justin chan princess margaret hospital july 27, 2013 blunt thoracic aortic injury
TRANSCRIPT
JUSTIN CHANPRINCESS MARGARET HOSPITAL
JULY 27, 2013
Blunt Thoracic Aortic Injury
Case Illustration
74/F
Good past health
RTA victim Back passenger of minibus Hit over left side by another car
Case Illustration
Trauma series CT Acute traumatic aortic injury at aortic isthmus 4.2cm intimal flap along descending thoracic aorta No mediastinal hematoma
Multiple rib fractures Pelvic fracture with left pelvic hematoma and active
contrast extravasation Blunt liver trauma with intraparenchymal hematoma
CT images
Case Illustration
Pelvic fracture with hematoma Angiogram: bleeding from branches of left internal
iliac artery Embolisation performed Pelvic fracture: minimal displacement conservative
Fractured ribs + liver hematoma Conservative
TEVAR Stenting of aortic dissection and left subclavian artery
Post-op CT Images
Blunt Thoracic Aortic Injuries
Incidence
Pathology/Pathogenesis
Management options
Issues unsolved
Conclusion
Incidence
Traumatic aortic injuries 2nd commonest cause of death due to blunt trauma
Autopsy series of blunt trauma patients Aortic rupture rates: 12%-23%
Autopsy study by Parmley et al. ~80% of patients die before arrival to hospital
1. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA et al (1997) Prospective study of blunt aortic injury: multicenter trial of the American Association for the surgery of trauma. J Trauma 42(3): 374-380; discussion 380-383
2. Schumacher H, Bockler D, von Tengg-Kobligk H, Allenberg JR (2006) Acute traumatic aortic tear: open versus stent-graft repair. Semin Vasc Surg 19(1):48-59
3. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086-1101
Incidence
Remained the same ~ past 12 years
Strongly correlated with Sudden change in velocity
Impact on patient’s side of car ~85% of thoracic aortic injury was due to side impact in
one study
Intrusion of vehicular wall into passenger compartment 1. Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J (2007)
Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 62(3):664–6672. Horton TG, Cohn SM, Heid MP, Augenstein JS, Bowen JC, McKenney MG et al (2000) Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma 48(6):1008–1013; discussion 1013–1014
Classification
Parmley (1958) Pathological features from autopsies
Grade Pathology
1 Intimal haemorrhage
2 Intimal hemorrhage plus intimal laceration
3 Laceration into the aortic media
4 Complete aortic laceration (transection)
5 Pseudoaneurysm
6 Complete aortic laceration with active hemorrhage
Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086-1101
Classification
Arizzadeh CT imaging
1. Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010
2. Arizzadeh A, Keyhani K, Miller CC III, Coogan SM, Safi HJ, Esttrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009;49:1403-8.
Pathology
Confined to specific locations
Classical site Isthmus of aorta
Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad . 2010
Sites of Injury
- Isthmus - (IIC – 70-90%)
- Ascending aorta/proximal arch - (I to IIB – 10-15%)
- Mid-descending aorta - (IIIA to IIIB – 5-10%)
Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad . 2010
Postulated Mechanisms
Shear and stretching forces Relative mobility of portion of vessel adjacent to a fixed
portion
Osseous pinch Compression of vessel between bony structures
‘Water-hammer’ effect Profound intraluminal hypertension during severe
trauma
Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad . 2010
Blunt Aortic Injury. N Engl J Med 2008. 359: 1708-16
Pathogenesis
Most likely: mixed mechanism
Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 2010
Management
Timing of operation Immediate Urgent (<24hrs) Delayed
Type of repair Open Endovascular
Timing of Operation
Hemodynamically unstable Mortality >90% Immediate surgery
Hemodynamically stable
Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 2010
Immediate Surgery
Standard surgical practice for many decades
Parmley: 30% who reach the hospital die within first 6 hours
Meta-analysis by Von Oppell et al: Death rate: hemodynamically stable patients ~21.3%
(0-54.2%) Majority of deaths: associated injuries to other organs
1. Parmley LF, Marian WC: Non-penetrating traumatic injury of the aorta. Circulation 17:1086-1100, 19582. Von Oppell UO, Dunne TT, De Groot MK, et al: Traumatic aortic rupture: Twenty-year metaanalysis of mortality and
risk of paraplegia. Ann Thorac Surg 58:585-595, 1994
Delayed Surgery
Prospective study by Fabian et al Delaying surgical repair plus maintaining blood pressure In-hospital free rupture Mortality
2 studies by Hemmila et al and Pacini et al No difference in mortality between urgent and delayed
repair
Risk: Aortic rupture ~ 2-5% of patients Most within 1st week after trauma
1. Pate JW, Fabian TC, Walker W (1995) Traumatic rupture of the aortic isthmus: an emergency? World J Surg 19(1):119–125; discussion 125–1262. Fabian TC, Davis KA, Gavant ML, Croce MA, Melton SM, Patton JH Jr et al (1998) Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg
227(5):666–676; discussion 676–6773. Holmes JH, Bloch RD, Hall RA, Carter YM, Karmy-Jones RC (2002) Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis. Ann Thorac Surg 73(4):1149–11544. Hemmila MR, Arbabi S, Rowe SA, Brandt MM, Wang SC, Taheri PA, et al. Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair? J Trauma 2004;56:13-23. 5. Pacini D, Angeli E, Fattori R, Lovato L, Rocchi G, Di Marco L, et al. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005;129:880-4.
