JUSTIN CHAN PRINCESS MARGARET HOSPITAL JULY 27, 2013 Blunt Thoracic Aortic Injury

JUSTIN CHANPRINCESS MARGARET HOSPITAL

JULY 27, 2013

Blunt Thoracic Aortic Injury

Case Illustration

74/F

Good past health

RTA victim Back passenger of minibus Hit over left side by another car

Case Illustration

Trauma series CT Acute traumatic aortic injury at aortic isthmus 4.2cm intimal flap along descending thoracic aorta No mediastinal hematoma

Multiple rib fractures Pelvic fracture with left pelvic hematoma and active

contrast extravasation Blunt liver trauma with intraparenchymal hematoma

CT images

Case Illustration

Pelvic fracture with hematoma Angiogram: bleeding from branches of left internal

iliac artery Embolisation performed Pelvic fracture: minimal displacement conservative

Fractured ribs + liver hematoma Conservative

TEVAR Stenting of aortic dissection and left subclavian artery

Post-op CT Images

Blunt Thoracic Aortic Injuries

Incidence

Pathology/Pathogenesis

Management options

Issues unsolved

Conclusion

Incidence

Traumatic aortic injuries 2nd commonest cause of death due to blunt trauma

Autopsy series of blunt trauma patients Aortic rupture rates: 12%-23%

Autopsy study by Parmley et al. ~80% of patients die before arrival to hospital

1. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA et al (1997) Prospective study of blunt aortic injury: multicenter trial of the American Association for the surgery of trauma. J Trauma 42(3): 374-380; discussion 380-383

2. Schumacher H, Bockler D, von Tengg-Kobligk H, Allenberg JR (2006) Acute traumatic aortic tear: open versus stent-graft repair. Semin Vasc Surg 19(1):48-59

3. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086-1101

Incidence

Remained the same ~ past 12 years

Strongly correlated with Sudden change in velocity

Impact on patient’s side of car ~85% of thoracic aortic injury was due to side impact in

one study

Intrusion of vehicular wall into passenger compartment 1. Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J (2007)

Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 62(3):664–6672. Horton TG, Cohn SM, Heid MP, Augenstein JS, Bowen JC, McKenney MG et al (2000) Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma 48(6):1008–1013; discussion 1013–1014

Classification

Parmley (1958) Pathological features from autopsies

Grade Pathology

1 Intimal haemorrhage

2 Intimal hemorrhage plus intimal laceration

3 Laceration into the aortic media

4 Complete aortic laceration (transection)

5 Pseudoaneurysm

6 Complete aortic laceration with active hemorrhage

Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086-1101

Classification

Arizzadeh CT imaging

1. Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010

2. Arizzadeh A, Keyhani K, Miller CC III, Coogan SM, Safi HJ, Esttrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009;49:1403-8.

Pathology

Confined to specific locations

Classical site Isthmus of aorta

Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad . 2010

Sites of Injury

- Isthmus - (IIC – 70-90%)

- Ascending aorta/proximal arch - (I to IIB – 10-15%)

- Mid-descending aorta - (IIIA to IIIB – 5-10%)


Postulated Mechanisms

Shear and stretching forces Relative mobility of portion of vessel adjacent to a fixed

portion

Osseous pinch Compression of vessel between bony structures

‘Water-hammer’ effect Profound intraluminal hypertension during severe

trauma


Blunt Aortic Injury. N Engl J Med 2008. 359: 1708-16

Pathogenesis

Most likely: mixed mechanism

Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 2010

Management

Timing of operation Immediate Urgent (<24hrs) Delayed

Type of repair Open Endovascular

Timing of Operation

Hemodynamically unstable Mortality >90% Immediate surgery

Hemodynamically stable


Immediate Surgery

Standard surgical practice for many decades

Parmley: 30% who reach the hospital die within first 6 hours

Meta-analysis by Von Oppell et al: Death rate: hemodynamically stable patients ~21.3%

(0-54.2%) Majority of deaths: associated injuries to other organs

1. Parmley LF, Marian WC: Non-penetrating traumatic injury of the aorta. Circulation 17:1086-1100, 19582. Von Oppell UO, Dunne TT, De Groot MK, et al: Traumatic aortic rupture: Twenty-year metaanalysis of mortality and

risk of paraplegia. Ann Thorac Surg 58:585-595, 1994

Delayed Surgery

Prospective study by Fabian et al Delaying surgical repair plus maintaining blood pressure In-hospital free rupture Mortality

2 studies by Hemmila et al and Pacini et al No difference in mortality between urgent and delayed

repair

Risk: Aortic rupture ~ 2-5% of patients Most within 1st week after trauma

1. Pate JW, Fabian TC, Walker W (1995) Traumatic rupture of the aortic isthmus: an emergency? World J Surg 19(1):119–125; discussion 125–1262. Fabian TC, Davis KA, Gavant ML, Croce MA, Melton SM, Patton JH Jr et al (1998) Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg

227(5):666–676; discussion 676–6773. Holmes JH, Bloch RD, Hall RA, Carter YM, Karmy-Jones RC (2002) Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis. Ann Thorac Surg 73(4):1149–11544. Hemmila MR, Arbabi S, Rowe SA, Brandt MM, Wang SC, Taheri PA, et al. Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair? J Trauma 2004;56:13-23. 5. Pacini D, Angeli E, Fattori R, Lovato L, Rocchi G, Di Marco L, et al. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005;129:880-4.

