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H. Rousseau et al. Chapter 33 Acute Traumatic Aortic Rupture: Stent-Graft Repair
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337
Fig. 33.7. The length of the proximal neck must be 10 mm or
more beneath the origin of the left subclavian artery. If needed
like in this case, covering the left subclavian artery to lengthen
the proximal neck could be a good alternative. A radioopaque
marker inside the ostium of the left subclavian artery is very
useful to implant accurately the stent-graft
Fig. 33.8. CT scan immediately before and 1 week after implantation. The spiral CT at 1 week shows the complete regression of the
pseudoaneurysm with a good apposition of the stent-graft to the aortic wall. The bilateral pneumothorax is also resolved
the vertebral arteries is mandatory. This can be done by
angiography just before the implantation.
Because most injuries occur at the aortic isthmus,
much concern has been raised regarding the placement
of rigid devices in an angulated aortic arch; however,
this has been largely overcome with the newer, more
flexible devices.
Vascular access is another determinant in the technical success of the endovascular procedure and is sometimes difficult in an emergency situation. Stenosis, tor-
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VII. Aortic Injury
tuosity, calcifications, or an iliofemoral axis of less than
8 mm in diameter can make the progression of a large
introducer sheath very hazardous. Spasm can also be a
frequent complication in young patients.
So far, most of the reported cases of aortic rupture
treated with an endovascular stent-graft have been done
in a subacute or chronic setting. With a mortality rate
of 8% (one in 12 patients), Lachat et al. [35] suggest
that the method might also be valid in an acute situation (Fig. 33.8). As discussed before, stent-graft treatment shows considerable advantages over open surgery.
Unfortunately, the costs of current devices make shelf
stock impractical in most hospitals and therefore require individual ordering of each device, a distinct disadvantage in emergencies. But as a single length of
stent-graft is sufficient, because most cases of rupture
are short and limited, we only keep a few stent-grafts of
various diameters in stock. In this way, implantation
can be done before or immediately after treatment of
other life-threatening injuries and in patients for whom
conventional surgery is contraindicated, because the
procedure is short and has little physiologic effect. The
stent-graft insertion could also be done without anticoagulation in some cases of major neurological complications.
33.9 Discussion
Although some authors reserve endovascular treatment
for patients in whom standard surgery is contraindicated [38], one might raise the issue of extending the
indication to all patients with traumatic injury of the
thoracic aorta. Controversy remains regarding the best
method of management. As a whole, for patients with
signs of imminent aortic rupture who are hemodynamically unstable, immediate treatment is mandatory. Open
surgery is still the most accepted treatment but acute
endovascular management when feasible shows many
advantages compared with conventional surgery, meaning that stent-grafts of different diameters are in stock
in the department and there is a team ready ªon the
clockº to perform this implantation 24 h a day.
If the patient is unstable but the aortic rupture is
contained without signs of active bleeding, based on the
fact that a contained pseudoaneurysmal traumatic lesion of the thoracic aorta is unlikely to rupture under
proper blood pressure control, delayed repair of the
aortic injury may be undertaken. This method permits
the patient to achieve hemodynamic and physiologic
stabilization and to first undergo emergent operations
of other injuries if needed. But contrary to situation
with surgery, as the stent-grafts can be placed without
heparin and without true complication, the benefit of a
delayed treatment is questionable as the risk of rupture
is always possible.
Finally, for stable patients with isolated thoracic lesion, we believe that little is gained by delaying repair
either by conventional surgery for young patients or by
a stent-graft for older patients with more comorbidities.
References
1. Fabian TC, Richardson JD, Croce M, et al. Prospective
study of blunt injury: multicenter trial of the American
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2. Parmley LF, Mattingly TW, Manion WC, et al. Non-penetrating traumatic injury of the aorta. Circulation 1958;
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5. Williams JS, Graff JA, Uku JM, et al. Aortic injury in
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6. Pate JW, Fabian TC, Walker W. Traumatic rupture of the
aortic isthmus: an emergency? World J Surg 1995; 19:119±
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7. Moar TJ. Traumatic rupture of the thoracic aorta. South
Afr Med J 1985; 67:383±385.
