Acute traumatic aortic rupture

1. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Acute Traumatic Aortic Rupture
Semih Buz
Deutsches Herzzentrum Berlin
XV. Uusal Vasküler Cerrahi Kongresi, Ekim 2011, Antalya

2. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Life-threatening surgical emergency.
The cause of death in ~ 20 % of all road accident fatalities.
In those who reach hospital alive rapid diagnosis
and treatment may be life saving.

3. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Causes

4. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Blunt trauma
Motor vehicle accidents with a side or a
frontal impact
Falls from hight
Deceleration:
Falls from great hights
Explosion
Pathopyhsiology
Rapid deceleration produces shearing injury between
fixed and mobile portions of the aorta

5. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Incomplete isthmic rupture
Obstructive intimal flap
(pseudo-coarctation)
Aortic Injury

6. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
144 surgical emergency cases
Hunt JP et al. J Trauma 1996; 40:547
275 post mortem
Parmley JP et al. Circulation 1958; 17:1086
Location of Injury

7. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Without treatment
10-15% of the initial survivors die
in the first hour
20-30% die within 6 hours
30-50% within 1 day
60-70% within 8 days
Many of these can be treated!
Natural Course
0
5
10
15
20
100
[%]
14 d7 d48 h24 h6 h1 h
1/2 h
accident 10
weeks
1 year
Gotzen, Hetzer 1982 (n = 40)
Parmley 1958 (n = 275)
Jahnke 1964 (n = 38)
Hartford 1986 (n = 86)

8. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Coexisting Injuries
90% have other organ injuries
51% cerebral injury
62% other thoracic injury
22% intraabdominal injury
34% pelvic or extremity fractures
Smith RS et al 1986, Fabian TC et al 1997.

9. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
• Chest X-ray
• Aortography
• Thoracic CT Scan
• Thoracic MRI
• Cardiac Echo (TEE)
Acute Traumatic Aortic rupture
Diagnosis

10. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Thoracic CT
 Sensitivity ~100%
 Specificity ~ 99%
Definitive Diagnosis
TEE
 Operator dependent
Aortography
 Sensitivity and
specificity similar
to CT
 Invasive
 In our practice
only combined with
treatment

11. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Management
 Prompt diagnosis
 Medical management
(strict blood pressure monitoring)
 Potentially urgent operative repair
Operative treatment options
Open surgical repair
Clamp and sew
Cardiopulmonary Bypass
Endovascular stent therapy

12. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
DHZB/ag-2003Diseases of the Aorta: E. Stanley Crawford MD · John L. Crawford MD
Operative Treatment Options
Open Surgical Repair
Direct suture technique Tube graft technique

13. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Aorta
Lung
CPB
Open Surgical Repair
 Left thoracotomy
 Single lung ventilation
 Use of bypass-perfusion with
systemic heparinization
 Aortic cross clamping

14. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Operative Treatment Options
Endovascular Stent Therapy - TEVAR

15. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
0%
20%
40%
60%
80%
100%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Endov.
Stent 1 3 5 7 6 15 29 35 62 50 50 102 78 85 58
Conv.
Surg. 167 168 250 250 238 309 254 265 231 250 242 304 357 376 234
Endovascular Stent Grafting vs. Conventional Aortic Surgery – DHZB
(incl. Aug. 2008)
Descending thoracic and thoraco-abdominal aorta
Ascending aorta

16. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Endovascular stent grafting

17. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Since 2008: Hybrid OR

18. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Advantages
Avoidance of
 Thoracotomy
 Single-lung ventilation
 Aortic cross-clamping
 Left heart bypass or CPB
 Systemic heparinization
 Requires less operation time
 Can be done promptly in unstable
patients
Limitations
 Treatment of selective aortic injuries distal
of the ascending aorta
 Staff trained in TEVAR
 Available stock of equipment
 Smaller aorta (younger patients)
 No long-term results about side effects and
durability
Endovascular Stent Therapy - TEVAR

19. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Operative Treatment Options
Endovascular Stent Therapy - TEVAR

20. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Case report
32-yr-old man
• Severe head injury
• Lung contusion
• Multiple pelvic and
extremity fractures
• discarghed on 25th
pod.
• Pat. is well 6 yrs.
postoperatively

21. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Deutsches Herzzentrum Berlin
Experience
1988 - August 2011
Total Patients 94
Open repair (1988 - 2006) 35
Endovascular Stent Therapy (1999 - 08/2011) 59

22. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture

23. Traumatic Rupture
Surgical group* Endovascular group*
Gender (m/f) 29/6 34/5
Age (yrs.) (mean) (range) 36 (14 – 73) 36 (15-82)
Delay between trauma
and treatment (median) 28 h 17 h
(range) (4 h – 219 days) (3 h – 169 days)
ISS (median) (range) 33.5 (17-57) 41 (13-66)
Associated injuries
Head 12 19
Face 7 10
Chest 31 36
Extremity 22 22
Abdomen 17 27
*p = n.s., ISS: Injury severity score
Conventional surgery (1988 – 2006) N=35
Endovascular stent graft (1999 – 2006) N=39

24. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Severity of trauma
Injury severity score (ISS)
0
10
20
30
40
50
60
0
Endovascular group
Injuryseverityscore
Surgical group
10
20
30
40
50
60
P = n.s.

25. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Multiple
ruptures
4
Isolated
ruptures
67
74
patients
Localization of Ruptures
6
63
3
2
1

26. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Operation technique
Cardiopulmonary bypass (CPB) 33
Deep hypothermia 9
Without CPB 2
Tube graft 25
Composite graft 2
Aortic reconstruction 8
Surgical group
N=35

27. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Operation Technique
Talent 27
E-vita 9
Relay 3
Diameter 28-42 mm
Length 100-150 mm
Covering of the left subclavian artery in 9 patients
►5 patients underwent carotico-subclavian bypass
Endovascular group (n = 39)

28. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Acute traumatic rupture at the isthmus and above the diaphragm
Multiple Ruptures

29. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Multiple Ruptures
CT reconstruction after surgery with two stentgrafts implanted
simultaneously

30. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Surgical group Endovascular group
Respiratory insufficiency 3 1
Pulmonary infection 2 0
Recurrent nerve palsy 2 0
Repeat thoracotomy 2 0
Compartment syndrome 1 0
Paraplegia 0 0
Total 28.5 % 3 %
Complications
Results

31. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Surgical group Endovascular group
30-day mortality 20% 7.7%
Causes of death
Brain death (hemorrhage) 4 1
Pulmonary failure 1 1
Low cardiac output 1 0
Bleeding 1 0
Immediate rupture 0 1
Mortality
Results

32. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Endograft Failures and Conversion
M, 41 yrs. M, 19 yrs. M, 39 yrs.
Diagnosis Traumatic rupture Traumatic rupture Traumatic rupture
Localization Isthmus Isthmus Isthmus
Indication Contained rupture Contained rupture Active bleeding
Failure Bare spring penetration Endoleak Ia Endoleak Ia
Immediate rupture
Intervention Secondary conversion – Primary conversion
POD 14 – Intraop.
Outcome Discharged Further hospitalization Fatal

33. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Case Report
39-year-old man
Road accident
Acute aortic isthmus rupture
Liver rupture, primary laparotomy
Bilateral hemato-pneumothorax
Multiple fractures
Admission 8 h after polytrauma

34. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Implantation of endovascular
stent graft
Intraop. further rupture,
massive bleeding
Resuscitation
Emergency conversion to surgery
Type-I
endoleak
E-vita®
Case Report
39-year-old man

35. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Case Report
Conversion to Surgery

36. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Kaplan-Meier Survival
0.00 5.00 10.00
Years after operation
15.00
P = n.s.
Endovascular group
Surgical group
0.0
0.2
Cum.survival
0.4
0.6
0.8
1.0
Endovasc. group Surgical group
1 year 88.3% 73.7%
5 years 88.3% 73.7%
10 years 73.7%

37. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Meta Analysis
17 included studies
Xenos E, et al. J Vasc Surg, 2008
TEVAR 220 pts.
Open rep. 369 pts.

38. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Procedure-related mortality
TEVAR 2%
Open repair 14%
(OR, 0.31;95% CI, p=0.002)
30-day mortality
TEVAR 8%
Open repair 20%
(OR, 0.44;95% CI, p=0.005)
Paraplegia/Paraparesis
TEVAR 0%
Open repair 7%
(OR, 0.32;95% CI, p=0.03)
Meta analysis
Results
Xenos E, et al. J Vasc Surg, 2008

39. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
Conclusions
Outcome after endovascular stent grafting for acute
traumatic thoracic aortic rupture is impressive and better
than after conventional surgery.
Stent-grafting avoids the heparin-induced bleeding complications
associated with conventional surgery.
Therefore our current policy is to consider stent-grafting primarily
if technically possible and in the early phase after trauma.
Stent-grafting should be performed by the
cardiothoracic surgeon in the OR, allowing rapid
conversion to conventional surgery in case of complications.

40. XV. Ulusal Vasküler Cerrahisi, Antalya, 2011Acute traumatic aortic rupture
Acute Traumatic Aortic Rupture
-Thank you –