Acute traumatic aortic rupture

XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture

Acute Traumatic Aortic Rupture


Semih Buz

Deutsches Herzzentrum Berlin XV. Uusal Vasküler Cerrahi Kongresi, Ekim 2011, Antalya



Life-threatening surgical emergency.

The cause of death in ~ 20 % of all road accident fatalities.

In those who reach hospital alive rapid diagnosis

and treatment may be life saving.



Causes

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Blunt trauma Motor vehicle accidents with a side or a frontal impactFalls from hight

Deceleration:Falls from great hightsExplosion

Pathopyhsiology

Rapid deceleration produces shearing injury between fixed and mobile portions of the aorta



Incomplete isthmic ruptureObstructive intimal flap

(pseudo-coarctation)

Aortic Injury



144 surgical emergency casesHunt JP et al. J Trauma 1996; 40:547

275 post mortemParmley JP et al. Circulation 1958; 17:1086

Location of Injury



Without treatment

10-15% of the initial survivors die in the first hour

20-30% die within 6 hours

30-50% within 1 day

60-70% within 8 days

Many of these can be treated!

Natural Course

0

5

10

15

20

100[%]

14 d7 d48 h24 h6 h1 h1/2 h

accident 10weeks

1 year

Gotzen, Hetzer 1982 (n = 40)

Parmley 1958 (n = 275)

Jahnke 1964 (n = 38)

Hartford 1986 (n = 86)



Coexisting Injuries

90% have other organ injuries

51% cerebral injury

62% other thoracic injury

22% intraabdominal injury

34% pelvic or extremity fractures

Smith RS et al 1986, Fabian TC et al 1997.



• Chest X-ray

• Aortography

• Thoracic CT Scan

• Thoracic MRI

• Cardiac Echo (TEE)

Acute Traumatic Aortic rupture

Diagnosis



Thoracic CT Sensitivity ~100% Specificity ~ 99%

Definitive Diagnosis

TEE Operator dependent

Aortography Sensitivity and

specificity similar to CT

Invasive In our practice

only combined with treatment



Management

Prompt diagnosis Medical management

(strict blood pressure monitoring) Potentially urgent operative repair

Operative treatment options

Open surgical repairClamp and sewCardiopulmonary Bypass

Endovascular stent therapy



DHZB/ag-2003Diseases of the Aorta: E. Stanley Crawford MD · John L. Crawford MD

Operative Treatment Options

Open Surgical Repair

Direct suture technique Tube graft technique



Aorta

Lung

CPB

Open Surgical Repair

Left thoracotomy Single lung ventilation Use of bypass-perfusion with

systemic heparinization Aortic cross clamping



Operative Treatment OptionsEndovascular Stent Therapy - TEVAR



0%

20%

40%

60%

80%

100%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008Endov.Stent 1 3 5 7 6 15 29 35 62 50 50 102 78 85 58Conv. Surg. 167 168 250 250 238 309 254 265 231 250 242 304 357 376 234

Endovascular Stent Grafting vs. Conventional Aortic Surgery – DHZB

(incl. Aug. 2008)

Descending thoracic and thoraco-abdominal aorta

Ascending aorta



Endovascular stent grafting



Since 2008: Hybrid OR



AdvantagesAvoidance of Thoracotomy Single-lung ventilation Aortic cross-clamping Left heart bypass or CPB Systemic heparinization Requires less operation time Can be done promptly in unstable

patients

Limitations Treatment of selective aortic injuries distal

of the ascending aorta Staff trained in TEVAR Available stock of equipment Smaller aorta (younger patients) No long-term results about side effects and

durability

Endovascular Stent Therapy - TEVAR



Operative Treatment OptionsEndovascular Stent Therapy - TEVAR



Case report 32-yr-old man

• Severe head injury• Lung contusion• Multiple pelvic and

extremity fractures

• discarghed on 25th pod.• Pat. is well 6 yrs.

postoperatively



Deutsches Herzzentrum Berlin

Experience1988 - August 2011

Total Patients 94

Open repair (1988 - 2006) 35

Endovascular Stent Therapy (1999 - 08/2011) 59

Traumatic Rupture

Surgical group* Endovascular group*

Gender (m/f) 29/6 34/5

Age (yrs.) (mean) (range) 36 (14 – 73) 36 (15-82)

Delay between trauma and treatment (median) 28 h 17 h

(range) (4 h – 219 days) (3 h – 169 days)

ISS (median) (range) 33.5 (17-57) 41 (13-66)

Associated injuriesHead 12 19Face 7 10Chest 31 36Extremity 22 22Abdomen 17 27

*p = n.s., ISS: Injury severity score

Conventional surgery (1988 – 2006) N=35 Endovascular stent graft (1999 – 2006) N=39



Severity of traumaInjury severity score (ISS)

0

10

20

30

40

50

60

0

Endovascular group

Inju

ry s

ever

ity s

core

Surgical group

10

20

30

40

50

60

P = n.s.