8. Von Oppell UO, Dunne TT, DeGroot MK, et al. Traumatic
aortic rupture: 20-year meta-analysis of mortality and
risk of paraplegia. Ann Thorac Surg 1994; 58:585±593.
9. Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS.
Traumatic rupture of the thoracic aorta: cohort study and
systematic review. J Vasc Surg 2001; 34:1029±1034.
10. Akins CW, Buckley MK, Daggett W, et al. Acute traumatic
disruption of the aorta: a 10-year experience. Ann Thorac
Surg 1981; 31:305±309.
11. Stulz P, Reymond MA, Bertschmann W, et al. Decisionmaking aspects in the timing of surgical intervention in
aortic rupture. Eur J Cardiothorac Surg 1991; 5:623±627.
12. Kipfer B, Leupi F, Schuepbach P, et al. Traumatic rupture
of the thoracic aorta: immediate or delayed surgical repair? Eur J Cardiothorac Surg 1994; 8:30±33.
13. Maggisano R, Nathens A, Alexandrova N. Traumatic rupture of the thoracic aorta: should one always operate immediately? Ann Vasc Surg 1995; 9:44±52.
14. Rousseau H, Soula P, Perreault P, et al. Delayed treatment
of traumatic rupture of the thoracic aorta with endoluminal covered stent. Circulation 1999; 99:498±504.
15. Pierangeli A, Turinetto B, Galli R, Caldarera R, Fattori R,
Gavelli G. Delayed treatment of isthmic aortic rupture.
Cardiovasc Surg 2000; 8:280±283.
16. Langanay T, Verhoye JP, Corbineau H, Agnino A, Derieux
T, Menestret P, et al. Surgical treatment of acute traumatic
rupture of the thoracic aorta: timing reappraisal. Eur J
Cardiothorac Surg 2002; 21:282±287.
17. Holmes JH, Bloch RD, Hall RA, Carter YM, Karmy-Jones
RC. Natural history of traumatic rupture of the thoracic
aorta managed nonoperatively: a longitudinal analysis.
Ann Thorac Surg 2002; 73:1149±1154.
18. Dake MD, Miller DC, Mitchell RS, Semba CP, Moore KA,
Sakai T. The ªfirst generationº of endovascular stent-grafts
for patients with aneurysms of the descending thoracic
aorta. J Thorac Cardiovasc Surg 1998; 116:689±703.
19. Greenberg R, Resch T, Nyman U, et al. Endovascular repair of descending thoracic aortic aneurysms: an early experience with intermediate-term follow-up. J Vasc Surg
2000; 31:147±156.
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20. Rousseau H, Dambrin C, Marcheix B, Richeux L, Mazerolles M, Cron C, Watkinson A, Mugniot A, Soula P, Chabbert V, Canevet G, Roux D, Massabuau P, Meites G, Tran
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21. Jacobs TS, Won J, Gravereaux EC, Faries PL, Morrissey N,
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22. Patel AP, Langan EM 3rd, Taylor SM, Snyder BA, Cull DL,
Carsten CG 3rd, Youkey JR, Gray BH, Sullivan TM. Has
the emergence of endovascular treatment for aneurysmal
and occlusive aortic disease increased the complexity and
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18:212±217.
23. Semba CP, Kato N, Kee ST, Lee GK, Mitchel RS, Miller
DC, et al. Acute rupture of the descending aorta: repair
with the use of endovascular stent grafts, J Vasc Interv
Radiol 1997; 8:337±342.
24. Kato N, Dake MD, Miller DC, et al. Traumatic thoracic
aortic aneurysm: Treatment with endovascular stentgrafts. Radiology 1997; 205:657±662.
