EJVES Extra
Volume 12, Issue 3 , Pages 25-29, September 2006

Combined Treatment, Endovascular and Surgical Treatment of Postraumatic Pseudoaneurysm in the Aortic Arch

Hospital Clinico Universitario de Valladolid, Angiologia y Cirugia Vascular, Avda. Ramon y Cajal no 3, 47005 Valladolid, Spain

Accepted 6 April 2006.

Article Outline

Traumatic rupture of the thoracic aorta has a high mortality. The endovascular alternative has been considered for aortic repair in high-risk patients with multiple trauma. We report a case of a 20 year-old man who suffered a multiple trauma secondary to motor vehicle accident. Arteriography revealed the existence of a pseudoaneurysm at the origin of left common carotid artery.

A short and immediate control of the thoracic aorta is needed in cases with active bleeding of the aorta when the patient is unstable. Endovascular treatment as a definitive repair or first control before performing surgical repair seems a good choice.

Our experience in this patient suggests that the combined endovascular and surgical treatment can be a valuable therapeutic alternative when treating a blunt aortic lesion. It is less invasive surgery and avoids aortic cross-clamping, circulatory assistance and high dose heparinization.

Further studies are required to determine the relevance of the endovascular treatment in the management of traumatic rupture of the aorta in young patients.

Keywords: Aorta, Endovascular, Postraumatic, Pseudoaneurysm

 

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Introduction 

Traumatic rupture of the thoracic aorta is a surgical emergency frequently secondary to rapid deceleration injuries such as motor vehicle accidents. Aortic lesions cause high mortality.1, 2, 8, 13 Only about 15 to 20 percent of patients survive trauma and get to the hospital. In patients who do not die, a contained rupture of the aorta at the adventitious and mediastinic structures occurs.13 Treatment for these patients is controversial.

Open surgery is the standard treatment. Different procedures for repair of injuries to the thoracic aorta have been described.18, 19 Surgical intervention requires a thoracotomy, systemic anticoagulation and aortic cross-clamping, which increase the morbidity and mortality of the intervention. In particular in cases of multiple injuries at other levels.1, 3, 8, 13

Several surgery-related complications such as paraplegia, bleeding, haemorrhage in visceral contusions, cardiac ischemia, respiratory failure, renal failure, sepsis or intestinal ischemia have been described.1, 8

Since the introduction of endovascular treatment for abdominal aortic aneurysms (AAA) and thoracic aortic aneurysms (TAA) by Parodi21 (1.991) and Dake,22 respectively, the endovascular alternative has been considered for aortic repair in high-risk patients with multiple trauma.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13

Many studies in the literature focus on the lower morbidity and mortality rates of endovascular treatment in multiple-trauma patients with traumatic lesion of the thoracic aorta.1, 2, 8

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Case Report 

A 20 year-old man was admitted in the intensive care unit for multiple trauma secondary to motor vehicle accident. He presented with pulmonary contusion, bone fractures in extremities at multiple levels and a tension pneumothorax which was resolved with a chest drain. His past medical history was unremarkable.

The patient was stabilized haemodynamically. A thoracic CT scan confirmed the existence of bilateral pulmonary contusion and a mass at left cervicothoracic level which was filled with contrast. An irregular wall at level of aortic arch was seen (Fig. 1). Following the finding of the thoracic CT scan, the patient underwent a transthoracic echocardiogram and arteriography. Pericardial effusion was not found on transthoracic echocardiogram. Ventricular and valvular functions were normal. Arteriography revealed the existence of a 3cm×4cm pseudoaneurysm at the origin of left common carotid artery. An anatomic variation was also seen: the exit of left vertebral artery from the aortic arch. (Fig. 2)

During the second day in hospital, the patient needed respiratory assistance because the development of an acute respiratory insufficiency. Varios fractures at different levels have to be stabilized. We did not see any significant changes in blood pressure, trying to maintain a pressure of about 100mmHg through the treatment with intravenous B-blocker and vasodilators.

No sign of impending rupture such as a widened mediastinum, haemothorax or transient hypotension were seen until the surgical procedure was decided, and the endovascular graft was obtained.

On the third day after admission into hospital we excluded the pseudoaneurysm with an endoprosthesis introduced from a left femoral artery.

Before the introduction of the endoprosthesis a carotid-subclavian bypass, from right common carotid to left subclavian artery, was performed with Dacron prosthesis of 8mm, though subcutaneous tissue. The left common carotid was taken of it with the proximal anastomosis to left subclavian artery.

Subsequently endovascular exclusion of the pseudoaneurysm through the implantation of two Talent 24mm×130mm endoprostheses was performed. On intraoperative arteriographic control he had a type I endoleak. Some hours later the patient underwent arteriographic control to analize leak persistence.

