The Egyptian Journal of Radiology and Nuclear Medicine (2012) 43, 193–201

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology andNuclearMedicine

www.elsevier.com/locate/ejrnmwww.sciencedirect.com

ORIGINAL ARTICLE

Endovascular repair of acute traumatic injury

of thoracic aorta

Ahmed H. Abou-Issa a,*, Wael Abdulghaffar a, Fady Elganayni a,

Mohammad Bafaraj b, Hesham Fathy Soliman c

a Diagnostic Radiology Department, Faculty of Medicine, Mansoura University, Egyptb Vascular Surgery Department, Alnoor Specialist Hospital, Holy Makkah, Saudi Arabiac Anesthesiology Department, Faculty of Medicine, Ain Shams University, Egypt

Received 12 August 2011; accepted 14 January 2012Available online 8 February 2012

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KEYWORDS

Endovascular;

Repair;

Traumatic;

Thoracic aorta;

Injury

bbreviations: ATAI, acute tr

moral artery; CTA, compute

nding aorta; EVR, endova

CA, left common carotid

O, left anterior oblique; L

rved reformat; TAG, thorac

Corresponding author. Tel.:

mail addresses: ahmharon

.H. Abou-Issa).

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Abstract Blunt thoracic aortic injury is associated with a high mortality rate. It is the second lead-

ing cause of death after head injury from vehicle accidents. Surgical repair with graft interposition

was the traditional treatment of blunt aortic injury however; the introduction of endovascular stent

graft has revolutionized the definitive treatment of these injuries.

Objectives: To review our experience with endovascular repair (EVR) of acute traumatic injury to

thoracic aorta regarding technique, device, complications and outcome.

Patients and methods: This series included 14 patients subjected to EVR for acute traumatic aortic

injury (ATAI) to the thoracic aorta between January 2010 and August 2011. The diagnosis was sus-

pected in 11 patients based on plain X-ray and the mechanism of trauma and was confirmed on CT

aortic injury; CFA, common

raphy angiography; DA, des-

pair; IA, innominate artery;

SCA, left subclavian artery;

g zone; MPCR, multiplanar

raft; VR, volume rendering

667623; fax: +966 25664314.

com, ahmharon@gmail.com

of Radiology and Nuclear

sevier B.V.

tian Society of Radiology and

lsevier

Open access under CC BY-NC-ND license.

194 A.H. Abou-Issa et al.

scan. The other 3 cases were diagnosed incidentally during CT scan for other indications. Gore

TAG device was used in all patients.

Results: EVR was well tolerated with no peri-procedural mortality, conversion to open surgery,

post-intervention paraplegia or significant blood loss. Complications encountered are: inadvertent

stent jump (1), endoleak type 1 (1), endoleak type 3 (1), and left common iliac artery thrombosis (1).

Conclusion: Endovascular repair of acute traumatic injury to thoracic aorta can be performed with

less risk than emergency surgical treatment. It is a less invasive therapeutic option even in young

and low risk patients. It can be performed rapidly with minimal blood loss and subsequent shorter

convalescent periods.

� 2012 Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V.

Open access under CC BY-NC-ND license.

1. Introduction

Blunt thoracic aortic injury is associated with a high mortalityrate. It is a devastating consequence of deceleration trauma.Aortic injury is second only to head injury as the leading cause

of death from vehicle accidents. More than 80% of patients dieat the scene, and most of those who survive the initial injurywill die without definitive treatment (1–3).

The force that causes the aorta to tear often leads to other

organ injuries. Up to 25% of patients with blunt aorta injuryrequire a major operation before aortic repair (4,5). Therefore,definitive treatment is often delayed due to these multiple con-

comitant injuries, an aspect that accounts for an in-hospitalrupture rate of 10–13%, usually within a few hours afteradmission (3,6,7). The aortic tear occurs most often at the aor-

tic isthmus, and, in order of frequency, affects the proximaldescending aorta, the ascending aorta, the aortic arch, distaldescending aorta, and the abdominal aorta (4,8).