25. Perreault P, Soula P, Rousseau H, et al. Acute traumatic
rupture of the thoracic aorta: delayed treatment with endoluminal covered stent. A report of two cases. J Vasc
Surg 1998; 27:538±544.
26. Deshpande A, Mossop P, Gurry J, et al. Treatment of traumatic false aneurysm of the thoracic aorta with endoluminal grafts. J Endovasc Surg 1998; 5:120±125.
27. Schonholz C, Donnini F, Naselli J, et al. Acute rupture of
an aortic false aneurysm treated with a stent-graft. Endovasc Surg 1999; 6:293±296.
28. Czermak BV, Waldenberger P, Perkmann R, Rieger M,
Steingruber I, Mallouhi A, Fraedrich G, Jaschke W. Placement of endovascular stent-grafts for emergency treatment of acute disease of the descending thoracic aorta.
AJR Am J Roentgenol 2002; 179:337±345.
29. Fujikawa T, Yukioka T, Ishimaru S, et al. Endovascular
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injury. J Trauma 2001; 50:223±229.
30. Fattori R, Napoli G, Lovato L, Russo V, Pacini D, Pierangeli A, Gavelli G. Indications for, timing of, and results of
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31. Hoffer EK, Karmy-Jones R, Bloch RD, et al. Treatment of
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32. Melnitchouk S, Pfammatter T, Kadner A, Dave H, Witzke
H, Trentz O, et al. Emergency stent-graft placement for
hemorrhage control in thoracic aortic rupture. Eur J Cardiothorac Surg 2004; 25:1032±1038.
33. Thompson CS, Rodriguez JA, Damaia VG, DiMugno L,
Shafique S, Olsen D, et al. Acute traumatic rupture of the
aorta treated with endoluminal stent grafts. J Trauma
2002; 52:1173±1177.
34. Orend KH, Pamler R, Kapfer X, Liewald F, Gorich J, Sunder-Plassman L. Endovascular repair of traumatic descending aortic transection. J Endovasc Ther 2002; 9:573±
578.
35. Lachat M, Pfammatter T, Witzke H, et al. Acute traumatic
aortic rupture: early stent-graft repair. Eur J Cardiothorac
Surg 2002; 26:959±963.
36. Orford VP, Atkinson NR, Thomson K, Milne PY, Campbell
WA, Roberts A, et al. Blunt traumatic aortic transection.
Ann Thorac Surg 2003; 75:100±111.
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A. Thoracic aorta endoprosthesis: the final countdown for
open surgery after traumatic aortic rupture. Ann Vasc
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38. Marty-An CH, Berthet JP, Branchereau P, Mary H, Alric
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thoracic aorta. Ann Thorac Surg 2003; 75:1803±1807.
39. Scheinert D, Krakenberg H, Schmidt A, Gummert JF,
Nitzsche S, Braunlich S, et al. Endoluminal stent-graft
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aorta. Eur Heart J 2004; 8:694±700.
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77:591±596.
41. Amabile 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.
42. Hausegger KA, Oberwalder P, Tiesenhausen K, Tauss J,
Stanger O, Schedlbauer P, Deutschmann H, Rigler B. Intentional left subclavian artery occlusion by thoracic aortic stent-grafts without surgical transposition. J Endovasc
Ther 2001; 8:472±476.
43. Gorich J, Ermis C, Kramer SC, Fleiter T, Wisianowsky C,
Basche S, Gottfried HW, Volkmer BG. Interventional treatment of traumatic priapism. J Endovasc Ther 2002; 9:614±
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44. Dake MD. Endovascular stent-graft management of thoracic aortic diseases. Eur J Radiol 2001; 39:42±44.
