Endovascular repair of traumatic aortic transection six years of experience
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Transcript of Endovascular repair of traumatic aortic transection six years of experience
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