Endovascular repair of traumatic aortic transection six years of experience

1. Endovascular repair ofEndovascular repair of
traumatic aortictraumatic 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 KarfisElias Karfis ¹¹, Harilaos Koutsogiannidis, Harilaos Koutsogiannidis ¹¹, Anastasia Apostolidou, Anastasia Apostolidou ²,²,
Angelos MegalopoulosAngelos Megalopoulos ¹¹, George Trellopoulos, George Trellopoulos ¹¹,,
Konstantinos PapadopoulosKonstantinos Papadopoulos ²²,,
George DrossosGeorge Drossos ¹¹

2. Traumatic aortic transectionTraumatic aortic transection
 Traumatic aortic transection (TAT) is a potentially lethal injury that isTraumatic aortic transection (TAT) is a potentially lethal injury that is
second only to head injury as the most common cause of deathsecond only to head injury as the most common cause of death
following blunt traumafollowing 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 TATRoad traffic accidents accounted for over 75% of cases of TAT
Ann Thorac Surg 1994;57:726–730Ann Thorac Surg 1994;57:726–730
 Multiple organ injuries are frequent in survivors of TAT. Survivors onMultiple organ injuries are frequent in survivors of TAT. Survivors on
average have two associated injuriesaverage have two associated injuries
Am J Surg 1986;152:660–663Am J Surg 1986;152:660–663
 An out hospital mortality ofAn out hospital mortality of 85%85%
Circulation 1958;17: 1086–1101Circulation 1958;17: 1086–1101

3. Location of injuryLocation of injury
 Most common (80-90%): isthmus,Most common (80-90%): isthmus,
just distal to the left subclavian arteryjust distal to the left subclavian artery
–– among those who reach hospitalamong those who reach hospital
alivealive
 20-25%: aorta ascendens20-25%: aorta ascendens
–– in post mortem materials.in post mortem materials.
 Few patients: descending thoracicFew patients: descending thoracic
aorta, hiatus diaphragmaticus, aorticaorta, hiatus diaphragmaticus, aortic
arch.arch.
Patel NH et al 1998.Patel NH et al 1998.

4. Mechanism of injuryMechanism of injury
 combination of forces,combination of forces, (stretching,(stretching,
shearing, torsion)shearing, torsion)
 ““waterhammer”effectwaterhammer”effect
(simultaneous occlusion of the(simultaneous occlusion of the
aorta and a sudden elevation inaorta and a sudden elevation in
blood pressure)blood pressure)
 ““osseous pinch” effectosseous pinch” effect
(entrapment of the aorta between(entrapment of the aorta between
the anterior chest wall and thethe anterior chest wall and the
vertebral column)vertebral column)
N Engl J Med 2008;359:1708-16N Engl J Med 2008;359:1708-16..

5. Open surgical repair forOpen surgical repair for TATTAT
 Significant morbiditySignificant 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

6. 12 patients12 patients
 All maleAll male
 Mean age 28.9Mean age 28.9 ± 8.38 years± 8.38 years
 Multiple injuriesMultiple 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

7. 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 ostiumDistance between the lesion and the ostium
of the left subclavian artery (LSA): 24.8 ±of the left subclavian artery (LSA): 24.8 ±
8.2 mm range 14 to 41 mm8.2 mm range 14 to 41 mm
 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

8.  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 placement.Nine patients had orthopedic/vascular surgery after the stent placement.
Injury managementInjury management

9. Endovascular techniqueEndovascular technique
 General anaesthesiaGeneral anaesthesia
 Open cut down of the right common femoralOpen cut down of the right common femoral
artery, insertion of J wires and 7 Fr arrowartery, insertion of J wires and 7 Fr arrow
catheter into the thoracic aortacatheter into the thoracic aorta
 Left brachial artery sheath insertion of a J wireLeft brachial artery sheath insertion of a J wire
and arrow 6 Fr catheter to left subclavian arteryand arrow 6 Fr catheter to left subclavian artery
and aortic arch.and aortic arch.
 Stent graft delivery system introduced underStent graft delivery system introduced under
fluoroscopic controlfluoroscopic control
 Stent graft position confirmed by digitalStent graft position confirmed by digital
subtraction angiographysubtraction angiography

10. 13 grafts13 grafts
 TALENTTALENT 66
 TAGTAG 77
 diameter:diameter: 27.6 ± 3.2 mm27.6 ± 3.2 mm
range 24 to 36 mmrange 24 to 36 mm
 length:length: 107.7 ± 18.8 mm107.7 ± 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 detailsStent grafts details