Surgical Treatment
https://t.me/med1917
and Endovascular Issue
in the Traumatic Rupture
of the Descending Aorta
Pascal Leprince, Philippe Cluzel, Alain Pavie
Contents
Chapter
34
34.1 Introduction ......................
34.2 Conventional Surgical Treatment .......... 341
34.2.1 Type of Repair ............... 342
34.2.1.1 Direct Repair ................ 342
34.2.1.2 Graft Interposition ............. 342
34.2.2 Spinal Cord Protection During
the Aortic Cross Clamp ..........
34.2.3 Results of the Surgery ...........343
34.3 Endovascular Treatment ................ 343
34.4 Conclusion ....................... 344
341
342
34.1 Introduction
Acute traumatic rupture of the aorta (ATRA) is a lifethreatening complication of blunt chest traumas, which
are mostly related to car crashes [1]. While more than
80% of patients showing this complication die on site,
only 10±20% can be transferred alive to the emergency
care unit. This represents four per 1,000 patients transferred to the emergency care unit after car accidents
[8].
In clinical series, the tear is located at the isthmus of
the aorta in 90% of cases (Fig. 34.1). However, in necropsy series, isthmic location represents only 50% of
the cases, highlighting the high rate of death associated
with other locations. Furthermore, 90% of patients
show polytraumatism and have other life-threatening
injuries.
In the past few decades, it was admitted that ATRA
must be managed aggressively with immediate surgical
repair. However, postoperative mortality remained high,
mostly related to associated lesions. Moreover, different
papers recently showed that surgical treatment could be
delayed with very low risk of rupture, as long as adequate antihypertensive treatment is given [5, 6, 11]. Finally, during the last decade, endovascular stent-grafting was established as an alternative to open surgery.
Fig. 34.1. Angiography showing isthmic location of the false an-
eurysm
So, owing to these new approaches surgical treatment
of ATRA has to be reevaluated.
34.2 Conventional Surgical Treatment
Surgical approach is made through a left postero-lateral
thoracotomy in the fourth intercostal space, which allows access to the descending thoracic aorta as well as
the heart and the trunk of the pulmonary artery. The
goal of the surgical treatment is to clamp the aorta
proximally and distally to the lesion, open the tear and
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VII. Aortic Injury
repair it. This treatment leads to two types of discussion: firstly, how to repair the lesion (direct repair or
graft interposition) and, secondly, how to protect the
spinal cord from ischemia?
34.2.1 Type of Repair
34.2.1.1 Direct Repair
Direct suture of the tear should be used whenever it
can be done since it allows complete healing of the aortic wall. Direct repair (Fig. 34.2a,c) is easy in the case
of incomplete rupture since there is no retraction of the
two ends of the rupture. In complete rupture, direct suture can be helped by moving the proximal and the distal part of the aorta. Direct repair becomes impossible
in the case of old lesions or very complex and extensive
lesions.
34.2.1.2 Graft Interposition
Replacement of the diseased segment of the aorta with
a synthetic graft is easy to perform. However, graft interposition (Fig. 34.2b,d) may lead to the occurrence of
several complications (inadequate length or diameter,
anastomotic false aneurysm, infection) which can be
surgically challenging to treat. This technique must be
used only when direct suture is not possible.
34.2.2 Spinal Cord Protection During
the Aortic Cross Clamp
Three techniques can be used.
1. No protection: ªclamp and sew.º This method is the
simplest. It does not require cardiopulmonary bypass (CPB) and can be performed without heparin;
however, it is associated with a high risk of paraplegia. The risk is proportional to the duration of the
aortic cross clamp. Close to 0% under 20 min of
Fig. 34.3. Passive shunt
cross-clamp time, this risk goes up to 20, 60 and
100% for clamping times of 30, 60 and 90 min, respectively [4, 10]. Nowadays, this method is rarely
used since patients with contraindications to CPB
are postponed and/or treated with a covered stent
graft.
2. Heparinized shunt (Fig. 34.3). A coated shunt can be
used to bypass the interrupted segment of the aorta.
This allows perfusion of the distal aorta without
using CPB and can be performed with no heparin.
