Blunt Thoracic Aortic Injury JUSTIN CHAN PRINCESS MARGARET

Blunt Thoracic Aortic Injury JUSTIN CHAN PRINCESS MARGARET HOSPITAL JULY 27, 2013

Case Illustration 74/F Good past health RTA victim Back passenger of minibus Hit over left side by another car

Case Illustration Trauma series CT Acute traumatic aortic injury at aortic isthmus 4. 2 cm intimal flap along descending thoracic aorta No mediastinal hematoma Multiple rib fractures Pelvic fracture with left pelvic hematoma and active contrast extravasation Blunt liver trauma with intraparenchymal hematoma

CT images

Case Illustration Pelvic fracture with hematoma Angiogram: bleeding from branches of left internal iliac artery Embolisation performed Pelvic fracture: minimal displacement conservative Fractured ribs + liver hematoma Conservative TEVAR Stenting of aortic dissection and left subclavian artery

Post-op CT Images

Blunt Thoracic Aortic Injuries Incidence Pathology/Pathogenesis Management options Issues unsolved Conclusion

Incidence Traumatic aortic injuries 2 nd commonest cause of death due to blunt trauma Autopsy series of blunt trauma patients Aortic rupture rates: 12%-23% Autopsy study by Parmley et al. ~80% of patients die before arrival to hospital 1. 2. 3. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA et al (1997) Prospective study of blunt aortic injury: multicenter trial of the American Association for the surgery of trauma. J Trauma 42(3): 374 -380; discussion 380 -383 Schumacher H, Bockler D, von Tengg-Kobligk H, Allenberg JR (2006) Acute traumatic aortic tear: open versus stentgraft repair. Semin Vasc Surg 19(1): 48 -59 Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086 -1101

Incidence Remained the same ~ past 12 years Strongly correlated with Sudden change in velocity Impact on patient’s side of car ~85% of thoracic aortic injury was due to side impact in one study Intrusion of vehicular wall into passenger compartment 1. Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J (2007) Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 62(3): 664– 667 2. Horton TG, Cohn SM, Heid MP, Augenstein JS, Bowen JC, Mc. Kenney MG et al (2000) Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma 48(6): 1008– 1013; discussion 1013– 1014

Classification Parmley (1958) Pathological features from autopsies Grade Pathology 1 Intimal haemorrhage 2 Intimal hemorrhage plus intimal laceration 3 Laceration into the aortic media 4 Complete aortic laceration (transection) 5 Pseudoaneurysm 6 Complete aortic laceration with active hemorrhage Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086 -1101

Classification Arizzadeh CT imaging 1. 2. Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010 Arizzadeh A, Keyhani K, Miller CC III, Coogan SM, Safi HJ, Esttrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009; 49: 1403 -8.

Pathology Confined to specific locations Classical site Isthmus of aorta Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad. 2010

Sites of Injury - Isthmus - (IIC – 70 -90%) - Ascending aorta/proximal arch - (I to IIB – 10 -15%) - Mid-descending aorta - (IIIA to IIIB – 5 -10%) Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad. 2010

Postulated Mechanisms Shear and stretching forces Relative mobility of portion of vessel adjacent to a fixed portion Osseous pinch Compression of vessel between bony structures ‘Water-hammer’ effect Profound intraluminal hypertension during severe trauma Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad. 2010

Blunt Aortic Injury. N Engl J Med 2008. 359: 1708 -16

Pathogenesis Most likely: mixed mechanism Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7 th edition, 2010

Management Timing of operation Immediate Urgent (<24 hrs) Delayed Type of repair Open Endovascular

Timing of Operation Hemodynamically unstable Mortality >90% Immediate surgery Hemodynamically stable Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7 th edition, 2010

Immediate Surgery Standard surgical practice for many decades Parmley: 30% who reach the hospital die within first 6 hours Meta-analysis by Von Oppell et al: Death rate: hemodynamically stable patients ~21. 3% (0 -54. 2%) Majority of deaths: associated injuries to other organs 1. 2. Parmley LF, Marian WC: Non-penetrating traumatic injury of the aorta. Circulation 17: 1086 -1100, 1958 Von Oppell UO, Dunne TT, De Groot MK, et al: Traumatic aortic rupture: Twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 58: 585 -595, 1994

Delayed Surgery Prospective study by Fabian et al Delaying surgical repair plus maintaining blood pressure In-hospital free rupture Mortality 2 studies by Hemmila et al and Pacini et al No difference in mortality between urgent and delayed repair Risk: Aortic rupture 1. 2. 3. 4. 5. ~ 2 -5% of patients Most within 1 st week after trauma Pate JW, Fabian TC, Walker W (1995) Traumatic rupture of the aortic isthmus: an emergency? World J Surg 19(1): 119– 125; discussion 125– 126 Fabian TC, Davis KA, Gavant ML, Croce MA, Melton SM, Patton JH Jr et al (1998) Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg 227(5): 666– 676; discussion 676– 677 Holmes JH, Bloch RD, Hall RA, Carter YM, Karmy-Jones RC (2002) Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis. Ann Thorac Surg 73(4): 1149– 1154 Hemmila MR, Arbabi S, Rowe SA, Brandt MM, Wang SC, Taheri PA, et al. Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair? J Trauma 2004; 56: 13 -23. Pacini D, Angeli E, Fattori R, Lovato L, Rocchi G, Di Marco L, et al. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005; 129: 880 -4.

