| | Blunt thoracic aortic injury: A single institution comparison of open and endovascular managementReceived 20 February 2007; accepted 31 May 2007. published online 31 August 2007. ObjectiveTo review the treatment of blunt thoracic aortic injuries (BAI) at a single institution over the past 12 years and compare pre-, peri-, and postoperative variables and outcomes of both open (OR) and thoracic endovascular (TEVAR) repair of these injuries. MethodsAll cases of confirmed BAI from 1994 to present were included in this retrospective review. Data collected included demographic data, injury severity score, Glasgow coma score, arrival hemodynamic variables, and associated injuries. Operative data included: type of procedure (OR or TEVAR), duration of procedure, need for and amount of blood transfused, use of anticoagulation, type of anesthesia, and service performing the procedure. Outcomes evaluated were: death, paraplegia, length of stay, days ventilated, and procedure related complications. Specific to EVAR; access, stent graft type and number, presence of endoleak and long-term clinical and radiologic follow-up were evaluated. ResultsThirty cases of blunt thoracic aortic injury were identified. Two patients received no treatment and died, 28 patients were treated (OR 16, TEVAR 12) and included for comparison. There were no significant differences between groups with respect to preoperative variables with the exception of significantly more associated intra-abdominal injuries in the TEVAR group (P = .03). Five patients in the OR group (31.2%) died in the perioperative period. There were no deaths in the TEVAR group (P =.05). One OR patient (6.25%) suffered postoperative paraplegia. No paraplegia occurred in the TEVAR group. Intraoperative variables were similar between groups with the exception of mean units of blood transfused (OR 8.5 units, vs TEVAR 0.2 units, P = .002). Ten patients in the OR group either died or had a procedure related complication compared with none in the TEVAR group (P = .001). There was no difference in length of stay or length of mechanical ventilation between the groups. There were no procedure or device related complications in the TEVAR group during follow-up (mean 15.3 months, range 1 to 53.5 months). ConclusionsEndovascular repair of BAI results in significantly less combined mortality and morbidity when compared to OR. Significantly less blood is needed intraoperatively in the TEVAR group. No complications from stent graft insertion have been observed during follow-up. Endovascular repair is replacing open repair as the treatment of choice for BAI at our institution. Acute thoracic aortic rupture or pseudoaneurysm formation as a result of blunt trauma is a serious and devastating consequence of deceleration trauma most commonly as a result of motor vehicle collisions and falls. It is the second most common cause of death from blunt trauma second only to major head injury.1 The majority of victims die at the scene with an 85% to 90% pre-hospital mortality.1, 2, 3, 4 The choice and timing of intervention for these often critically ill patients in the acute setting must be individualized. Definitive treatment is often delayed in these patients due to the need to manage multiple associated injuries. The risk of delaying treatment is the in hospital rupture rate of 10% to 13%.5, 6, 7 Rupture usually occurs within a few hours of admission 5, 6, 7 thus, requiring the treating physician to have appropriate treatment available in an expeditious manner. Approaches to these patients include careful monitoring and blood pressure control, open surgical repair, and more recently, endovascular repair of the blunt thoracic aortic injury (BAI). Open repair carries an 8% to 24% 5, 8, 9, 10, 11 risk of paraplegia and an operative mortality rate of up to 30% in published series.5, 6, 11 The potential benefits of thoracic endovascular aortic repair (TEVAR) over open repair include: no thoracotomy, no need for single lung ventilation, decreased use of systemic anticoagulation, avoidance of aortic cross clamping, less blood loss, less postoperative pain, and lower paraplegia rate. These factors could potentially result in improved overall survival and recent reports and case series from groups performing TEVAR demonstrate perioperative mortality rates of 0% to 20% and paraplegia rates of zero.