Endovascular repair of traumatic aortic transection
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Endovascular repair of traumatic aortic transection
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Endovascular repair of traumatic aortic transection
- 1. Endovascular repair ofEndovascular repair of traumatic aortictraumatic aortic transectiontransection George TrellopoulosGeorge Trellopoulos Vascular SurgeonVascular Surgeon Department of Cardiothoracic SurgeryDepartment of Cardiothoracic Surgery ““G. Papanikolaou” General Hospital, Thessaloniki, Greece.G. Papanikolaou” General Hospital, Thessaloniki, Greece.
- 2. Traumatic aortic transectionTraumatic aortic transection Traumatic aortic transection (TAT) is a potentially lethal injury that isTraumatic aortic transection (TAT) is a potentially lethal injury that is second only to head injury as the most common cause of deathsecond only to head injury as the most common cause of death following blunt traumafollowing 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 TATRoad 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 onMultiple organ injuries are frequent in survivors of TAT. Survivors on average have two associated injuriesaverage have two associated injuries Am J Surg 1986;152:660–663Am J Surg 1986;152:660–663 An out hospital mortality ofAn out hospital mortality of 85%85% Circulation 1958;17: 1086–1101Circulation 1958;17: 1086–1101
- 3. Localization and IncidenceLocalization and Incidence TransectionTransection
- 4. Mechanism of injuryMechanism of injury combination of forces,combination of forces, (stretching,(stretching, shearing, torsion)shearing, torsion) ““waterhammer”effectwaterhammer”effect (simultaneous occlusion of the aorta(simultaneous occlusion of the aorta and a sudden elevation in bloodand a sudden elevation in blood pressure)pressure) ““osseous pinch” effectosseous pinch” effect (entrapment(entrapment of the aorta between the anteriorof 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..
- 5. CT angiographyCT angiography Digital subtraction angiographyDigital subtraction angiography Imaging and measurementsImaging and measurements Intravascular ultrasoundIntravascular ultrasound TransesophagealTransesophageal echocardiographyechocardiography
- 6. General anaesthesiaGeneral anaesthesia Open cut down of both common femoral arteries, insertion of J wires andOpen cut down of both common femoral arteries, insertion of J wires and 7 Fr. X 90 cm arrow catheter into the thoracic aorta7 Fr. X 90 cm arrow catheter into the thoracic aorta Left brachial artery sheath insertion of a J wire and arrow 6 Fr catheterLeft 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 controlStent graft delivery system introduced under fluoroscopic control Stent graft position confirmed by digital subtraction angiographyStent graft position confirmed by digital subtraction angiography ENDOVASCULAR TREATMENTENDOVASCULAR TREATMENT Lower rates of:Lower rates of: –MortalityMortality –paraplegiaparaplegia Endovascular techniqueEndovascular technique
- 7. ENDOVASCULARENDOVASCULAR TREATMENTTREATMENT CUT DOWNCUT DOWN OF BOTHOF BOTH COMMONCOMMON FEMORALFEMORAL ARTERIESARTERIES PLACEMENTPLACEMENT OFOF SHEATHS FROMSHEATHS FROM FEMORAL ANDFEMORAL AND BRANCHIALBRANCHIAL ARTERIESARTERIES INTRODUCED STENTINTRODUCED STENT GRAFT TO THEGRAFT TO THE APPROPRIATE POSITIONAPPROPRIATE POSITION
- 8. 669 pts with traumatic aortic transections669 pts with traumatic aortic transections Endovascula r repair Open surgical patients 370 329 Mortalit y 7.6% 15.2% Parapleg ia 0% 5.6% Stroke 0.85% 5.3% 589 pts with traumatic descending589 pts with traumatic descending thoracic aortic rupturethoracic aortic rupture Endovascu lar repair Open repair Patients 220 369 Mortality 8% 20% paraplegia 0% 7% J Vasc Surg 2008;47:671-5J Vasc Surg 2008;47:671-5 J Vasc Surg 2008;48:1343-51 Endovascular versus open surgicalEndovascular versus open surgical treatment of traumatic aortic transectionstreatment of traumatic aortic transections
