Endovascular Treatment

Since 1996, the introduction of endovascular techniques for the thoracic aorta in the clinical practice has opened less invasive options for patients in which emergency treatment is necessary. After initial limited series and case reports, endovascular treatment is evolving as the method of choice in management of TAR71-74. Because of the lower invasivity, avoiding thoracotomy, and the use of heparin, endovascular repair can be applied in the acute patients without the risk of destabilizing pulmonary, head, or abdominal traumatic lesions. At present, standard sizes of thoracic stent grafts are available allowing its use in an emergency. In recent years, initial medical management and delayed surgery of the aortic traumatic injury have represented important advances in the difficult management of polytrauma, substantially reducing operative and overall mortality. However, there are some patients in whom delayed surgery cannot be applied. Even if the majority of traumatic aortic ruptures are stable lesions, in approximately 5% of them the risk of rupture may be high in the acute phase. Signs of impending rupture (such as periaortic hematoma, repeated hemotorax, and uncontrolled blood pressure) are considered signs of instability. Sometimes the aortic tear, acting with a valve mechanism, may cause a pseudocoarctation syndrome, producing a reduction of flow in the descending aorta with lower extremity ischemia. This complication, which represents a surgical emergency, is accounted for in 10% of victims. In these unstable patients, endovascular techniques offer a suitable alternative to open repair. In early clinical series, endovascular treatment demonstrated lower morbidity and mortality in comparison with open surgical repair even in high-risk patients (Figure 15.9). There is no requirement for full heparinization, and blood loss is minimal. The risk of paraplegia seems to be very low even in extensive atherosclerotic aneurysms in which the coverage of the stent graft extends from the left subclavian artery to the celiac axis. At present, no case of paraparesis-paraplegia has been reported in the literature in endovascular treatment of traumatic aortic lesion.

In the chronic posttraumatic aneurysm endovascular treatment represents a favorable alternative treatment of asymptomatic disease that is frequently recognized several years after the trauma. Chronic posttraumatic aneurysms are potential evolving lesions. Death from rupture may occur many years after injury sometimes without any premonitory signs and symptoms. Because it is impossible to predict which aneurysm still remains quiescent, elective repair is always recommended for both symptomatic and asymptomatic lesions. Advances in surgical techniques and spinal cord protection over the years significantly reduced operative mortality and paraplegia in elective surgical repair of the thoracic aorta. In the largest surgical series, operative mortality for chronic posttraumatic aneurysms ranges from 0-10% and paraplegia accounts for 5% of cases. The risk of paraplegia in surgery of chronic posttraumatic aneurysms is very low compared to atherosclerotic aneurysms because of the limited extension of the pseudo-aneurysm that usually does not extend beyond

Aortic Dissection Uncovered Stent

Figure 15.9. (a) Intraoperative aortography of a traumatic aortic injury before stent placement. (b) Aortography after stent placement. The stent has been deployed in isthmic aorta, with aneurysm exclusion and patency of left subclavian artery. (c) CT follow-up images (longitudinal reconstruction). Complete thrombosis of aneurysm.

Figure 15.9. (a) Intraoperative aortography of a traumatic aortic injury before stent placement. (b) Aortography after stent placement. The stent has been deployed in isthmic aorta, with aneurysm exclusion and patency of left subclavian artery. (c) CT follow-up images (longitudinal reconstruction). Complete thrombosis of aneurysm.

the first pair of intercostals arteries. However, patients with chronic asymptomatic aneurysm are not always prone to accept a major thoracotomy and the risk of dreadful complications. Endovascular treatment may play an important role in chronic posttraumatic aneurysm management.

Aortic Dissection

Figure 15.9. (Continued).

Figure 15.9. (Continued).

Traumatic Aortic Rupture

Figure 15.10. (a) Schematic drawing of an incomplete acute traumatic aortic rupture repaired with primary sutures with or without pledgets. (b) End-to-end anastomosis repair of a circumferential linear laceration.

Figure 15.10. (a) Schematic drawing of an incomplete acute traumatic aortic rupture repaired with primary sutures with or without pledgets. (b) End-to-end anastomosis repair of a circumferential linear laceration.

Endovascular treatment needs some peculiar anatomical conditions to be performed, so not all the patients can be treated. At a minimum, a proper peripheral vascular access is requested. The most important anatomical characteristic of a posttraumatic lesion allowing endovascular treatment is the presence of an adequate proximal neck or a distance more than 5 mm from the

Bypass Graft End End Anastomosis

Figure 15.11. Schematic drawing of a complete aortic transaction and repair with the interposition of a straight prosthetic graft.

subclavian artery and the absence of mural thrombus or calcifications or hemorrhage on the aortic wall at the neck site. Several studies reported the artificial creation of an aortic neck, covering the left subclavian artery with the stent graft, with or without previous subclavian to carotid transposition or bypass grafting. However, subclavian-to-carotid transposition is an invasive adjunctive procedure that carries the risk of mortality and stroke (4.2%), while the abrupt closure of the left subclavian artery may evolve into chronic or acute subclavian steal syndrome. The risk of vertebral ischemia and cerebellar infarction is reported up to 13% for interventional treatment of intracranial aneurysm treated by vertebral ligation. Therefore, we may expect the same rate of complication for endovascular coverage of the left subclavian artery with a stent graft. Moreover, the long-life expectancy of the uncovered part of the stent graft to the left carotid artery is a potential source of emboli. Preoperative imaging studies are fundamental to define the indication to endovascular treatment and to customize the stent graft. The accuracy of measurements becomes then essential to verify the efficacy of the procedure during long-term follow-up. Both helical CT and MR imaging represent excellent imaging modalities for evaluation of traumatic aortic lesion, displaying the extent of the disease without partial volume errors and providing accurate details of the aortic wall structure. Angiography can provide only luminal information on the aortic vessel and should be reserved to the few cases in which the necessary details have not been achieved by noninvasive methods.

For many years, traumatic aortic injury has been considered a highly lethal lesion and a potential cause of death in blunt chest trauma. Despite evidence in the literature of lower morbidity and mortality, initial medical management of uncomplicated aortic injury and subsequent delayed surgery have not been easily accepted in the clinical practice. The development of endovascular techniques represents a viable alternative with a very low risk and a limited impact on further multisystem destabilization.

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SECTION VI: FUTURE FRONTIERS

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