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 At our institution we have been performing TEVAR to treat various lesions of the descending thoracic aorta since 1998, and in 2002, we started treating selected patients with BAI using endovascular stent grafts. The purpose of the present study was to review the management of BAI at our institution and evaluate the impact of TEVAR on perioperative morbidity and mortality. Methods  Case identification The management of all patients presenting to our institution with a diagnosis of BAI from 1994 to July 2006 was reviewed retrospectively. The Institutional Review Board Ethics Committees granted approval for this study. Patients were identified through searches of the medical records database, trauma database, and a prospectively created endovascular database. Inclusion criteria were all patients presenting with a confirmed diagnosis of BAI who underwent attempted repair, either open or endovascular, of their injury. Using our search methods, 44 cases were identified as thoracic aortic trauma from 1994 to November 2006. Sixteen cases were excluded from the comparative analysis. Reasons for exclusion were, 4 had penetrating injury, 3 were dead on arrival, 2 had suspected BAI at the time of admission but this was not confirmed on subsequent imaging, 2 patients had emergency room thoracotomies and died before any type of repair was possible, 1 patient had a left ventricular outflow injury, and 1 patient had a proximal ascending aortic lesion and therefore would not have been candidates for endovascular repair. One patient had an endovascular repair of a chronic pseudoaneurysm of the descending aorta caused by a remote trauma. Thirty patients were considered eligible for operative repair. Two patients had no intervention, one was very elderly and the family refused operative treatment, and the other was deemed to have an extremely poor neurologic prognosis and no treatment was offered. Both of these patients died in hospital. A total of 28 patients (16 open, 12 endo) remained eligible for comparative analysis. Data collection Preoperative variables collected included age, gender, date of injury and diagnosis, injury severity score (ISS), associated injuries, Glascow coma scale (GCS), preoperative hemodynamic variables (heart rate, blood pressure), arterial pH, creatinine, and blood transfusion. The times from admission to intervention and from diagnosis of BAI to intervention were also recorded. Operative variables recorded included: procedure performed, service performing the procedure (cardiothoracic or vascular surgery), duration of the procedure, aortic cross clamp duration, use of systemic heparinization, use of circulatory support, type of anesthesia, and intraoperative blood use. Specific to endovascular repair, the use of adenosine during stent deployment, the need for a conduit for endovascular access, the number and type of stent grafts used per patient, covering of the left subclavian artery and the need for extra-anatomic bypass were all recorded. Postoperative variables included: mortality, paraplegia, need for re-intervention, complications attributable to the procedure, duration of mechanical ventilation, and length of stay (intensive care unit [ICU] and total). For patients in the endovascular group only, the presence of an endoleak and the length of radiographic and clinical follow-up were recorded. Procedure description BAI was first treated by TEVAR in 2002 at our institution. Prior to this, all repairs were open repairs. Cases of BAI were referred to either the cardiothoracic surgery service or the vascular surgery service at the discretion of the treating trauma physician. As the trauma service became increasingly aware of the vascular surgeons’ ability and interest to treat BAI with TEVAR, there was an increase in consultation to the vascular surgery service for treatment of this pathology and thus a trend toward increased use of TEVAR. The use of endovascular stent grafts for BAI patients was possible due to special access to these devices granted by Health Canada at our institution. All endovascular procedures were performed in the operating room by the vascular surgery service using portable C-arm fluoroscopy (OEC 9800, GE medical Systems, Milwaukee, Wis). All repairs were done using the Talent (Medtronic, Santa Rosa, Calif) self-expanding thoracic endovascular stent grafts. The grafts were oversized by 10 % with respect to aortic diameter and ranged in size from 22 to 44 mm proximal diameters. The proximal configuration of the grafts was the bare