However, the output of the shunt is not controlled;
in the case of sudden hemorrhage, it is not possible
to immediately reinfuse the blood; the system does
not prevent hemodynamic instability or oxygenation
impairment that can occur during this surgery. With
Fig. 34.2. Types of lesions and repair: A incomplete rupture with no retraction; B complete rupture with retraction; C direct repair;
D graft interposition
P. Leprince et al. Chapter 34 Surgical Treatment and Endovascular Issue in the Traumatic Rupture of the Descending Aorta
https://t.me/med1917
As described before, the rate of spinal cord ischemia
related complication depends on the surgical technique.
A definitive lesion of the left laryngeal nerve is reported
in 6±8% of cases [4, 7].
In the case of direct repair, the long-term prognosis
is excellent with an ad integrum restitution of the aortic
wall and preservation of growth potential in children
and adolescents.
34.3 Endovascular Treatment
Over the last decade, the covered stent graft became
more and more an alternative to open repair in patients
with acute and chronic disease of the thoracic aorta. In
1999, Rousseau et al. [9] reported a series of five subacute and four chronic aortic traumatic ruptures treated
with a covered stent graft. They reported 100% success
of the exclusion of the false aneurysm, no death and
only two major complications: one occlusion of the ostium of the left subclavian artery treated with stents
and one transitory compression of the left main
bronchus. Similar results were reported by Kato et al.
[3]. In a recent paper, Dunham et al. [2] analyzed a total of nine series published between 2001 and 2003 and
Fig. 34.4. Cardiopulmonary bypass
this technique, the rate of paraplegia is about 11%
[4, 7, 10].
3. CPB (Fig. 34.4). Venous blood is drained from the
right atrium through a cannula inserted through the
femoral vein or from the pulmonary artery and is reinfused distally to the clamped segment, mostly into
the femoral artery. The method has many advantages: oxygenation of the reinfused blood, control of
the output, control of the bleeding through blood reinfusion directly with the CPB. This method allows
us to repair complex lesions requiring a long crossclamp time with a rate of paraplegia lower than 2%
[10]. However, the use of CPB requires the infusion
of a high dose of heparin (3 mg/kg). This dramatically increases the risk of bleeding complications in
patients with polytraumatism, particularly bleeding
into the brain or the lungs.
34.2.3 Results of the Surgery
Postoperative mortality is reported to be between 6 and
35%, mainly related to associated lesions [4, 7, 10]. This
is why, in the case of associated lesions with a risk of
bleeding, the surgery is postponed and other lesions
are treated primarily. Then the postoperative rate of
death is lowered to 0±5% [5].
reporting at least four patients with ATRA treated with
a covered stent graft. These series represent a total of
68 patients with a technical success rate of 98.5%, an
overall mortality of 5.9%, a graft-related death rate of
1.5%, an endoleak rate of 7.4% and no postoperative
paralysis. These results compare favorably with those of
surgical series.
The prerequisites for ATRA treatment with covered
stent graft are essentially anatomical: a proximal and
distal landing zone of at least 1.5-cm length with a diameter not bigger than the available graft (46 mm), and
an iliac artery diameter of at least 8 mm. If necessary
the proximal landing zone can extend proximally to the
left subclavian artery. This artery can be left occluded,
the left upper limb being perfused through collaterals,
or a carotid±suclavian bypass can be performed. In the
review by Dunham et al., there was one case of secondary left arm claudication. Also, in their own series, the
authors reported a case of posterior fossa infarction
after occlusion of a dominant vertebral artery.
Long-term results remain unknown. Most of the series report a mean follow-up of less than 2 years. Patients need to be followed with repeated imaging to survey for stent-graft failure and secondary occurrence of
an endoleak. If the occurrence of a secondary endoleak
related to evolving aortic disease or covered stent-graft
failure is a major concern, it may not be relevant in patients with ATRA. Indeed, once the false aneurysm has
been excluded, the aortic tear heals underneath the
stent and the false aneurysm shrinks and finally disappears (Fig. 34.5).