Current Recommendations

Urgent (<24 hours) repair Except: other serious concomitant non-aortic injuries

or

After other injuries have been treated but prior to hospital discharge

Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010

Current Recommendations

Consider delayed repair in patients with

Respiratory insufficiency due to lung contusion

Head injury with abnormal CT showing haemorhage or edema

Coagulopathy

Severe abdominal solid organ injury and pelvic fractures

Cardiac risk factors/blunt cardiac injury

Multiple medical co-morbidities1. Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 20102. Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical

considerations. Sem Int Rad . 2010

Surgical Approach

Open

Endovascular

Open Surgery

Conventional treatment of choice

Surgical technique Left-sided posterolateral thoracotomy Proximal and distal control of proximal descending

aorta Direct aortic suture or Tube-graft interposition with clamp-and-sew

technique



Open Surgery: Drawbacks

M0rtality rate 28%

Paraplegia rate 16%

Need for thoracotomy and one-lung ventilation

Aortic cross clamping intracranial pressure Hazardous in patients with head injuries

1. Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma. A 15-year experience. J Thoracic Cardiovas Surg 1990; 100:652-60.

2. Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 56:565-70.

TEVAR - Thoracic Endovascular Aortic Repair

Began in United States in 1994

Dake and colleagues 1997 10 patients with traumatic lesions of thoracic aorta

1. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–1734

2. Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology 1997;205:657–662


Preprocedure Imaging Multislice computed tomography

Access Open approach to access iliac vessels (≤8 mm in

diameter) Consider percutaneous approach

Where iliofemoral system is very adequate for endograft access

1. Peterson BG, Matsumura JS, Morasch MD, West MA, Eskandari MK. Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005;59:1062–1065

2. Tehrani HY, Peterson BG, Katariya K, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006;82: 873–877; discussion 877–87


Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS (2001) Traumatic rupture of the thoracic aorta: Cohort study and systematic review. J Vasc Surg 34(6):1029–1034

Published in January 2011

Systematic review: 7768 patients from 139 studies


TEVAR vs Open

TEVAR Mortality

9% VS 19% (p<0.01) Non-operative management 46%

Spinal cord ischemia 3% VS 9% (p=0.01)

Open repair Graft infection

Systemic infections Pneumonia mostly


TEVAR: Drawbacks

Designed for use in degenerative disease

Most traumatic injuries occur in younger patients Existing graft diameters may not be appropriate for smaller

aortas

Lack of long-term results Material failures such as stent fractures and fabric fatigue

may become more significant during ensuing decades of follow up

Conclusions

Overall morbidity and mortality in recent years Both open and endovascular repair for blunt aortic

injury

Timing of Surgery Urgent repair (<24 hrs)

Endovascular repair is superior to open repair In terms of operative mortality and complication rate

Thank you

References

1. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA et al (1997) Prospective study of blunt aortic injury: multicenter trial of the American Association for the surgery of trauma. J Trauma 42(3): 374-380; discussion 380-383

2. Schumacher H, Bockler D, von Tengg-Kobligk H, Allenberg JR (2006) Acute traumatic aortic tear: open versus stent-graft repair. Semin Vasc Surg 19(1):48-59

3. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086-1101

4. Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J (2007) Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 62(3):664–667

5. Horton TG, Cohn SM, Heid MP, Augenstein JS, Bowen JC, McKenney MG et al (2000) Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma 48(6):1008–1013; discussion 1013–1014

6. Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010

7. Arizzadeh A, Keyhani K, Miller CC III, Coogan SM, Safi HJ, Esttrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009;49:1403-8.

8. Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad . 20109. Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7th edition, 201010. Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma. A

15-year experience. J Thoracic Cardiovas Surg 1990; 100:652-60.11. Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic injuries: endovascular stents

versus open repair. J Trauma 2004; 56:565-70.12. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for

the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–173413. Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology

1997;205:657–662.14. Peterson BG, Matsumura JS, Morasch MD, West MA, Eskandari MK. Percutaneous endovascular repair of blunt thoracic

aortic transection. J Trauma 2005;59:1062–106515. Tehrani HY, Peterson BG, Katariya K, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006;82: 873–877;

discussion 877–8716. Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS (2001) Traumatic rupture of the thoracic aorta: Cohort study and

systematic review. J Vasc Surg 34(6):1029–1034

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JUSTIN CHAN PRINCESS MARGARET HOSPITAL JULY 27, 2013 Blunt Thoracic Aortic Injury