stent. Access for graft delivery was either through the common femoral artery or an iliac artery via retroperitoneal exposure. A catheter used for angiography during graft deployment was placed percutaneously either through the contralateral femoral artery or the right brachial artery. Patients were anticoagulated with intravenous heparin during stent-graft deployment when there was no contraindication for anticoagulation. Follow-up post TEVAR was by serial CT scan with contrast, prior to discharge and every 6 months post discharge. Open procedures were all performed under general anesthetic by the cardiothoracic surgery service. A left posterolateral thoracotomy was used in all cases of open repair. The technique of repair was at the surgeon’s discretion and included interposition grafting and direct suture repair. The use of extracorporeal circulatory support was also at the discretion of the attending surgeon. Statistical analysis Statistical analysis was performed using StatView (Abacus Concepts, Berkley, Calif). The Mann-Whitney U test was used to analyze data with non-normal distribution of the variables. Normally distributed continuous variables were analyzed using the Student t-test. Nominal variables were compared using the Fischer exact test. A P value less than .05 was chosen to denote statistical significance. Results Over the 12 years of the study 28 patients were treated for BAI (range 0 to 6 per year, mean 2.33 per year). Prior to 2002, all patients (11 patients) were treated with open surgery, while from 2002 to 2006, 12 were treated with TEVAR and five with open surgery (Fig 1). There was no significant difference between the patients treated with TEVAR and those treated with open repair with respect to preoperative demographic and physiologic variables (Table I) or associated injuries (Fig 2) with the exception of the TEVAR group having more associated intra-abdominal injuries (TEVAR 75.0%, open 31.25%, P = .03). | | |  | Preoperative variable | Open (n = 16) | TEVAR (n = 12) | P value | |
|---|
| Mean age in years (+/−SD) | 42.9 (18.6) | 43.8(19.9) | 0.90 | | | Males (%) | 12(75) | 8(66.7) | 0.69 | | | Mean ISS score (+/−SD) | 45.8(18.2) | 37.9(12.6) | 0.28 | | | Mean GCS (+/−SD) | 11.1(4.5) | 13.1(3.9) | 0.26 | | | Mean heart rate (+/−SD) | 105.3(20.0) | 108.9(21.8) | 0.65 | | | Patients with Bp < 90 mm Hg systolic | 1 | 1 | 0.99 | | | Patients with preop blood transfusion (%) | 9(56.3) | 8(66.7) | 0.40 | | | Mean arterial pH (+/−SD) | 7.27(0.08) | 7.27(0.06) | 0.95 | | | Mean creatinine⁎ (+/−SD) | 102.2(21.8) | 93.1(30.7) | 0.38 | | | | |
The median time from arrival at the trauma center to aortic intervention was 14.7 hours (3.6 to 380.1 hours) in the TEVAR group and 7.0 hours (2.0 to 124.8 hours) in the open surgical group. (P = .29). For TEVAR patients, the diagnosis and graft sizing was made with CT scan in all patients (two patients also had preoperative angiography), while for OR patients 14 patients had diagnosis made on CT scan alone, one patient had CT and angiography, and two on angiography alone. The median time from diagnosis, defined as the time of diagnostic imaging test which confirmed the diagnosis to repair, was 8.1 hours (3.1 to 376 hours) in the TEVAR group and 4.5 hours (1.9 to 69.2 hours)in the open group (P = .04). All OR patients had their diagnostic study performed at the treating institution, only one of the 12 TEVAR patients was transferred to the trauma center with the diagnosis of BAI. All patients in the open group underwent repair under general anesthesia with single lung ventilation through a left posterolateral thoracotomy. Of those patients undergoing open repair, 15 had placement of an interposition graft and a single patient had simple suture repair of the site of injury. Thirteen patients underwent “clamp and sew” technique without circulatory support. Two patients underwent left heart bypass (left atrial to femoral vein bypass) and one patient, in extremis, underwent intentional circulatory and hypothermic arrest. Mean aortic cross clamp time was 41 minutes (9 to 163 minutes). Eleven of the 12 TEVAR procedures were performed under general anesthesia, while a single patient had a repair under spinal anesthesia. The indication for general anesthesia in this group was concomitant injury requiring endotracheal intubation. In the group of patients treated with TEVAR, all the procedures were successful with deployment of a single endograft, and there were