343
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VII. Aortic Injury
abc
de
Fig. 34.5. Computed tomography scan imaging showing a±c acute traumatic rupture of the aorta before treatment and d±f 1-year
follow-up after covered stent-graft placement. The false aneurysm disappeared
4. Kodali S, Jamieson WR et al. (1991) Traumatic rupture of
34.4 Conclusion
ATRA is a life-threatening lesion but if the patient survives the acute trauma the risk of secondary rupture remains low under strict blood-pressure control. Thus,
treatment of the aortic lesion can be postponed particularly if the patient shows multiple injuries. The use of a
covered stent graft appears promising with good immediate results and shrinking of the false aneurysm
cavity occurring at midterm follow-up.
References
1. Brundage SI, Harruff R et al. (1998) The epidemiology of
thoracic aortic injuries in pedestrians. J Trauma 45:1010±
1014.
2. Dunham MB, Zygun D et al. (2004) Endovascular stent
grafts for acute blunt aortic injury. J Trauma 56:1173±
1178.
3. Kato N, Dake MD et al. (1997) Traumatic thoracic aortic
aneurysm: treatment with endovascular stent-grafts. Radiology 205:657±662.
the thoracic aorta. A 20-year review: 1969±1989. Circulation 84:III40±46.
5. Langanay T, Verhoye JP et al. (2002) Surgical treatment of
acute traumatic rupture of the thoracic aorta a timing reappraisal? Eur J Cardiothorac Surg 21:282±287.
6. Maggisano R, Nathens A et al. (1995) Traumatic rupture
of the thoracic aorta: should one always operate immediately? Ann Vasc Surg 9:44±52.
7. Pate JW, Fabian TC et al. (1995) Traumatic rupture of the
aortic isthmus: an emergency? World J Surg 19:119±125;
discussion 125-116.
8. Pate JW, Fabian TC et al. (1995) Acute traumatic rupture
of the aortic isthmus: repair with cardiopulmonary bypass. Ann Thorac Surg 59:90±98; discussion 98±99.
9. Rousseau H, Soula P et al. (1999) Delayed treatment of
traumatic rupture of the thoracic aorta with endoluminal
covered stent. Circulation 99:498±504.
10. von Oppell UO, Dunne TT et al. (1994) Traumatic aortic
rupture: twenty-year metaanalysis of mortality and risk of
paraplegia. Ann Thorac Surg 58:585±593.
11. Walker WA, Pate JW (1990) Medical management of acute
traumatic rupture of the aorta. Ann Thorac Surg 50:965±
967.
f
Classification
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and Decision Algorithm
of Posttraumatic Chronic Lesions
of the Isthmus
and the Descending Thoracic Aorta
Jean-Philippe Verhoye, Bertrand De Latour,
Cyryl Kakon, Jean-Franois Heautot
Chapter
35
Contents
35.1 Introduction ......................
35.2 Classification of Patients with Posttraumatic
Injuries of the Aortic Isthmus or the
Descending Aorta ...................
35.3 Decision Algorithm .................. 347
35.4 Results of a Multicenter Retrospective Study .... 347
35.5 Results from the Literature .............. 348
35.6 Discussion ........................ 348
35.7 Conclusion ....................... 349
345
346
35.1 Introduction
The natural history of chronic isthmus and descending
aorta posttraumatic false aneurysms has been directly
related to the limitations of diagnostic imaging. The
considerable progress made in noninvasive angiography
during the last 10 years (mainly through the easy access
to multislice computed tomography, CT, scanners) will
probably contribute to the disappearance of chronic lesions discovered fortuitously by revealing the injuries at
the acute stage.