Multipleruptures

4

Isolatedruptures

67

74patients

Localization of Ruptures

6

63

3

2

1



Operation technique

Cardiopulmonary bypass (CPB) 33

Deep hypothermia 9

Without CPB 2

Tube graft 25

Composite graft 2

Aortic reconstruction 8

Surgical groupN=35



Operation Technique

Talent 27

E-vita 9

Relay 3

Diameter 28-42 mm

Length 100-150 mm

Covering of the left subclavian artery in 9 patients►5 patients underwent carotico-subclavian bypass

Endovascular group (n = 39)



Acute traumatic rupture at the isthmus and above the diaphragm

Multiple Ruptures



Multiple Ruptures

CT reconstruction after surgery with two stentgrafts implantedsimultaneously



Surgical group Endovascular group

Respiratory insufficiency 3 1

Pulmonary infection 2 0

Recurrent nerve palsy 2 0

Repeat thoracotomy 2 0

Compartment syndrome 1 0

Paraplegia 0 0

Total 28.5 % 3 %

ComplicationsResults



Surgical group Endovascular group

30-day mortality 20% 7.7%

Causes of death

Brain death (hemorrhage) 4 1

Pulmonary failure 1 1

Low cardiac output 1 0

Bleeding 1 0

Immediate rupture 0 1

MortalityResults



Endograft Failures and Conversion

M, 41 yrs. M, 19 yrs. M, 39 yrs.

Diagnosis Traumatic rupture Traumatic rupture Traumatic rupture

Localization Isthmus Isthmus Isthmus

Indication Contained rupture Contained rupture Active bleeding

Failure Bare spring penetration Endoleak Ia Endoleak IaImmediate rupture

Intervention Secondary conversion – Primary conversion

POD 14 – Intraop.

Outcome Discharged Further hospitalization Fatal



Case Report39-year-old man

Road accident

Acute aortic isthmus rupture

Liver rupture, primary laparotomy

Bilateral hemato-pneumothorax

Multiple fractures

Admission 8 h after polytrauma



Implantation of endovascular stent graft

Intraop. further rupture, massive bleeding

Resuscitation

Emergency conversion to surgery

Type-I endoleak

E-vita®

Case Report39-year-old man



Case ReportConversion to Surgery



Kaplan-Meier Survival

0.00 5.00 10.00

Years after operation15.00

P = n.s.

Endovascular group

Surgical group

0.0

0.2

Cum

. sur

viva

l

0.4

0.6

0.8

1.0

Endovasc. group Surgical group

1 year 88.3% 73.7%

5 years 88.3% 73.7%

10 years 73.7%



Meta Analysis

17 included studies

Xenos E, et al. J Vasc Surg, 2008

TEVAR 220 pts.Open rep. 369 pts.



Procedure-related mortalityTEVAR 2%Open repair 14%(OR, 0.31;95% CI, p=0.002)

30-day mortalityTEVAR 8%Open repair 20%(OR, 0.44;95% CI, p=0.005)

Paraplegia/ParaparesisTEVAR 0%Open repair 7%(OR, 0.32;95% CI, p=0.03)

Meta analysisResults

Xenos E, et al. J Vasc Surg, 2008



ConclusionsOutcome after endovascular stent grafting for acute traumatic thoracic aortic rupture is impressive and better than after conventional surgery.

Stent-grafting avoids the heparin-induced bleeding complications associated with conventional surgery.

Therefore our current policy is to consider stent-grafting primarily if technically possible and in the early phase after trauma.

Stent-grafting should be performed by the cardiothoracic surgeon in the OR, allowing rapid conversion to conventional surgery in case of complications.



-Thank you –

Acute traumatic aortic rupture

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