no conversions to open repair. Specific technical details of the TEVAR procedures are presented in Table II. | ⁎ Adenosine was used selectively for Zone 2 deployments. †Talent thoracic endovascular stent graft (Medtronic, Santa Rosa, Calif). ‡No patient required extra-anatomic bypass as a result of covering of the origin of the left subclavian artery. §Zone of repair refers to the site of the proximal landing zone of the endograft. Zone 1, distal to the origin of the innominate artery; Zone 2, distal to left common carotid artery origin; Zone 3, distal to the left subclavian artery origin; Zone 4, greater than 2 cm distal to the origin of the left subclavian artery. |
Intraoperative variables for the two groups are summarized in Table III. The only statistically significant difference noted is the decreased need for intraoperative blood transfusion in the TEVAR group. | | | | Operative variable | Open N = 16 | TEVAR N = 12 | P value | |
|---|
| Mean duration of procedure in hours (+/−SD) | 2.9(1.5) | 2.2(0.8) | 0.14 | | | Mean Aortic cross clamp time⁎(range) | 41(9-163) | NA | | | | No of patients systemically heparinized (%) | 7(44) | 5(41.7) | 0.99 | | | Anesthesia type | 16 General | 11General 1Spinal | 0.43 | | | Mean no of units PRBC transfused (+/−SD) | 8.5(7.9) | 0.2(0.4) | 0.002 | | | | |
There were no deaths in the endovascular group and five (31.25%) deaths in the open group (P = .05) (Table IV). Three patients died in the operating room following surgical repair. One patient died within 12 hours of the procedure from severe lung injury, and the final patient died 25 days postoperatively following a cardiac arrest. One patient (6.25%) in the open group had lower limb paraplegia postoperatively. One patient (6.25%) in the open group was returned to the operating room for postoperative bleeding. No patients in the endovascular group required a vascular re-intervention. A combined end point of death or any complication related to the procedure, shows a statistically significant difference (62.5% open vs 0% endo, P = .001) favoring endovascular repair. The two groups were similar with respect to number of postoperative days requiring mechanical ventilation and the total number of ICU and hospital days. All TEVAR patients have had postprocedure CT follow-up exams, and the average length of clinical and/or radiologic follow-up time in the endovascular group was 15.3 months with a single patient having been followed for over 4 years. There have been no procedure related complications, including endoleak, migration, graft failure, or late death, during the follow-up period in the endovascular group. Discussion Disruption of the thoracic aorta as a result of sudden impact injury is a major cause of mortality in the trauma population. The standard treatment for most patients with BAI, who survive the initial injury to reach hospital and to diagnosis, has been open surgical repair. Recently, with the introduction of thoracic endovascular repair for differing thoracic aortic pathologies, TEVAR has been used to treat trauma patients with BAI. In our short experience with TEVAR for repair of these injuries at our institution, we have seen a low perioperative complication rate when compared to open repair. During the 12 years of this study, there were five deaths in the open group and none in the endovascular group despite the patients being well matched for preoperative variables. Four of the five deaths in the open group occurred during the era of endovascular repair. In our series, there were no procedure related complications in the endovascular group, however, procedure related complications of TEVAR for BAI have been previously reported in the literature. In the largest series of endovascular repair for BAI published to date, Tehrani et al24 reported that three of 30 patients had a complication related to the procedure. These included an iliac artery rupture, one cerebellar stroke and one case in which partial stent collapse was seen. Other reported complications as a direct result of endovascular repair of BAI include: endoleaks, stent fracture, the need for open conversion and stent migration.15, 18, 20, 21, 23, 24 In four patients with severe associated head or other injuries where systemic heparinization was contraindicated, we were able to perform TEVAR with local heparin saline flushes of the access arteries to prevent local thromboses due to the large bore deployment sheaths. In those patients who were