Current Recommendations
Urgent (<24 hours) repair Except: other serious concomitant non-aortic injuries
or
After other injuries have been treated but prior to hospital discharge
Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010
Current Recommendations
Consider delayed repair in patients with
Respiratory insufficiency due to lung contusion
Head injury with abnormal CT showing haemorhage or edema
Coagulopathy
Severe abdominal solid organ injury and pelvic fractures
Cardiac risk factors/blunt cardiac injury
Multiple medical co-morbidities1. Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 20102. Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical
considerations. Sem Int Rad . 2010
Surgical Approach
Open
Endovascular
Open Surgery
Conventional treatment of choice
Surgical technique Left-sided posterolateral thoracotomy Proximal and distal control of proximal descending
aorta Direct aortic suture or Tube-graft interposition with clamp-and-sew
technique
Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 2010
Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 2010
Open Surgery: Drawbacks
M0rtality rate 28%
Paraplegia rate 16%
Need for thoracotomy and one-lung ventilation
Aortic cross clamping intracranial pressure Hazardous in patients with head injuries
1. Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma. A 15-year experience. J Thoracic Cardiovas Surg 1990; 100:652-60.
2. Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 56:565-70.
TEVAR - Thoracic Endovascular Aortic Repair
Began in United States in 1994
Dake and colleagues 1997 10 patients with traumatic lesions of thoracic aorta
1. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–1734
2. Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology 1997;205:657–662
TEVAR - Thoracic Endovascular Aortic Repair
Preprocedure Imaging Multislice computed tomography
Access Open approach to access iliac vessels (≤8 mm in
diameter) Consider percutaneous approach
Where iliofemoral system is very adequate for endograft access
1. Peterson BG, Matsumura JS, Morasch MD, West MA, Eskandari MK. Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005;59:1062–1065
2. Tehrani HY, Peterson BG, Katariya K, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006;82: 873–877; discussion 877–87
TEVAR - Thoracic Endovascular Aortic Repair
Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS (2001) Traumatic rupture of the thoracic aorta: Cohort study and systematic review. J Vasc Surg 34(6):1029–1034
Published in January 2011
Systematic review: 7768 patients from 139 studies
Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010
TEVAR vs Open
TEVAR Mortality
9% VS 19% (p<0.01) Non-operative management 46%
Spinal cord ischemia 3% VS 9% (p=0.01)
Open repair Graft infection
Systemic infections Pneumonia mostly
Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010
TEVAR: Drawbacks
Designed for use in degenerative disease
Most traumatic injuries occur in younger patients Existing graft diameters may not be appropriate for smaller
aortas
Lack of long-term results Material failures such as stent fractures and fabric fatigue
may become more significant during ensuing decades of follow up
Conclusions
Overall morbidity and mortality in recent years Both open and endovascular repair for blunt aortic
injury
Timing of Surgery Urgent repair (<24 hrs)
Endovascular repair is superior to open repair In terms of operative mortality and complication rate
Thank you
References
1. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA et al (1997) Prospective study of blunt aortic injury: multicenter trial of the American Association for the surgery of trauma. J Trauma 42(3): 374-380; discussion 380-383
2. Schumacher H, Bockler D, von Tengg-Kobligk H, Allenberg JR (2006) Acute traumatic aortic tear: open versus stent-graft repair. Semin Vasc Surg 19(1):48-59
3. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086-1101
4. Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J (2007) Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 62(3):664–667
5. Horton TG, Cohn SM, Heid MP, Augenstein JS, Bowen JC, McKenney MG et al (2000) Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma 48(6):1008–1013; discussion 1013–1014
6. Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010
7. Arizzadeh A, Keyhani K, Miller CC III, Coogan SM, Safi HJ, Esttrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009;49:1403-8.
8. Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad . 20109. Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 201010. Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma. A
15-year experience. J Thoracic Cardiovas Surg 1990; 100:652-60.11. Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic injuries: endovascular stents
versus open repair. J Trauma 2004; 56:565-70.12. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for
the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–173413. Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology
1997;205:657–662.14. Peterson BG, Matsumura JS, Morasch MD, West MA, Eskandari MK. Percutaneous endovascular repair of blunt thoracic
aortic transection. J Trauma 2005;59:1062–106515. Tehrani HY, Peterson BG, Katariya K, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006;82: 873–877;
discussion 877–8716. Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS (2001) Traumatic rupture of the thoracic aorta: Cohort study and
systematic review. J Vasc Surg 34(6):1029–1034