Endovascular repair of Endovascular repair of traumatic aortic traumatic aortic

transectiontransectionGeorge Trellopoulos George Trellopoulos

Vascular SurgeonVascular SurgeonDepartment of Cardiothoracic Surgery Department of Cardiothoracic Surgery

““G. Papanikolaou” General Hospital, Thessaloniki, Greece. G. Papanikolaou” General Hospital, Thessaloniki, Greece.

Traumatic aortic transectionTraumatic aortic transection

Traumatic aortic transection (TAT) is a potentially lethal injury that is Traumatic aortic transection (TAT) is a potentially lethal injury that is second only to head injury as the most common cause of death second only to head injury as the most common cause of death following blunt trauma 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 TAT Road 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 on Multiple organ injuries are frequent in survivors of TAT. Survivors on average have two associated injuries 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

Localization and IncidenceLocalization and Incidence

Transection Transection

Mechanism of injuryMechanism of injury

combination of forces, combination of forces, (stretching, (stretching, shearing, torsion)shearing, torsion)

““waterhammer”effect waterhammer”effect (simultaneous occlusion of the aorta (simultaneous occlusion of the aorta and a sudden elevation in blood and a sudden elevation in blood pressure)pressure)

““osseous pinch” effect osseous pinch” effect (entrapment (entrapment of the aorta between the anterior of the aorta between the anterior chest wall and the vertebral column)chest wall and the vertebral column)

N Engl J Med 2008;359:1708-16N Engl J Med 2008;359:1708-16..

CT angiographyCT angiography

Digital subtraction angiographyDigital subtraction angiography

Imaging and measurementsImaging and measurements

Intravascular ultrasoundIntravascular ultrasound

Transesophageal Transesophageal echocardiographyechocardiography

General anaesthesiaGeneral anaesthesia

Open cut down of both common femoral arteries, insertion of J wires and Open cut down of both common femoral arteries, insertion of J wires and 7 Fr. X 90 cm arrow catheter into the thoracic aorta 7 Fr. X 90 cm arrow catheter into the thoracic aorta

Left brachial artery sheath insertion of a J wire and arrow 6 Fr catheter Left brachial artery sheath insertion of a J wire and arrow 6 Fr catheter to left subclavian artery and aortic arch.to left subclavian artery and aortic arch.

Appropriate orientation of C- arm to “OPEN “ the aortic archAppropriate orientation of C- arm to “OPEN “ the aortic arch

Stent graft delivery system introduced under fluoroscopic control Stent graft delivery system introduced under fluoroscopic control

Stent graft position confirmed by digital subtraction angiographyStent graft position confirmed by digital subtraction angiography

ENDOVASCULAR TREATMENTENDOVASCULAR TREATMENTLower rates of:Lower rates of:

–MortalityMortality–paraplegiaparaplegia

Endovascular techniqueEndovascular technique

ENDOVASCULAR ENDOVASCULAR TREATMENTTREATMENT

CUT DOWN CUT DOWN OF BOTH OF BOTH COMMON COMMON FEMORAL FEMORAL ARTERIESARTERIESPLACEMENT OFPLACEMENT OFSHEATHS FROM SHEATHS FROM FEMORAL ANDFEMORAL ANDBRANCHIAL BRANCHIAL ARTERIESARTERIES

INTRODUCED STENTINTRODUCED STENTGRAFT TO THE GRAFT TO THE APPROPRIATE POSITIONAPPROPRIATE POSITION

669 pts with traumatic aortic transections669 pts with traumatic aortic transections

Endovascular repair

Open surgical

patients 370 329

Mortality

7.6% 15.2%

Paraplegia

0% 5.6%

Stroke 0.85% 5.3%

589 pts with traumatic descending 589 pts with traumatic descending thoracic aortic rupturethoracic aortic rupture

Endovascular repair

Open repair

Patients 220 369

Mortality 8% 20%

paraplegia 0% 7%

J Vasc Surg 2008;47:671-5J Vasc Surg 2008;47:671-5J Vasc Surg 2008;48:1343-51

Endovascular versus open surgical Endovascular versus open surgical treatment of traumatic aortic transectionstreatment of traumatic aortic transections