not systemically heparinized during the endovascular procedure, there were no cases of embolic or thrombotic complications as a result. By avoiding systemic anticoagulation repair of BAI was not delayed for fear of increased bleeding from concomitant injuries while allowing for prompt repair of BAI eliminating the risk of late rupture. The results of other published series comparing TEVAR and open repair for treatment BAI are summarized in Table V.12, 13, 14, 15, 16, 17 Only four of these studies included a preoperative comparison between the groups which included the ISS. The mean time to repair was delayed beyond 24 hours in the majority of the endovascular procedures. Although these studies are heterogeneous with respect to the type of endovascular prosthesis, and the timing of intervention, all report better early outcomes following endovascular repair including decreased mortality in the TEVAR group in all six studies (Open mortality rate 9.1% to 50.0%, TEVAR mortality 0% to 20.0%). A single patient died as a direct result of endovascular repair as reported by Andrassy et al.15 In this patient, a stent fracture and collapse of the endoprosthesis caused acute aortic occlusion which was repaired with an open procedure, the patient, however, died as a result of severe reperfusion injury. This is the only death reported in the literature as a direct result of an endovascular complication for repair of BAI. | | | | Author (year) | Preop variables compared? | Group | N | Mean time to repair | Mortality (%) | Procedure related complications (count) | |
|---|
| Kasirajan et al. (2003) (12) | Noa | Open | 10 | 12.3hrs | 50.0 | None reported | | | Endo | 5 | 42hrs | 20.0 | None reported | | | Amabile et al. (2004) (17) | No | Open | 11 | 55.2hrs | 9.1 | RLN palsy (1), phrenic nerve palsy (1), hemopericardium (1) | | | Endo | 9 | 17.8days | 0.0 | None | | | Ott et al. (2004) (13) | Yes | Open | 12 | 48.9hrs | 17.0 | Paraplegia (2), RLN palsy (1) | | | Endo | 6 | 31.2hrs | 0.0 | None | | | Rousseau et al. (2005) (14) | Yes | Open | 35b | Seeb | 21.0c | Paraplegia (2), paraperesis (1) | | | Endo | 29d | 72days | 0 | Left main bronchus compression (1) | | | Andrassy et al. (2006) (15) | No | Open | 22e | NAe | 13.6 | RLN palsy (3), Paraplegia (2) | | | Endo | 24f | NAf | 8.3 | Endoleak (3), Conversion to open procedure (3) | | | Broux et al. (2006) (16) | Yes | Open | 17 | 15hrs | 23.0 | Neurologic (3), Aortic dissection (1), perioperative rupture (1), periprosthetic leak (1) | | | Endo | 13 | 17hrs | 15.0 | None | | | Present Study | Yes | Open | 16 | 8.4hrs | 31.2 | RLN palsy (1), phrenic nerve palsy (1), paraplegia (1), major bleed (1), wound infection (1), severe post-thoracotomy pain (1) | | | Endo | 12 | 46.1ghrs | 0 | None | | | Combined (range) | | Open | | | 23.6 (9.1-50) | | | | | Endo | | | 6.2 (0-20) | | | | | |
| a preoperative variables were compared. The TEVAR group had a higher ISS. b28 patients treated within 48 hrs, the remaining 7 were treated at an average of 66 days from diagnosis. cin the group undergoing repair within 48 hrs. d8 patients treated within 14 days of diagnosis. e16 acute, 6 elective (repair was remote from traumatic event), median time to repair in acute = 1 day. f15 acute, 9 elective (repair was remote from traumatic event), median time to repair in acute = 1 day. g72.7% treated within 24 hrs of diagnosis. |
Postoperative paraplegia due to spinal cord ischemia is a significant risk of repair of BAI. The etiology of this complication is multifactorial and includes spinal cord ischemia secondary to: interruption of intercostal blood, embolization, hypoperfusion of the spinal cord during aortic cross clamping, and spinal cord edema. In recent years, many techniques have been used to reduce the risk of paraplegia after surgery for lesions of the descending thoracic aorta including repair of post traumatic lesions. These adjuncts to surgery include the use of perioperative cerebrospinal fluid drainage, and lower body perfusion techniques such as the Gott shunt, left heart bypass techniques, and cardiopulmonary bypass. In a review of their 30 year experience with traumatic aortic rupture, Cardelli et al11 demonstrated that the incidence of paraplegia following open repair was significantly less with the use of lower body bypass support. In a large multicenter prospective trial on the treatment of BAI, both a clamp and sew technique and an aortic cross clamp time of greater than 30 