- 9. Critical issuesCritical issues 1. timing of repair1. timing of repair 2.2. small diameter aorta 16 – 22 mmsmall diameter aorta 16 – 22 mm 3. Endograft Collapse3. Endograft Collapse 4. Occlusion of the LSA4. Occlusion of the LSA
- 10. CRITICAL ISSUE 1CRITICAL ISSUE 1 TIMING OF REPAIRTIMING OF REPAIR Scenario 1Scenario 1 – Aortic related haemodynamic instabilityAortic related haemodynamic instability Active bleedingActive bleeding Left haemothoraxLeft haemothorax Massive mediastinal haematomaMassive mediastinal haematoma The 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 first Endovascular treatment within next daysEndovascular treatment within next days Scenario 3Scenario 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 (EndovascularThe 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
- 11. Critical issue 2Critical issue 2 small aortic diameter (16 – 19 mm)small aortic diameter (16 – 19 mm) -- consider AAA aortic cuff via carotidconsider 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
- 12. Critical Issue 3Critical Issue 3 Endograft Collapse - RepairEndograft Collapse - Repair BallooningBallooning Palmaz stentingPalmaz stenting New stent graft placement proximallyNew stent graft placement proximally
- 13. How to prevent itHow to prevent it Less oversizing inLess oversizing in transection (2mm)transection (2mm) Overstendting of LSAOverstendting of LSA Stent graft with betterStent graft with better apposition in the innerapposition in the inner curvecurve Stent graft with moreStent graft with more radial force and precurvedradial force and precurved configurationconfiguration Critical Issue 3Critical Issue 3 Endograft CollapseEndograft Collapse RISK FACTORSRISK FACTORS OVERSIZING > 10%OVERSIZING > 10% SHARP AORTIC ARCHSHARP AORTIC ARCH ANGULATIONANGULATION SMALL AORTICSMALL AORTIC DIAMETER IN YOUNGDIAMETER IN YOUNG PATIENTSPATIENTS Relay Bolton precurvedRelay Bolton precurved
- 14. Critical issue 4Critical issue 4 OCCLUSION OF LSAOCCLUSION OF LSA RISKS of occlusionRISKS of occlusion of LSAof LSA – PARAGLEGIAPARAGLEGIA – STROKESTROKE – ISCHEMIA OFISCHEMIA OF LEFT UPPERLEFT UPPER EXTREMITYEXTREMITY PREVENTION ANDPREVENTION AND TREATMENTTREATMENT – REVASCULARIZATIONREVASCULARIZATION Long segment aorticLong segment aortic coverage(>20 cm)coverage(>20 cm) Prior or concominantPrior or concominant infrarenal aorticinfrarenal aortic replacementreplacement Renal insuffiencyRenal insuffiency Dominant left vertebralDominant left vertebral arteryartery Incomplete Circle of WillisIncomplete Circle of Willis Patent LIMAPatent LIMA
- 17. Newer endograftsNewer endografts Valiant Captivia (Medtronic)Valiant Captivia (Medtronic) The Captivia Delivery SystemThe Captivia Delivery System offersoffers Addition of tip captureAddition of tip capture which enhances control ofwhich enhances control of deploymentdeployment Precise stent graftPrecise stent graft placement andplacement and conformabilityconformability Possibility to treat a broadPossibility to treat a broad range of anatomies.range of anatomies.
- 18. Safe and effective therapeutic method with low midtermSafe and effective therapeutic method with low midterm morbidity and mortality rates.morbidity and mortality rates. Close long-term follow-up is requiredClose long-term follow-up is required Technical improvements are requiredTechnical 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 ofEndovascular treatment of traumatic aortic transectionstraumatic aortic transections
Notas del editor
- The traumatic transection of the thoracic aorta is a life threatening condition which carries an out of hospital mortality of 85%. Often, the survivors of traumatic aortic transection have injuries in multiple organs such as the brain, abdominal organs and bones. 75% of transections occur during road traffic accidents.