Arteriography on postoperative day 2 revealed the persistence of filling in the aortic pseudoaneurysm, due to a leak between the endoprosthesis and the wall of the aortic arch. The endoprosthesis was implanted on the aortic arch and at the beginning it partially occluded the origin of brachiocephalic trunk. It was also observed that the carotid-subclavian bypass remained patent. (Fig. 3)

The patient underwent a new intervention on the 6th day after trauma, to consider the exclusion of the aneurysm through the implantation of a new endoprosthesis which would cover the origin of the brachiocephalic trunk (BCT).

A bifurcated bypass from the ascending aorta to left subclavian artery and brachiocephalic trunk, with bifurcated Dacron prosthesis 14mm×7mm was performed through a median sternotomy. Proximal aortic anastomosis was carried out through lateral cross-clamping of the ascending aorta.

Subsequently endovascular exclusion of the pseudoaneurysm and origin of brachiocephalic trunk was performed through the implantation of an Talent 28mm×130mm endoprosthesis. An intra-operative arteriogram did not show any endoleak.

Transoesophageal echocardiogram on the eight day after the second intervention revealed a normal diameter endoprosthesis with its origin in the middle of the ascending aorta. No endoleaks were seen on the segment of the aorta under study. The patient's postoperative course was favourable.

On the 21st day after the second operation the patient was transferred to the Vascular Surgery ward. The cerebral state of patient was unknown during his stay in intensive care unit, as he was constantly under sedation. At this moment his cerebral functions improved almost to normal. On the fifth day after transfer to the vascular ward the patient was discharged from hospital.

Arteriographic control on the first month after the operation revealed two overlapping endoprosthesis in the aortic arch, without evidence of proximal endoleaks. Aorto-brachiocephalic and aorto-carotid-subclavian bifurcated bypass were patent. (Fig. 4)

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Discussion 

The aortic rupture occurs after a sudden deceleration and aortic traction in the isthmus. Aortic thoracic ruptures occur in 50–70% of cases in the isthmus, 18% in the ascending aorta and aortic arch and 14% in the descending thoracic aorta.1, 20

In the traumatic rupture of the aorta, mortality at the moment of trauma occurs in 75–90 percent of cases.1, 2, 8, 23

Standard treatment for aortic rupture is open surgery, due to its good long term results.18, 19 Repair can be by performing a simple suture of the aorta or a resection of the portion affected or by deploying a prosthesis. Surgical repair of the aorta requires thoracotomy, circulatory assistance, aortic cross-clamping and systemic heparinization. It presents high postoperative mortality rates (20%). The intervention can be complicated with paraplegia (15%), which decreases up to 3 percent with circulatory assistance techniques.1, 2, 8, 10 Open repair is associated with morbidity and mortality rates, up to 20–50 percent. This is mainly due to the severity of associated lesions as well as to the patient's preoperative instability. Delayed surgery under strict monitoring can be considered in stable patients so that the associated injuries can be treated.13, 14, 15, 16 Results in these cases seem better. Immediate repair should be performed in patients who present active bleeding, increase of mediastinic or pleural haematoma, syndrome of aortic pseudo-coarctation or respiratory failure.1 A quick and immediate control of the thoracic aorta is needed in unstable patients with active bleeding. In these cases endovascular treatment as a definitive repair or first control, before performing surgical repair is a good alternative.2, 8, 17

Several studies have been recently published in which thoracic aortic repair in multiple-trauma patients is done through endovascular treatment.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13

Endovascular treatment is less invasive, and it is associated to lower morbidity and mortality rates,1, 2, 7 since it does not require thoracotomy, circulatory assistance is not necessary, haemorrhages are less likely, and it does not need aortic cross-clamping, so that the risk of spinal cord and visceral ischemia decreases. Due to the lower morbidity and mortality rates endovascular treatment is considered a good alternative to open surgery for aortic repair.

The first studies in the literature on the endovascular repair of traumatic rupture of the thoracic aorta in multiple-trauma patients provide encouraging results. It is not possible to estimate the durability of this fixation or the anatomic changes of the wall of the artery after the introduction of the endoprosthesis. Multiple-trauma patients are often young patients with no evidence of aortic disease, and with possibly a higher fixation-ability. Probabilities of changes in the wall of the aorta are smaller in this group, so that migration could be less likely. However the long-term durability of this device remains unknown, mainly in these young patients.1, 2, 8

Our experience in this patient suggests that the combined endovascular and surgical treatment seems to be a valuable therapeutic alternative when treating a blunt aortic lesion, in order perform a less aggressive surgery and to avoid aortic cross-clamping, circulatory assistance and high dose heparinization.17

Long-term follow-up of a higher number of patients is required to assess and confirm these positive results in order to determine the relevance of the endovascular treatment in the management of traumatic rupture of the aorta in young patients.

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References 

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PII: S1533-3167(06)00062-8

doi:10.1016/j.ejvsextra.2006.04.005

EJVES Extra
Volume 12, Issue 3 , Pages 25-29, September 2006

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