minutes were associated with the development of postoperative paraplegia.5 The single patient in our series who experienced paraplegia as a result of open surgery was supported during the procedure with left heart bypass and lower body perfusion. In our small series, we did not have any cases of paraplegia in the TEVAR group. To our knowledge, no case of lower extremity paraplegia as a result of endovascular repair of BAI has been reported in the literature. There are certain criteria which must be met in order to offer endovascular repair for BAI. First, an endovascular surgeon or interventionalist who is able to perform endovascular thoracic aortic procedures must be available along with the appropriate interventional suite or operating room and support. Second, an appropriate endovascular stent graft device must be available. This can be a problem if the device is not “on the shelf” or available in an acceptable period of time. There appears to be decreased complications and re-interventions with industry supplied stent grafts when compared with homemade stent grafts. The third issue is that of anatomic suitability. In the present study, no patients were denied endovascular repair based on anatomical criteria. As our experience with endovascular procedures grows we are more aggressive with stent graft utilization in what may previously have been considered unsuitable anatomy. To extend the proximal landing zone, coverage of the left subclavian artery has not resulted in any complications or need for intervention in this series. For patients with external iliac arteries considered too small for sheath insertion (<8 mm), a temporary common iliac artery or aortic conduit can be used with a limited retroperitoneal approach. The trauma population is younger than the population of patients receiving TEVAR for aneurysmal or other pathologies. This younger population has a smaller aortic diameter compared with the aneurysmal population for which many of the commercially available endoprostheses were designed. In this series, we did not have any complications due to oversizing of the graft nor did we deny any patient TEVAR due to small aortic diameter. The development of smaller diameter devices with lower profile delivery systems would be of benefit in treating these patients and some day may allow for a total percutaneous approach. As with any new procedure, follow-up and long-term outcomes are important. In our small series, we demonstrate no mid-term complications as a result of this procedure with the longest follow-up of a single patient being 40 months. Lifelong follow-up surveillance is indicated for these patients to monitor for any potential device related complication and this may be difficult given the younger age of the trauma population. The pathology of BAI injury is different from the underlying atherosclerotic process seen in the majority of thoracic aortic aneurysm treated with endovascular devices and stent graft deployment in these non-diseased aortas is expected to stand the test of time. Further long-term follow-up is required. This study is limited by its retrospective nature and relatively small numbers. Despite these uncontrollable shortcomings, endovascular treatment of BAI has been demonstrated to be superior to open repair with respect to decreased mortality, decreased procedural complication and decreased need for operative blood transfusion. As a result of this review and previously published reports, at our institution, endovascular repair is being offered preferentially over open surgery in patients suffering BAI whenever possible. References 1. 1Smith RS, Chang FC. Traumatic rupture of the aorta: still a lethal injury. Am J Surg. 1986;152:660–663. MEDLINE |
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2. 2Parmley LF, Mattingly TW, Mariom WC, Jahnke EJ. Non-penetrating traumatic injury of the aorta. Circulation. 1958;17:1086–1101. MEDLINE 3. 3Williams JF, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicular trauma. Ann Thorac Surg. 1994;57:726–730. MEDLINE 4. 4Feczko JD, Lynch L, Pless JE, Clark MA, McClain J, Hawley DA. An autopsy case review of 124 non-penetrating (blunt) injuries of the aorta. J Trauma. 1992;33:846–849. MEDLINE 5. 5Fabian TC, Richardson DJ, Croce MA, Smith JS, Rodman G, et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma Injury Infect Crit Care. 1997;42:374–383. 6. 6Von Oppell UO, Dunne TT, DeGroot MK, Zilla P. Traumatic aortic rupture: twenty year meta analysis of mortality and risk of paraplegia. Ann Thorac Surg. 1994;58:585–593. MEDLINE 7. 7Gammie JS, Shah AS, Hattler BG, Kormos RL, Peitzman AB, Griffith BP, et al. Traumatic aortic rupture: diagnosis and management. Ann Thorac Surg. 1998;66:1295–1300. MEDLINE |