The lesion is often an intimal tear, more or less circumferential, misdiagnosed at the initial stage, which
evolves towards a saccular pseudoaneurysm, incidentally demonstrated by a thoracic imaging study performed for another reason (Fig. 35.1). Some become
symptomatic by a mechanism of compression (either
ab
Fig. 35.1. a Angiography during endovascular treatment of a chronic posttraumatic pseudoaneurysm, showing the stent-graft in its
sheath. b After deployment, angiographic control shows the complete exclusion of the aneurysm
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VII. Aortic Injury
tracheo-bronchial or recurrent nerve) and are discovered by a targeted imaging study.
Today the progress in intensive care and the wide accessibility to efficient vascular imaging studies in emergency situations have allowed better management of
polytrauma patients. The advances in intensive care
have induced an evolution of therapeutic strategy of
acute ruptures of the aortic isthmus towards delayed
surgery [1], the imaging advances have contributed to a
drastic decrease, nearly disappear of misdiagnosed
chronic false aneurysms.
According to the criteria defined by Langanay et al.
(Chap. 32), the only remaining surgical indication in an
emergency is isolated lesions of less than 24 h, hemodynamically unstable, without associated lesion contraindicating a cardiopulmonary bypass.
It is easy to figure out now, in the precarious context
of a polytrauma patient, that an isthmus lesion can be
medically controlled and treated after a delay, to limit
the inherent morbidity/mortality of the surgical procedure under cardiopulmonary bypass in an emergency.
It is now a consciously ªdelayed acuteº surgical management, where the lesion is voluntarily ªchronicized.º
In spite of intensive care and careful follow-up, patients have suffered ruptures during these periods of
ªcontrolled chronicization.º
Stent-grafts will probably help to prevent these sudden early ruptures while allowing a quick initial treatment of the lesion. This technique does not command
systemic anticoagulation during or after the procedure,
thus limiting the hemorrhagic complications in polytrauma patients. Encouraging results are currently
being published [1, 2]. The challenge of this new management is linked to the midterm and long-term exclusion of the lesion in a definitive way like conventional
surgery does.
The nonendothelialization of the stent-graft and the
increasing aortic diameter with the patient's age carries
a risk of late type I endoleaks which could potentially
activate a degeneration of the initial lesion into a
chronic false aneurysm. In this case, the nonendothelialization would be an advantage by facilitating the surgical explantation of the stent-graft and conventional repair of the aorta, even a long time after the endovascular procedure (Fig. 35.2).
The endovascular therapy is a major step in the history of therapeutic management of traumatic injuries of
the isthmus and the descending aorta. Because of this
trend, it has appeared necessary to us to propose a new
classification of these lesions, to better define the management, whichever therapeutic solution is used. The
classification must allow us to define stages for the purpose of comparing therapeutic results among homogeneous groups of patients. It must also propose a decision algorithm to better select the most appropriate
therapeutic choice with respect to the priorities in patient management.
35.2 Classification of Patients
with Posttraumatic Injuries
of the Aortic Isthmus
or the Descending Aorta
Class I: acute (< 48 h)
A: Isolated lesion B: Polytrauma
1: Stable 2: Unstable
Class I corresponds to a post-raumatic lesion of the
isthmus or the descending aorta, with two subclasses:
ab
Fig. 35.2. a CT angiography. Control 6 months after stent-graft
treatment of a chronic posttraumatic pseudoaneurysm, showing a type I endoleak. The endoleak was monitored and spontaneously resolved, but at 3 years the patient suffered bronchial
compression due to endotension. Surgical conversion had to be
performed (graft interposition and aneurysm thrombus resection). b CT angiography, 3D reconstruction, volume rendering.
Control after surgical conversion
J.-P. Verhoye et al. Chapter 35 Classification and Decision Algorithm of Posttraumatic Chronic Lesions of the Isthmus and the Descending Thoracic Aorta
https://t.me/med1917
347
the lesion is either isolated (A) or associated with
others injuries (polytrauma, B), and the patient is hemodynamically stable (1) or unstable (2).