Current Recommendations Urgent (<24 hours) repair Except: other serious concomitant non-aortic injuries or After other injuries have been treated but prior to hospital discharge Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010

Current Recommendations Consider delayed repair in patients with Respiratory insufficiency due to lung contusion Head injury with abnormal CT showing haemorhage or edema Coagulopathy Severe abdominal solid organ injury and pelvic fractures Cardiac risk factors/blunt cardiac injury Multiple medical co-morbidities 1. 2. Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7 th edition, 2010 Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad. 2010

Surgical Approach Open Endovascular

Open Surgery Conventional treatment of choice Surgical technique Left-sided posterolateral thoracotomy Proximal and distal control of proximal descending aorta Direct aortic suture or Tube-graft interposition with clamp-and-sew technique Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7 th edition, 2010

Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7 th edition, 2010

Open Surgery: Drawbacks M 0 rtality rate 28% Paraplegia rate 16% Need for thoracotomy and one-lung ventilation Aortic cross clamping intracranial pressure Hazardous in patients with head injuries 1. 2. Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma. A 15 year experience. J Thoracic Cardiovas Surg 1990; 100: 652 -60. Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 56: 565 -70.

TEVAR - Thoracic Endovascular Aortic Repair Began in United States in 1994 Dake and colleagues 1997 10 patients with traumatic lesions of thoracic aorta 1. 2. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatm of descending thoracic aortic aneurysms. N Engl J Med 1994; 331: 1729– 1734 Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology 1997; 205 – 662

TEVAR - Thoracic Endovascular Aortic Repair Preprocedure Imaging Multislice computed tomography Access Open approach to access iliac vessels (≤ 8 mm in diameter) Consider percutaneous approach Where iliofemoral system is very adequate for endograft access 1. 2. Peterson BG, Matsumura JS, Morasch MD, West MA, Eskandari MK. Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005; 59: 1062– 1065 Tehrani HY, Peterson BG, Katariya K, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006; 82: 873– 877; discussion 877– 87

TEVAR - Thoracic Endovascular Aortic Repair Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS (2001) Traumatic rupture of the thoracic aorta: Cohort study and systematic review. J Vasc Surg 34(6): 1029– 1034

Published in January 2011 Systematic review: 7768 patients from 139 studies Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010

TEVAR vs Open TEVAR Mortality 9% VS 19% (p<0. 01) Non-operative management 46% Spinal cord ischemia 3% VS 9% (p=0. 01) Open repair Graft infection Systemic infections Pneumonia mostly Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010

TEVAR: Drawbacks Designed for use in degenerative disease Most traumatic injuries occur in younger patients Existing graft diameters may not be appropriate for smaller aortas Lack of long-term results Material failures such as stent fractures and fabric fatigue may become more significant during ensuing decades of follow up

Conclusions Overall morbidity and mortality in recent years Both open and endovascular repair for blunt aortic injury Timing of Surgery Urgent repair (<24 hrs) Endovascular repair is superior to open repair In terms of operative mortality and complication rate

Thank you

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA et al (1997) Prospective study of blunt aortic injury: multicenter trial of the American Association for the surgery of trauma. J Trauma 42(3): 374 -380; discussion 380 -383 Schumacher H, Bockler D, von Tengg-Kobligk H, Allenberg JR (2006) Acute traumatic aortic tear: open versus stent-graft repair. Semin Vasc Surg 19(1): 48 -59 Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17(6): 1086 -1101 Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J (2007) Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 62(3): 664– 667 Horton TG, Cohn SM, Heid MP, Augenstein JS, Bowen JC, Mc. Kenney MG et al (2000) Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma 48(6): 1008– 1013; discussion 1013– 1014 Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2010 Arizzadeh A, Keyhani K, Miller CC III, Coogan SM, Safi HJ, Esttrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009; 49: 1403 -8. Clouse WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad. 2010 Cronenwett JL, Johnston WK, Rutherford’s Vascular Surgery, 7 th edition, 2010 Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma. A 15 -year experience. J Thoracic Cardiovas Surg 1990; 100: 652 -60. Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 56: 565 -70. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994; 331: 1729– 1734 Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology 1997; 205: 657– 662. Peterson BG, Matsumura JS, Morasch MD, West MA, Eskandari MK. Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005; 59: 1062– 1065 Tehrani HY, Peterson BG, Katariya K, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006; 82: 873– 877; discussion 877 – 87 Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS (2001) Traumatic rupture of the thoracic aorta: Cohort study and systematic review. J Vasc Surg 34(6): 1029– 1034