with intravenous contrast and plain chest radiographs were obtained <5 days postoperatively. Routine follow-up surveillance includes a CT scan and chest radiography 6 months postoperatively and yearly thereafter.

Injury Severity Scores (ISS) and Revised Trauma Scores on Admission (RTS-A) were obtained on all patients. A normal ISS score is 0, with 75 the highest possible score. A normal RTS score is 7.84. Comparisons of trauma scores between groups were performed with a two-tailed t test.

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Results 

The mean age was 40 years (range, 17 to 88 years), and 17 (85%) of the 20 patients were men. All cases were completed without intraoperative death or complication. All devices were successfully delivered through a groin cutdown with no intraoperative conversions to an open procedure. Four patients died in the postoperative period for a 30-day mortality of 20%. There were no instances of paraplegia.

The mechanism of injury was motor vehicle crash in 15 patients, motorcycle crash in three, and fall in two. Twelve patients underwent endovascular repair <24 hours after injury. The average delay from injury to repair in the remaining eight patients was 4 days (range, 2 to 6 days).

The average intraoperative estimated blood loss was 174 mL (range, 50 to 400 mL). The left subclavian artery was spared in 14 patients, partially covered in four, and completely covered in two. There were no short-term or mid-term sequelae of subclavian artery coverage.

From an anatomic standpoint, the average proximal aortic diameter at the planned landing zone was 22.9 mm (range, 19 to 30 mm). The injury in one patient was located at the mid arch and required branch exclusion and placement of the graft proximal to the left common carotid artery. In the remaining 19 cases, the average distance from the left subclavian artery to the site of injury was 19.9 mm (range, 0 to 50 mm), and in 14 was ≥2 cm.

Three types of device were used. Proximal and distal Zenith TX2 thoracic endograft extension pieces were used in our first patient. Gore abdominal aortic extension cuffs were used for the repair in nine of the remaining patients, and Gore TAG thoracic endografts were used in 10. The mean graft diameter was 24.7 mm (range, 23 to 34 mm). For cases in which abdominal cuffs were used, two cuffs were required in three patients, three cuffs in five patients, and four cuffs in one patient. For cases in which TAG thoracic endografts were used, one device was required in six patients and two devices in four patients. The additional TAG device in these four patients was required to treat insufficient proximal landing zone or proximal endoleak. Average coverage length was 9 cm (range, 4.5 to 15 cm).

Postoperative imaging was available in 19 of 20 patients, and no endoleak was detected in 16. Of the remaining three, a small proximal endoleak was detected in one patient on postoperative day 3. This was expected to thrombose spontaneously, but care was withdrawn before follow-up studies. One patient had a proximal endoleak that was successfully treated with a device placed more proximally, with successful resolution on follow-up imaging. A type I endoleak developed with graft collapse in one patient that was successfully treated by open explantation and repair. The early endoleak rate, therefore, was 15.8% (3/19). No further leaks or device related complications occurred during an average follow-up of 5.4 months (range, 1 to 15 months). This includes eight patients with CT follow-up of ≥4 months. No patients had endoleak after discharge. Of the 16 survivors, 14 were discharged in good condition to acute or subacute rehabilitation facilities, and two were discharged to home. The average length of stay was 16.5 days. The average length of stay for the survivors was 19.1 days (range, 8 to 33 days).

The mean ISS was 41.1 and the mean RTS-A was 7.21. Mean ISS (P = .64) and RTS-A (P = .96) scores were 44 and 7.19 for nonsurvivors and 40.38 and 7.22 for survivors. In a comparison of patients delayed >24 hour vs those treated <24 hours, the mean ISS (P = .50) and RTS-A (P = .053) scores were 43.4 and 6.5 in the delay group and 39.6 and 7.7 in the nondelay group.

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Discussion 

Although endografting may provide a promising alternative to a far-from-ideal traditional approach, many questions still remain unanswered. These cases are not always straightforward. Currently available devices were not designed for use in young, otherwise healthy, small aortas. Blunt traumatic lesions are often near the extreme angulation of the aorta. Patients have often sustained multiple injuries, including head trauma, which create issues related to the use of systemic anticoagulation. Perhaps of most importance, the unknown long-term behavior of these devices will have the greatest impact on patients expected to live >60 more years.