11. ResultsResults
 Secure exclusion of the traumatic transectionSecure exclusion of the traumatic transection 100%100%
 MortalityMortality 0%0%
 ParaplegiaParaplegia 0%0%
 EndoleakEndoleak 0%0%
 LSA ostiumLSA ostium Partly covered (2/12)Partly covered (2/12)
CoveredCovered (2/12)(2/12)

12. Stent collapseStent collapse
 44thth
postop daypostop day
 Acute renal failureAcute renal failure
 Acute pulmonary oedemaAcute pulmonary oedema
 No pulse on femoral arteriesNo pulse on femoral arteries
 SBP gradient of 85 mmHg between upper/lower limbsSBP gradient of 85 mmHg between upper/lower limbs
 CT scan : proximal graft collapseCT scan : proximal graft collapse
ComplicationsComplications

13. Stent CollapseStent Collapse

14. Stent CollapseStent Collapse
 Immediate reinterventionImmediate reintervention
 New instent placementNew instent placement

15.  41.541.5 ± 22.4 months± 22.4 months
range 6 - 64 monthsrange 6 - 64 months
 All patients alive noAll patients alive no
complicationscomplications
Follow upFollow up

16. 699 pts with699 pts with traumatic aortic transectionstraumatic aortic transections
endovascularendovascular 370370 ptspts open surgicalopen surgical 329329ptspts
 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 surgicalEndovascular versus open surgical
treatment of traumatic aortic transectionstreatment of traumatic aortic transections

17. Marcheix et alMarcheix et al Tehrani et alTehrani 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 SurgJ Thorac Cardiovasc Surg Ann Thorac SurgAnn Thorac Surg
2006;132:1037-4 2006;82:873-72006;132:1037-4 2006;82:873-7
Endovascular treatment of traumaticEndovascular treatment of traumatic
aortic transectionsaortic transections

18. Timing of repairTiming of repair
 Aortic related haemodynamic instabilityAortic 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 InstabilityNon-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

19. LimitationsLimitations
 vascular access and sizevascular access and size
 small aortic diameter in young patients <19 mmsmall aortic diameter in young patients <19 mm
excessive oversizing,excessive oversizing, device collapsedevice collapse
 sharp aortic arch angulationsharp aortic arch angulation
device collapse, endoleakdevice collapse, endoleak
 short proximal landing zone 15-20mmshort proximal landing zone 15-20mm
LSA ostium occlusionLSA ostium occlusion
 durability of endovascular devicesdurability of endovascular devices

20. 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

21.  Safe and effective therapeutic method with low midterm morbiditySafe and effective therapeutic method with low midterm morbidity
and mortality rates.and mortality rates.
 Close long-term follow-up is requiredClose long-term follow-up is required
 Technical improvements are requiredTechnical improvements are required (size(size
and flexibility of devices)and flexibility of devices)
 Should be the therapy of choiceShould be the therapy of choice
Endovascular treatment of traumatic aorticEndovascular treatment of traumatic aortic
transectionstransections

22. Localization and Incidence
TransectionTransection

23.  Traumatic rupture of the aorta isTraumatic rupture of the aorta is
usually fatal; only 10%-20% reach theusually fatal; only 10%-20% reach the
hospital alivehospital alive
 Of those reaching the hospital alive, anOf those reaching the hospital alive, an
additional 5-10% die within a few hours dueadditional 5-10% die within a few hours due
toto
massive, multi-system injurymassive, multi-system injury
 The appropriate treatment of the remainingThe appropriate treatment of the remaining
5- 10%5- 10%
remains controversialremains controversial
TransectionTransection
Open Surgery
• Mortality 5-25%
• Paraplegia 9-19%

24. TransectionTransection
 39 published case series (2001-2006)39 published case series (2001-2006)
 352 patients352 patients
 30 d mortality = 11.2% (0-23.1)30 d mortality = 11.2% (0-23.1)
 Paraplegia = NoneParaplegia = None
Endovascular Repair

25. AVAILABLE DEVICESAVAILABLE DEVICES

26. 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)

27. 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

28. Medtronic Talent Thoracic / ValiantMedtronic Talent Thoracic / Valiant
Valiant Talent Valiant

29. Critical Issue (1)Critical Issue (1)
 Paraplegia after endovascular stent graftingParaplegia after endovascular stent grafting
Factors: Prevention andFactors: 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

30. 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

31. 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