Endovascular repair of Endovascular repair of traumatic aortic traumatic aortic

transection: transection: six years of experiencesix years of experience

Department of Cardiothoracic Surgery ¹, Department of Cardiothoracic Surgery ¹, Department of Cardiothoracic Anaesthesiology ², Department of Cardiothoracic Anaesthesiology ²,

““G. Papanikolaou” General Hospital, Thessaloniki, GreeceG. Papanikolaou” General Hospital, Thessaloniki, Greece. .

Eleftherios Chalvatzoulis ¹Eleftherios Chalvatzoulis ¹, Pavlos Papoulidis , Pavlos Papoulidis ¹¹, Olga Ananiadou , Olga Ananiadou ¹¹, , Elias Karfis Elias Karfis ¹¹, Harilaos Koutsogiannidis , Harilaos Koutsogiannidis ¹¹, Anastasia Apostolidou , Anastasia Apostolidou ²,²,

Angelos Megalopoulos Angelos Megalopoulos ¹¹, George Trellopoulos , George Trellopoulos ¹¹, , Konstantinos Papadopoulos Konstantinos Papadopoulos ²², ,

George Drossos George Drossos ¹¹

Traumatic aortic transectionTraumatic aortic transection

Traumatic aortic transection (TAT) is a potentially lethal Traumatic aortic transection (TAT) is a potentially lethal injury that is second only to head injury as the most injury that is second only to head injury as the most common cause of death following blunt trauma common cause of death following blunt trauma

Am J Surg 1986;152:660–663Am J Surg 1986;152:660–663

Road traffic accidents accounted for over 75% of cases of Road traffic accidents accounted for over 75% of cases of TAT TAT

Ann Thorac Surg 1994;57:726–730Ann Thorac Surg 1994;57:726–730

Multiple organ injuries are frequent in survivors of TAT. Multiple organ injuries are frequent in survivors of TAT. Survivors on average have two associated injuries Survivors on average have two associated injuries

Am J Surg 1986;152:660–663Am J Surg 1986;152:660–663

An out hospital mortality of An out hospital mortality of 85%85%Circulation 1958;17: 1086–1101Circulation 1958;17: 1086–1101

Location of injuryLocation of injury

Most common (80-90%): isthmus, Most common (80-90%): isthmus, just distal to the left subclavian just distal to the left subclavian artery artery – – among those who reach hospital among those who reach hospital alivealive

20-25%: aorta ascendens 20-25%: aorta ascendens – – in post mortem materials.in post mortem materials.

Few patients: descending thoracic Few patients: descending thoracic aorta, hiatus diaphragmaticus, aorta, hiatus diaphragmaticus, aortic arch.aortic arch.

Patel NH et al 1998.Patel NH et al 1998.

Mechanism of injuryMechanism of injury

combination of forces, combination of forces, (stretching, shearing, torsion)(stretching, shearing, torsion)

““waterhammer”effect waterhammer”effect (simultaneous occlusion of the (simultaneous occlusion of the aorta and a sudden elevation aorta and a sudden elevation in blood pressure)in blood pressure)

““osseous pinch” effect osseous pinch” effect (entrapment of the aorta (entrapment of the aorta between the anterior chest between the anterior chest wall and the vertebral column)wall and the vertebral column)N Engl J Med 2008;359:1708-16N Engl J Med 2008;359:1708-16..

Open surgical repair for Open surgical repair for TATTAT

Significant morbidity Significant morbidity

Mortality rates 8% to15%Mortality rates 8% to15%J Vasc Surg 2001; 34: 1029–1034J Vasc Surg 2001; 34: 1029–1034

Paraplegia rate 2.3% to 25.5%Paraplegia rate 2.3% to 25.5% Ann Thorac Surg 1999; 67:957-64Ann Thorac Surg 1999; 67:957-64

Ann Thorac Surg 1994; 58 :585-93Ann Thorac Surg 1994; 58 :585-93

12 patients12 patients

All maleAll male Mean age 28.9 Mean age 28.9 ± 8.38 years± 8.38 years Multiple injuries Multiple injuries Hemodynamically unstableHemodynamically unstable

Motor vehicle accident 9 ptsMotor vehicle accident 9 pts Fall from height 3 ptsFall from height 3 pts

Materials and MethodsMaterials and Methods

CT angiography

Digital subtraction angiography

Imaging and measurementsImaging and measurements

False aneurysm 8 ptsFalse aneurysm 8 pts Complete laceration 4 ptsComplete laceration 4 pts Distance between the lesion and the Distance between the lesion and the

ostium of the left subclavian artery ostium of the left subclavian artery (LSA): 24.8 ± 8.2 mm range 14 to 41 (LSA): 24.8 ± 8.2 mm range 14 to 41 mmmm

Proximal aortic neck diameter: Proximal aortic neck diameter: 24.7 ± 3.7 mm range 20 to 34 mm24.7 ± 3.7 mm range 20 to 34 mm

Five patients had an operation prior to endovascular procedureFive patients had an operation prior to endovascular procedure-three due to intraabdominal hemorrhage-three due to intraabdominal hemorrhage-two due to subdural haematoma-two due to subdural haematoma

Nine patients had orthopedic/vascular surgery after the stent Nine patients had orthopedic/vascular surgery after the stent placement.placement.