Clearly, the aortas of young patients are significantly different compared with the population typically treated for aneurysmal disease. The young aorta tends to be more narrow and the turn radius of the aortic arch much tighter. In our experience, arterial size has not been a problem from an access standpoint. Although the access vessels may appear smaller on preoperative imaging or even on the initial cutdown, a component of reactive vasospasm is often present. In addition, the access vessels are generally otherwise healthy and free of calcification and stretch easily to admit the passage of relatively large sheaths. Fortunately, the largest available devices and corresponding sheaths are rarely required in treating transections.

We have found the turn radius in the arch of young patients to be too tight for the stiffer wires such as the Lunderquist. It simply cannot be bent to that degree without permanently kinking. In this setting, the Amplatz wire is sufficiently stiff for easy access, yet is pliable enough to not kink in a tight aortic arch. There is essentially no iliac or distal aortic tortuosity in these patients, making delivery of the device to the proximal aorta quite simple and extra-stiff wires unnecessary.

The small size of the aorta in young patients does create new dilemmas that are rarely an issue in patients with aneurysms. The aortic diameter in transection patients is often <20 mm in diameter (Fig 1). The smallest thoracic endograft currently available commercially in the United States is the 26-mm-diameter Gore TAG device. Attempts to place this device in aorta 23 mm in diameter can create a situation of significant oversizing and have been associated with numerous instances of device collapse.21

  • View full-size image.
  • Fig 1. 

    A, The predeployment angiogram of a 17-year-old boy with a 19-mm aorta demonstrates a traumatic aortic pseudoaneurysm. Use of a 26-mm TAG device would have caused significant oversizing. B, The completion angiogram after placement of three 23-mm Gore abdominal aortic cuffs demonstrates exclusion of the pseudoaneurysm and preserved patency of the left subclavian artery.

We have avoided the issue of oversizing with TAG devices by using Gore abdominal aortic cuffs in smaller aortas. These devices are fairly well suited for this purpose because they are on the longest delivery systems of the commercially available abdominal devices and have the shortest tip distal to the device, which is desirable when working at the aortic arch. All our cases in which the abdominal cuffs were used were successful and without endoleak or other complication.

One shortcoming of the abdominal cuffs is obviously their short length, requiring the use of multiple devices and creating the potential for device separation. This could be a particular problem in situations involving a large defect. Another issue with respect to the abdominal cuffs is the relatively short delivery system. To this point, we have been able to deliver the cuffs to the desired location through femoral access in all cases. However, access through the iliac arteries should allow delivery of an abdominal cuff to the distal aortic arch of most tall patients. We have found Gore abdominal cuffs to be an excellent tool in treating blunt aortic transection.

Oversizing is only part of the issue of thoracic endograft device collapse, however. Collapse without excessive oversizing has been reported,22 and our case of collapse also occurred without oversizing. Probably the more important factor related to device collapse is lack of device opposition to the aortic wall as it enters the horizontal portion of the aortic arch (Fig 2). Such malpositioning subjects the device to extreme tangential forces and causes collapse with a fair degree of predictability. Options for treatment of device collapse include explantation with open repair, as in our patient, or insertion of a second stent graft device or balloon-expandable stent within the collapsed device.21, 22 We would recommend particular attention in planning a treatment strategy in cases involving a transection at or very close to the left subclavian artery in a tightly curved aortic arch.

  • View full-size image.
  • Fig 2. 

    A, This preoperative computed tomography (CT) scan demonstrates aortic transection with pseudoaneurysm in a 23-year-old man with a 24-mm aorta. B, Completion angiogram after placement of a 26-mm TAG device. Note extension of device into lumen of aorta (arrow) with presence of endoleak (arrowhead). C, A CT scan on postoperative day 6 demonstrates collapse of the TAG device.

Another issue that arises during the endovascular treatment of aortic transection is whether to cover the left subclavian artery. It has become fairly well accepted that coverage of this vessel is usually safe, but is not without complication. Perhaps of more importance, however, is that coverage of the left subclavian artery brings the device into the transverse portion of the aortic arch. This subjects the devices to collapse, as just discussed, or it may provide a lip for blood to track under and create a proximal endoleak. It is our opinion and experience that the left subclavian artery does not need to be covered in most cases.

