Emergency Endovascular Treatment of a Traumatic Sub-Diaphragmatic Abdominal Aorta Rupture Caused by a Firearm
Article Outline
Abstract
We report a case of a sub-diaphragmatic abdominal aorta rupture in a 50-year-old man, due to a shot at point-blank range with a firearm. Following a diagnostic thoraco-abdominal computed tomography (CT) scan, he was immediately transferred to the operating room where a Talent aortic cuff was implanted. There were no postoperative neurological sequelae or complications. The endoprosthesis was in the correct position with no evidence of migration, fracture or endoleak even after 9 months of follow-up.
Keywords: Vascular trauma, Gunshot, Endovascular treatment, Abdominal aorta, Penetrating trauma
Penetrating injury of the sub-diaphragmatic abdominal aorta by a gunshot is one of the most serious and complex situations a vascular surgeon can face. We present the case of a patient, who in a suicide attempt, shot himself at point-blank range with a firearm, causing among other lesions, the rupture of the sub-diaphragmatic abdominal aorta.
Case
A 50-year-old man was presented with a gunshot wound with an entry orifice at the level of the xiphoid process and an exit orifice in the dorsal lumbar region. He was haemodynamically stable on arrival to the emergency room. Therefore, a thoraco-abdominal CT scan was performed, where a lesion in the abdominal aorta at the level of the diaphragmatic hiatus was found (Fig. 1a). The computed tomography angiography (CTA) study was performed with a 64 multi-slice CTA (Light Speed VCT 64; General Electric Medical Systems, Milwaukee, WI, USA). The post-processing analysis of the images was made on a workstation. The diameter of the abdominal aorta was 22.3
mm; the length of the ruptured aorta was 15mm, considering the beginning and the end of the loss of continuity of the aortic wall. The length from the distal aortic injury to coeliac artery was 28mm. The patient was transferred to the operating room for an angiography of the abdominal aorta, accessed through the right brachial artery, by means of a portable C-arm fluoroscopy (Philips Nederland BV Medical Systems, Eindhoven, The Netherlands), where a rupture of the aorta at the supracoeliac level was confirmed (Fig. 1b). A Talent aortic cuff (Medtronic AVE, Santa Rosa, Calif) measuring 30mm in diameter×28mm in length was implanted through the right femoral artery. After confirming a correct repair of the aortic lesion during the follow-up angiogram, 5000U of heparin sodium was administered intravenously. A media supra- and infra-umbilical exploratory laparotomy was done, and the entry orifice of the projectile at the sternum was observed (Fig. 1c). The bullet had penetrated the pleural cavity, piercing the diaphragm and injuring the minor gastric curvature, in addition to fragmenting the left lobe of the liver. A left hemi-hepatectomy was performed. Preoperative antibiotic prophylaxis was 2g of intravenous cefazolin. Postoperatively, the patient received 1g of intravenous cefazolin every 6h and 500mg intravenous metronidazole every 8h for 7 days. There were no postoperative neurological sequelae or complications. Follow-up of the patient was done after 1 week, 1 month, 3 and 9 months by radiograph, CT scan and analytical means. The endoprosthesis was in the correct position with no evidence of migration, fracture or endoleak (Fig. 2).
Figure 1
(a) Abdominal CT scan with contrast, showing contrast extravasation of the sub-diaphragmatic aortic lesion, as well as burst of the left pedicle and superior articular process of the twelfth thoracic vertebra. (b) Intraoperational aortic arteriography accessed through the right brachial artery. Observation of the aortic lesion with contrast extravasation at 2
cm proximal to the exit orifice from the coeliac trunk. (c) Graphic representation of the trajectory by the gunshot's projectile.
Figure 2
CT scan at 9 months. Observation of the correct position of the endoprosthesis without migration, fracture, or endoleak.
Discussion
Waldrop and collaborators published the reports on endovascular reparation of an aortocava fistula at the level of the supracoeliac abdominal aorta by means of an aortic cuff 19 days after a gunshot wound.1 Yeh and collaborators reported endovascular treatment of an abdominal aortic mycotic pseudo-aneurysm rupture with an iliac extension stent graft 2 weeks after open repair of an ‘infrarenal abdominal aortic’ penetrating gunshot injury.2 The case presented by our group is unusual due to the immediate endovascular repair and the technical success using a unique aortic cuff.
Endovascular repair in aortic trauma could have several advantages: it enables the effective treatment of difficult-to-access zones; the need for heparin could be reduced to a minimum, which is beneficial to patients with associated intracranial or abdominal lesions3, 4; and it results in lesser blood loss and a shorter operating time, which is very important for patients with multiple lesions.4 A higher rate of paraplegia has been associated with clamping periods greater than 30min in open aortic surgery.3 The endovascular technique avoids or reduces the aortic clamping time, therefore avoiding significant changes in arterial pressure, and it would also reduce the ischaemic events that could affect the spinal cord, viscera and kidneys.3 In endovascular surgery there is a lesser probability of iatrogenic lesions in the dissection of an already complicated surgical field, and it avoids vascular reparation in a field frequently contaminated with associated visceral lesions.
Endovascular surgery is promising; however, current devices are not yet designed for young patients with small aortic diameters and are much less available in an emergency situation. In our case, the implanted aortic cuff was 34.5% larger in size with respect to the adjacent healthy abdominal aorta of the lesion. Our current reality is that the available emergency stock is focussed on the more common aortic aneurysms. According to Wellons and collaborators, in an aortic trauma context, the proximal and the distal anchor zones of the endoprosthesis need not be ruled by the same guidelines that apply to aortic aneurysm repairs. Therefore, a smaller anchor zone could be sufficient to guarantee a seal.5
Another important issue is the currently unknown long-term performance of the device implanted in patients whose life expectancy is 40 or 50 years, usually with a healthy aorta. This warrants a continuous follow-up of these patients.
Conclusion
Emergency endovascular reparation of the sub-diaphragmatic abdominal aorta is technically feasible for an experienced surgical team. The endovascular treatment of the vascular trauma to the abdominal aorta is very promising, essentially as devices improve and a greater array of diameters and lengths become available and the results continue to be satisfactory in the long term.
Conflict of Interest
None.
Funding
None.
References
- . Endovascular stent graft treatment of a traumatic aortocaval fistula. Ann Vasc Surg. 2005;4:562–565
- . Endovascular repair of an actively haemorrhaging gunshot injury to the abdominal aorta. J Vasc Surg. 2005;42:1007–1009
- . Endovascular treatment of traumatic thoracic aortic injury – should this be the new standard of treatment?. J Vasc Surg. 2006;43:A22–A29
- . Emergency repair of traumatic aortic rupture: endovascular versus conventional open repair. J Thorac Cardiovasc Surg. 2007;4:897–901
- . Stent-graft repair of traumatic thoracic aortic disruptions. J Vasc Surg. 2004;40:1095–1100
PII: S1533-3167(09)00008-9
doi:10.1016/j.ejvsextra.2009.03.002
© 2009 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Emergency endovascular treatment of the traumatic subdiaphragmatic abdominal aorta rupture by firearm , 25 May 2009