Injury managementInjury management

Endovascular techniqueEndovascular technique General anaesthesiaGeneral anaesthesia

Open cut down of the right common Open cut down of the right common femoral artery, insertion of J wires and 7 Fr femoral artery, insertion of J wires and 7 Fr arrow catheter into the thoracic aorta arrow catheter into the thoracic aorta

Left brachial artery sheath insertion of a J Left brachial artery sheath insertion of a J wire and arrow 6 Fr catheter to left wire and arrow 6 Fr catheter to left subclavian artery and aortic arch.subclavian artery and aortic arch.

Stent graft delivery system introduced Stent graft delivery system introduced under fluoroscopic control under fluoroscopic control

Stent graft position confirmed by digital Stent graft position confirmed by digital subtraction angiographysubtraction angiography

13 grafts13 grafts

TALENTTALENT 6 6 TAGTAG 77

diameter: diameter: 27.6 ± 3.2 mm27.6 ± 3.2 mm range 24 to 36 mm range 24 to 36 mm

length: length: 107.7 ± 18.8 mm 107.7 ± 18.8 mm range 100 to 150 mmrange 100 to 150 mm

oversizing:oversizing: 12.28% ± 5.32%12.28% ± 5.32% range 5.88% - 23.80%range 5.88% - 23.80%

Stent grafts Stent grafts detailsdetails

ResultsResults

Secure exclusion of the traumatic transectionSecure exclusion of the traumatic transection 100%100%

MortalityMortality 0%0%

ParaplegiaParaplegia 0%0%

Endoleak Endoleak 0%0%

LSA ostium LSA ostium Partly covered (2/12)Partly covered (2/12)Covered Covered (2/12) (2/12)

Stent collapseStent collapse

44thth postop day postop day Acute renal failure Acute renal failure Acute pulmonary oedemaAcute pulmonary oedema No pulse on femoral arteriesNo pulse on femoral arteries SBP gradient of 85 mmHg between upper/lower limbs SBP gradient of 85 mmHg between upper/lower limbs CT scan : proximal graft collapse CT scan : proximal graft collapse

ComplicationsComplications

Stent CollapseStent Collapse

Stent CollapseStent Collapse

Immediate reintervention Immediate reintervention

New instent placementNew instent placement

41.541.5 ± 22.4 months ± 22.4 months range 6 - 64 monthsrange 6 - 64 months

All patients alive no All patients alive no complicationscomplications

Follow upFollow up

699 pts with 699 pts with traumatic aortic transectionstraumatic aortic transections

endovascularendovascular 370 370 pts pts open surgicalopen surgical 329 329ptspts

MMortalityortality 7.6% 7.6% 15.2% 15.2% p=0.0076p=0.0076

ParaplegiaParaplegia 0% 0% 5.6% 5.6% p<0.0001p<0.0001

SStroketroke 0.85% 0.85% 5.3% 5.3% p=0.0028p=0.0028

J Vasc Surg 2008;47:671-5J Vasc Surg 2008;47:671-5

Endovascular versus open surgical Endovascular versus open surgical treatment of traumatic aortic treatment of traumatic aortic

transectionstransections

Marcheix et alMarcheix et al Tehrani et al Tehrani et al

33 pts33 pts 30 pts30 pts

Technical successTechnical success 91%91% 100%100% Stent graft related mortalityStent graft related mortality 0% 0% 7% (2/30) 7% (2/30) ParaplegiaParaplegia 0% 0% 0% 0% StrokeStroke 0% 0% 3% (1/30) 3% (1/30) EndoleakEndoleak 9% (3/33) 9% (3/33) 0% 0% Stent collapseStent collapse 0% 0% 3% (1/30) 3% (1/30)

J Thorac Cardiovasc Surg J Thorac Cardiovasc Surg Ann Thorac Surg Ann Thorac Surg 2006;132:1037-4 2006;82:873-72006;132:1037-4 2006;82:873-7

Endovascular treatment of Endovascular treatment of traumatic aortic transectionstraumatic aortic transections

Timing of repairTiming of repair Aortic related haemodynamic instability Aortic related haemodynamic instability