Critical issuesCritical issues

1. timing of repair1. timing of repair2. 2. small diameter aorta 16 – small diameter aorta 16 –

22 mm22 mm 3. Endograft Collapse3. Endograft Collapse4. Occlusion of the LSA 4. Occlusion of the LSA

CRITICAL ISSUE 1CRITICAL ISSUE 1TIMING OF REPAIRTIMING OF REPAIR

Scenario 1Scenario 1– Aortic related haemodynamic instabilityAortic related haemodynamic instability

Active bleedingActive bleedingLeft haemothoraxLeft haemothoraxMassive mediastinal haematomaMassive mediastinal haematomaThe transection treated first (Endovascular management)The transection treated first (Endovascular management)

Scenario 2Scenario 2– Non aortic related haemodynamic instabilityNon aortic related haemodynamic instability

Life threatening injuries treated firstLife threatening injuries treated firstEndovascular treatment within next daysEndovascular treatment within next days

Scenario 3 Scenario 3 – Stable patient without evidence of contrast extravasion on CTStable patient without evidence of contrast extravasion on CT

The transection treated within next days or weeks (Endovascular The transection treated within next days or weeks (Endovascular management) management)

Or open repair if limitations for endovascular repairOr open repair if limitations for endovascular repair

Critical issue 2Critical issue 2small aortic diameter (16 – 19 mm)small aortic diameter (16 – 19 mm)

- - consider AAA aortic cuff via carotid consider AAA aortic cuff via carotid approach or femoral approachapproach or femoral approach

- use of the iliac extensions of the endurant - use of the iliac extensions of the endurant bifurcated graftbifurcated graft

- use of the C-TAG- use of the C-TAG

Critical Issue 3Critical Issue 3Endograft Collapse - RepairEndograft Collapse - Repair

BallooningBallooningPalmaz stentingPalmaz stentingNew stent graft placement proximallyNew stent graft placement proximally

How to prevent itHow to prevent it

Less oversizing in Less oversizing in transection (2mm)transection (2mm)

Overstendting of LSAOverstendting of LSAStent graft with better Stent graft with better

apposition in the inner apposition in the inner curve curve

Stent graft with more Stent graft with more radial force and precurved radial force and precurved configurationconfiguration

Critical Issue 3Critical Issue 3Endograft CollapseEndograft Collapse

RISK FACTORSRISK FACTORS

OVERSIZING > 10%OVERSIZING > 10%

SHARP AORTIC ARCH SHARP AORTIC ARCH ANGULATIONANGULATION

SMALL AORTIC SMALL AORTIC DIAMETER IN YOUNG DIAMETER IN YOUNG PATIENTSPATIENTS

Relay Bolton precurvedRelay Bolton precurved

Critical issue 4Critical issue 4OCCLUSION OF LSAOCCLUSION OF LSA

RISKS of occlusion RISKS of occlusion of LSAof LSA– PARAGLEGIAPARAGLEGIA– STROKESTROKE– ISCHEMIA OF ISCHEMIA OF

LEFT UPPER LEFT UPPER EXTREMITYEXTREMITY

PREVENTION AND PREVENTION AND TREATMENT TREATMENT – REVASCULARIZATIONREVASCULARIZATION

Long segment aortic Long segment aortic coverage(>20 cm)coverage(>20 cm)

Prior or concominant Prior or concominant infrarenal aortic infrarenal aortic replacementreplacement

Renal insuffiencyRenal insuffiencyDominant left vertebral Dominant left vertebral

arteryarteryIncomplete Circle of WillisIncomplete Circle of WillisPatent LIMAPatent LIMA

Newer endographsNewer endografts

Newer Newer endograftsendografts

Newer endograftsNewer endograftsValiant Captivia (Medtronic)Valiant Captivia (Medtronic)

The Captivia Delivery System The Captivia Delivery System offersoffers

Addition of tip capture Addition of tip capture which enhances control of which enhances control of deploymentdeployment

Precise stent graft Precise stent graft placement and placement and conformabilityconformability

Possibility to treat a broad Possibility to treat a broad range of anatomies.range of anatomies.

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 Endovascular treatment of traumatic aortic transectionstraumatic aortic transections