- In 60-90% of cases the transection occurs in the area of the isthmus of the thoracic aorta. Other areas also affected are the ascending and distal descending thoracic aorta at the level of the diaphragm.
- During the accident, the combination of different forces such as stretching, shearing and torsion on the thoracic aorta lead to the transection. Other mechanisms of thoracic injury are the “waterhammer” and “osseous pinch” effects.
- The “gold standard” of diagnosis is CT Angiography, which is useful for appropriate measurements, such as the diameter of the thoracic aorta proximally and distally of the site of the transection and the distance from the left subclavian artery to the transection.
- The endovascular technique for the treatment of aortic transection is performed under general anaesthesia and includes open cut down of both common femoral arteries and of the left brachial artery and insertion of sheaths for diagnostic angiography. The appropriate orientation of the C- arm is also significant when attempting to optimize the visualization of the aortic arch. The stent graft delivery system is introduced under fluoroscopic control and the placement and the final result are confirmed by digital subtraction angiography.
- Here you can see the procedure of the placement of the stent graft step by step. At the right you can see the final images of CT angiography where we can see the good result.
- There are two metaanalyses comparing the open and the endovascular repair. The mortality rate for the endovascular approach is 8% and for the open repair is 15 to 20%. The paraplegia rate is 0% for the endovascular technique and 5-7% for the open repair.
- There are 4 critical issues which we may encounter when approaching the transection of the thoracic aorta. These are the timing of the repair, the small aorta (with diameter between 16 and 22 mm), endograft collapse and the occlusion of the left sublavian artery.
- The critical point is the timing of the repair of the transection. If there is aortic related haemodynamic instability, the transection is treated first. If the haemodynamic instability is not aortic related, the life threatening injuries are treated first. The transection is treated within the next days or weeks, when the patient is haemodynamicly stable without evidence of extravasion. The patient's systolic blood pressure and heart rate should be aggresivelly controlled
- The problem of the small aortic diameter which is usually seen in young patients and women can be overcomed by using aortic cuffs via the carotid, femoral or iliac approach. Another option is to use the iliac extensions of the endurant endograft which have a larger diameter. Within the next three months, the Gore company will make the C tag available which will have a graft of 21 mm diameter and which can be used in aortas with diameter of 16 to 19.5 mm
- Treatment of a collapsed endograft is balloning, palmaz stent placement and proximal insertion of a new stent graft.
- Risk factors for endograft collapse are oversizing more than 10%, a sharp aortic arch angulation and a small aortic diameter in young patients . We can prevent it by oversizing up to 10%, overstending the left subclavian artery and selecting stent graft with better apposition, more radial force and precurved configuration.
- The occlusion of the left subclavian artery occasionally may lead to paraplegia, stroke and left upper extremity ischemia. It is preferable to revascularizate the left subclavian artery when there is a long aortic coverage, a prior or concominant infrarenal aortic replacement, a dominant left vertebral artery and a patent left internal mammary artery.
- The Gore company introduces in 2010 a new thoracic aorta graft by the name of C-tag (letter c derives from the first letter of the word comformability). The graft introduces significant changes which help prevent collapse in the area of the aortic arch.
- The new imporvements are 1. Elimination of the flared scallops and covered proximal stent which optimizes graft apposition 2. Increased wire diameter which optimizes radial force with resultant increased resistance to compression in high flow rates 3. Ninth apex added to stent pattern which further distributes point load and contributes to adequate fatigue life in maximum oversizing conditions
- Medtronic has improved the delivery system of the Valiant stent graft which will be named Valiant Captivia. The new delivery system offers the addition of a tip capture which enhances control of deployment, precise stent graft placement and conformability and possibility to treat a broad range of anatomies.
- Endovascular treatment of traumatic aortic transections is a safe and effective therapeutic method with low morbidity and mortality. It requires long-term follow-up and more technical improvements of stent grafts are required. It should be the therapy of choice.