((massive mediastinal hematoma, active bleeding or left haemothorax)massive mediastinal hematoma, active bleeding or left haemothorax) ↓↓Emergency endovascular treatmentEmergency endovascular treatment

Non-aorta-related Haemodynamic Instability Non-aorta-related Haemodynamic Instability ↓↓Life-threatening injuries treated firstLife-threatening injuries treated first↓↓Endovascular treatment of the aortic injury within 24 hoursEndovascular treatment of the aortic injury within 24 hours

Stable patients, Stable patients, ↓↓Endovascular management within 24 hoursEndovascular management within 24 hours↓↓Contraindications ?Contraindications ?↓↓Conventional surgical managementConventional surgical management

J Thorac Cardiovasc Surg 2006;132:1037-4J Thorac Cardiovasc Surg 2006;132:1037-4

LimitationsLimitations vascular access and sizevascular access and size

small aortic diameter in young patients <19 mmsmall aortic diameter in young patients <19 mmexcessive oversizing,excessive oversizing, device collapsedevice collapse

sharp aortic arch angulation sharp aortic arch angulation device collapse, endoleakdevice collapse, endoleak

short proximal landing zone 15-20mm short proximal landing zone 15-20mm LSA ostium occlusionLSA ostium occlusion

durability of endovascular devicesdurability of endovascular devices

Endovascular vs Open SurgeryEndovascular vs Open Surgery

No thoracotomyNo thoracotomy No single lung ventilationNo single lung ventilation No CPBNo CPB No Aortic Cross ClampNo Aortic Cross Clamp No Systemic HeparinizationNo Systemic Heparinization Lower blood lossesLower blood losses Shorter operative timeShorter operative time

Safe and effective therapeutic method with low midterm Safe and effective therapeutic method with low midterm morbidity and mortality rates.morbidity and mortality rates. Close long-term follow-up is required Close long-term follow-up is required Technical improvements are required Technical improvements are required

(size and flexibility of devices)(size and flexibility of devices)

Should be the therapy of choiceShould be the therapy of choice

Endovascular treatment of traumatic Endovascular treatment of traumatic aortic transectionsaortic transections

Localization and IncidenceTransection Transection

Traumatic rupture of the aorta is Traumatic rupture of the aorta is usually fatal; only 10%-20% reach the usually fatal; only 10%-20% reach the hospital alivehospital alive

Of those reaching the hospital alive, an Of those reaching the hospital alive, an additional 5-10% die within a few hours additional 5-10% die within a few hours due to due to massive, multi-system injurymassive, multi-system injury

The appropriate treatment of the The appropriate treatment of the remaining 5- 10% remaining 5- 10% remains controversialremains controversial

Transection Transection Open Surgery• Mortality 5-25%• Paraplegia 9-19%

TransectionTransection 39 published case series (2001-39 published case series (2001-

2006)2006) 352 patients352 patients

30 d mortality = 11.2% (0-23.1)30 d mortality = 11.2% (0-23.1) Paraplegia = NoneParaplegia = None

Endovascular Repair

AVAILABLE DEVICESAVAILABLE DEVICES

Commercially Available GraftsCommercially Available Grafts

• GORE TAG• MEDRONIC TALENT (Valiant)• BOLTON RELAY • ZENITH XT2• ENDOMED ENDOFIT

• Variety of different technical properties and deployment techniques.

• Up to 10% oversizing and long overlapping (4-5 cm)

GORE TagGORE Tag

After 2001:• the 2 longitudinal nitinol

spines were removed. (due to fractures)

• The middle layers of the PTFE were reworked to add rigitidity and assist with tracking and delivery of device

Medtronic Talent Thoracic / Medtronic Talent Thoracic / ValiantValiant

Valiant Talent Valiant

Critical Issue (1) Critical Issue (1) Paraplegia after endovascular stent graftingParaplegia after endovascular stent grafting

Factors: Prevention and Factors: Prevention and Treatment: Treatment:

• Number of devices• Length of coverage >205 mm• Prior AAA• Hypotension (MAP <90)

• Preoperative imaging and identification of critical vessels• Cerebrospinal fluid drainage• Avoid perioperative hypotension

Critical Issue (3)Critical Issue (3)Endograft CollapseEndograft Collapse

• Out of 68 device compression reported to GORE, 72% occurred in patients with trauma related injuries

• 51/68 patients successful re- intervention confirmed

How to preventHow to prevent

Less oversizing in transection (2mm)Less oversizing in transection (2mm) Overstendting of LSAOverstendting of LSA Stent graft with better apposition in the inner curveStent graft with better apposition in the inner curve Stent graft with more radial forceStent graft with more radial force

Critical Issue (3a)Critical Issue (3a)Endograft CollapseEndograft Collapse