CrossRef
8. 8Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of the thoracic aorta caused by blunt trauma, a fifteen year experience. J Thorac Cardiovasc Surg. 1990;100:652–660. MEDLINE 9. 9Hunt JP, Baker CC, Lentz CW, Rutledge RR, Oller DW, et al. Thoracic aortic injuries: Management and outcomes of 144 patients. J Trauma. 1996;40:547–555. MEDLINE 10. 10Hilgenberg AD, Logan DL, Akins CW, Buckley MG, Daggett WM, Vlahakes GJ, et al. Blunt injuries of the thoracic aorta. Ann Thorac Surg. 1992;53:233–238. MEDLINE 11. 11Cardarelli MG, McLaughlin JS, Downing MD, Brown JM, Attar S, Griffith BP, et al. Management of traumatic aortic rupture: a 30-year experience. Ann Surg. 2002;236:465–470. MEDLINE |
CrossRef
12. 12Kasirajan 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;17:589–595. Abstract | Full Text |
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13. 13Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic: endovascular stents versus open repair. J Trauma Injury Infect Crit Care. 2004;56:565–570. 14. 14Rousseau H, Dambrin C, Marcheix B, Richeux L, Mazarolles M, Cron C, et al. Acute traumatic aortic rupture: a comparison of surgical and stent graft repair. J Thorac Cardiovasc Surg. 2005;129:1050–1055. Abstract | Full Text |
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15. 15Andrassy J, Weidenhagen R, Meimarakis G, Lauterjung L, Jaunch KW, Kopp R. Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta: a single-center experience. J Trauma Injury Infect Crit Care. 2006;60:765–772. 16. 16Broux C, Thony F, Chavanon O, Chevanon O, Bach V, Hacini R, et al. Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective case control study. Intensive Care Med. 2006;32:770–774. MEDLINE |
CrossRef
17. 17Amabile P, Collart F, Gariboldi V, Rollet G, Bartoli JM, Piquet P. Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg. 2004;40:873–879. Abstract | Full Text |
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18. 18Karmy-Jones R, Hoffer E, Meissner MH, Nicholls S, Mattos M. Endovascular stent grafts and aortic rupture: a case series. J Trauma Injury Infect Crit Care. 2003;55:805–810. 19. 19Thompson CS, Rodriguez JA, Ramaiah VG, DiMugno L, Shafique S, Olsen D, et al. Acute traumatic rupture of the thoracic aorta treated with endoluminal stent grafts. J Trauma Injury Infect Crit Care. 2002;52:1173–1177. 20. 20Neuhauser B, Czermak B, Jaschke W, Waldenberger P, Fraedrich G, Perkmann R. Stent-graft repair for acute traumatic thoracic aortic rupture. Am Surg. 2004;70:1039–1044. MEDLINE 21. 21Marty-Ane CH, Berthet JP, Branchereau P, Mary H, Alric P. Endovascular repair for acute traumatic rupture of the thoracic aorta. Ann Thorac Surg. 2003;75:1803–1807. MEDLINE |
CrossRef
22. 22Daenen G, Maleux G, Daenens K, Fourneau I, Nevelsteen A. Thoracic aorta endoprosthesis: the final countdown for open surgery after traumatic aortic rupture?. Ann Vasc Surg. 2003;17:185–191. Abstract | Full Text |
Full-Text PDF (617 KB)
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23. 23Wellons ED, Milner R, Solis M, Levitt A, Rosenthal D. Stent-graft repair of traumatic thoracic aortic disruptions. J Vasc Surg. 2004;40:1095–1100. Abstract | Full Text |
Full-Text PDF (184 KB)
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24. 24Tehrani HY, Peterson BG, Katariya K, Morasch MD, Stevens R, DiLuozzo G, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg. 2006;82:873–878.
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25. 25Dunham MB, Zygun D, Petrasek P, Kortbeek JB, Karmy-Jones R, Moore RD. Endovascular stent grafts for acute blunt aortic injury. J Trauma Injury Infect Crit Care. 2004;56:1173–1178. Division of Vascular Surgery, McGill University, Montreal, Quebec, Canada.  Correspondence: Oren K. Steinmetz, MD, Chief, Division of Vascular Surgery, McGill University, Royal Victoria Hospital, 687 Avenue des Pins Ouest, Montreal, Quebec, Canada, H3A 1A1.
Competition of interest: Oren K. Steinmetz, MD, has a consulting agreement with Medtronic of Canada as a clinical preceptor. PII: S0741-5214(07)00995-0 doi:10.1016/j.jvs.2007.05.061 © 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. | |
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