It is well documented that most aortic tears occur at the isthmus.6, 39 The tear in our series occurred an average of 19.9 mm from the origin of the left subclavian artery, with 14 of 20 tears being of ≥2 cm distance. In addition, it is likely that the previously normal aorta at the site of injury will heal over time. In short, the total length of fixation may not need to be as long as required for long-term satisfactory outcomes in the endograft repair of atherosclerotic aneurysms.

Obviously, answers to questions about the long-term behavior of these devices and the involved aorta will only be answered by careful long-term follow-up. A widely prevalent observation is that it is notoriously difficult to maintain close follow-up of trauma patients over time. A victim of penetrating trauma may have a number of reasons for not wanting to be easily found; however, this is not generally the case in patients with blunt aortic injury. In addition, vascular surgeons have well-established mechanisms for the long-term follow-up of their patients. We have not have had any difficulty maintaining contact will all of our surviving patients, although one patient did move to a distant state and arrangements were made for follow-up by a different vascular group.

Other unanswered questions involve timing of repair and anticoagulation with respect to the patient’s other injuries, particularly head trauma. Up to this point, we have been reluctant to avoid systemic anticoagulation during endografting procedures because of concerns of potential thromboembolic complications. In cases of head trauma, we have delayed treatment until anticoagulation was no longer contraindicated; this delay averaged about 4 days. Although trauma scores trended toward more severe injury in the group in whom repair was delayed >24 hours, the main reason for delay in this series was head injury and anticoagulation concerns. Our comfort with a selective delayed approach in stable patients who can tolerate judicious blood pressure control is based on reports of the safety of a delayed approach.40 With this protocol, six of the eight patients in our series with head injuries underwent a successful repair and were discharged from the hospital neurologically intact. One patient with massive head injury and a tear in the transverse aortic arch and one elderly patient with multiple other injuries and abdominal sepsis did not survive, however.

The reasons to consider an alternative approach are compelling. Although most authors of published reports used heparin routinely, excellent outcomes have been reported with selective use or even complete avoidance of anticoagulation.8, 29 Clearly, by not requiring systemic anticoagulation, patients with head injuries could be treated earlier, thereby simplifying blood pressure management issues.

Despite what appears to be a less invasive approach, the mortality in our series was a disappointing 20%. The four deaths were due to dysrhythmia in the setting of cardiac contusion, brain injury, intra-abdominal sepsis, and pulmonary embolism. Of interest was that trauma scores between survivors and nonsurvivors were similar, suggesting it would be difficult to predict outcome before aortic repair.

As with all other series we are aware of, the paraplegia rate in our experience was zero. This is likely due to the absence of aortic clamping and intraoperative hypotension and also to the location and relative short length of aorta covered.

As for the future, technologic advances will create endograft designs even more suitable for the treatment of traumatic aortic injury. Devices designed for this purpose will likely have a covered proximal aspect without flares. The proximal end will require more frequent, smaller articulations to better appose to the inner wall in the turn of the aortic arch. A broader range of diameters and lengths will be available. The ideal device would also allow for more precise placement and not be subject to the blood forces in the proximal aorta. Even more sophisticated devices may have a scallop at the outer curve and a covered flap designed to fully appose to the inner curve of the aorta.

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Conclusion 

We believe this report provides a relatively large experience to the growing body of literature about endograft repair of traumatic aortic transection. Although retrospective in design, the involvement of a single surgical team over a short period of time helps reduce confounding variables. With two exceptions, this series includes all transections treated at our institution during the stated time period and, therefore, essentially eliminates selection bias. Endovascular approaches to traumatic aortic injury hold great promise, particularly as improved devices become available and if long-term results remain excellent.

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Author contributions 


Conception and design: DN, SM

Analysis and interpretation: DN, WF

Data collection: DN, BG

Writing the article: DN, WF

Critical revision of the article: DN, TS

Final approval of the article: DN, BG

Statistical analysis: DN

Obtained funding: Not applicable

Overall responsibility: DN

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 Competition of interest: none.CME article

PII: S0741-5214(06)02091-X

doi:10.1016/j.jvs.2006.11.038

Journal of Vascular Surgery
Volume 45, Issue 3 , Pages 487-492, March 2007

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