Class II: delayed acute (> 48 h)
A: Isolated lesion B: Polytrauma
1: Stable 2: Unstable
Class II corresponds to a lesion initially not treated because of misdiagnosis or surgical contraindication. The
lesion is either isolated (A) or associated with other injuries (polytrauma, B), and the patient is hemodynamically stable (1) or unstable (2).
Class III: incidental chronic
A: Stable diameters/unknown
evolutivity
1: Asymptomatic 2: Symptomatic
Class III corresponds to an incidental posttraumatic
chronic pseudoaneurysm of the isthmus or the descending aorta. This lesion can be stable, or its evolutivity unknown (A), or increasing (more than 1 cm/year)
or a contained ruptured (B). It can also be asymptomatic (1) or symptomatic (dysphonia, cough, bronchitis, chest pain, pleural effusion) (2).
B: Increasing
patient status, it can be performed in an acute emergency, a delayed emergency, or after a period of controlled chronicization.
A careful CT scan follow-up is mandatory, at 1 and
6 months, and yearly thereafter, for the current generations of stent-grafts. The patients must be informed of
this requisite and that late disorders can occur, which
can then lead to elective surgery.
The other field of endovascular treatment is the
management of patients older than 70, in which surgery
carries a significantly higher risk. The lesions are often
incidentally diagnosed, asymptomatic, and often large
(maximum diameter frequently more than 60 mm),
after trauma occurred several decades before. The risk
of rupture of these lesions is not known, and endovascular solution seems a better first choice for these patients.
So, a therapeutic decision algorithm is proposed is
as follows:
Class I, II A1 < 70 years old Surgery except
contra-indication
A1 > 70 years old,
A2 and B
Class III A1 CT follow-up
A2 < 70 years old Surgery, except
A2 > 70 years, B Stent-graft
Stent-graft
contra-indication
35.3 Decision Algorithm
Starting from this classification, it is possible to define
a decision algorithm taking into account the surgical
and endovascular results of the last 10 years. Surgery
assisted by cardiopulmonary bypass has proven its
long-term efficacy at the cost of reduced postoperative
morbidity/mortality in patients younger than 70, with
no major risk factor.
The follow-up for patients treated by a stent-graft is
hardly 8 years in the most expert teams, but the best indications are already being defined. To deploy a stentgraft is not to cure because we know now that stentgrafts do not get endothelialized, which can cause midterm and long-term endoleaks and endotension, which
reactivate the aneurysmal process and the risk of sudden rupture.
Regarding this technique, the current strategy is
rather based on getting over the acute phase to avoid
rupture in the critical context of a polytrauma patient.
The surgical access is limited to the groin (depending
on the quality of the iliac arteries) even if it is preferable to perform the operation in an operating room
with cardiopulmonary bypass at hand. According to the
35.4 Results
of a Multicenter Retrospective Study
In order to validate the appropriateness of this classification and algorithm, a retrospective study was conducted in six French university centers. We report the
midterm results for 47 class II and III patients. The aortic injuries were diagnosed at the time of the trauma
(63.8%, n=30), or incidentally (36.2%, n=17). Between
January 1996 and June 2004, endovascular repair of the
descending thoracic aorta with commercially available
stent-grafts was performed in 47 patients (mean age,
43 Ô 19 years) at an average of 6 Ô 11 years after the injury. Because of comorbidities, eight patients (17%)
were judged not to be reasonable surgical candidates
for a conventional surgical approach. Follow-up was
100% complete and averaged 18 Ô 13 months.
Stent-graft deployment was successful in all patients.
No early death occurred. One late transient paraparesia
occurred. Two patients had a primary endoleak, one
type I and one type II which spontaneously resolved at
1 and 6 months, respectively. Two endotensions were
described after 36 months (currently being monitored)
and 30 months (surgical conversion). The actuarial survival estimates at 1 and 3 years were 97.7 Ô 2.3 and
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