Traditional treatment of blunt aortic injury has been earlyopen surgical repair with graft interposition, with or withoutadjuncts to maintain distal perfusion. Open repair carries a2.9–7% risk of paraplegia and an operative mortality rate

ranging from 15% to 23.5%. Nevertheless, the introductionof endovascular stent grafts is revolutionizing the definitivetreatment of these injuries. Although endovascular manage-

ment of aortic rupture was initially restricted to high-risk pa-tients with multiple injuries, in many centers it has nowbecome the preferred first treatment even in young or low-risk

patients. The potential benefits of thoracic endovascular aorticrepair (TEVAR) over open repair include no need for thora-cotomy or single lung ventilation, avoidance of aortic cross-clamping, decreased use of systemic anticoagulation, less

blood loss, less procedure time, can be done with local anesthe-sia, less postoperative pain and lower paraplegia rate. Thesefactors can improve overall survival as documented by several

meta-analyses (2–4,9–12).

2. Aim of study

To review our experience with endovascular repair of acutetraumatic aortic injury to thoracic aorta regarding technique,

device used, complications and outcome in 14 patients.

3. Patients and methods

This study included 14 patients subjected to EVR for thoracicATAI between January 2010 and August 2011. Before the

starting date, surgical repair was the treatment option for these

cases. The diagnosis was suspected in 11 patients based onplain X-ray and mechanism of trauma and was confirmed on

CT scan. The other 3 cases were diagnosed incidentally duringCT scan for other indications.

All cases were done in Angio Suite (Siemens Axiom Artis)with interdisciplinary cooperation between interventional radi-

ologists, vascular surgeons, anesthesiologists and intensivecare teams. Standby operative room was ready for surgicalconversion if required.

Pre-intervention planning was based on CT scan which wasreviewed for the following points: (1) Length of injured seg-ment and pattern of injury; (2) length and diameter of proxi-

mal landing zone (LZ); (3) diameter of distal LZ; (4) relationto LSCA; (5) measure C-arm angle required during interven-tion; (6) diameter of common femoral and iliac arteries tochoose larger access; (7) aorta distal to injured segment for

any injury or abnormality and (8) any associated organ injuriesor hematoma as heparin would be avoided with these injuries.

Under general anesthesia and strict sterilization, diagnostic

aortography in LAO projection was done with 5F pigtail cath-eter through RT CFA in 12 cases. Rt brachial access was donein 2 cases due to RT hip injury in one patient and severe aortic

injury in the second one to minimize negotiation with the guidewire (Fig. 1, Table 1). The LAO angle ranged from 60� to 75�and was predefined on CT scan. This angle is very important to

have a clear view of the landing zone, LSCA and LCCA. IVheparin 5000 IU used regularly except in 1 case with cerebralhematoma.

Exposure of left common femoral artery and arteriotomy

then performed, 0.035 Amplatz super stiff J-shaped wire,260 cm (Boston Scientific) introduced into ascending aorta.An introducer sheath (18–22Fr) was advanced; sheath size de-

pends on the stent diameter. Stent is then advanced throughthe sheath to cover the injured segment. Proper positioningof the wire and stent is confirmed before release. After stent re-

lease, trilobed balloon used to touch the distal and proximallanding zones respectively to fix the stent. Finally, completionaortography is done to confirm stent position, relation to great

vessels and to exclude endoleak (Fig. 2).The Gore TAG endoprosthesis was used in 13 patients. The

stent diameter ranged from 26 to 34 mm and was pre-defineddepending on diameter of proximal LZ on CT scan. This de-

vice is composed of a symmetric expanded polytetrafluoroeth-ylene (ePTFE) graft with an outer self-expanding nitinolsupport structure to combine both device flexibility and mate-

rial durability. The function of the endoprosthesis is to inter-nally reline the thoracic aorta and isolate the diseasedsegment from blood circulation. Two radiopaque gold bands

Figure 1 32 YOM, RTA victim with ATAI of proximal DA. (A) Aortography via RT brachial access confirmed the diagnosis.

(B) Completion angiography shows exclusion of the injured segment. (C) Follow upCTA after 1 month: no endoleak or other complications.

Table 1 shows age, sex, access site, stent diameter and complications in 14 patients subjected to EVR in our series.

Case Age Sex Access LZ diameter (mm) Stent size (mm)b LSCA coveragec Complications

Diagnostic Therapeutic

1 31 M RT CFA LT CFA 20 26 · 100 Total –

2 32 M RT brachial A LT CFA 26 31 · 150 Non –

3 25 M RT CFA LT CFA 23 26 · 100 Partial –

4 28 F RT CFA LT CFA 27 31 · 100 Total Stent jump

5 55 M RT CFA LT CFA 30 34 · 150 Total Endoleak type 3

6 42 M RT brachial A LT CFA 26 31 · 100 Total –

7 22 M RT CFA LT CFA 25 28 · 100 Total LT CFA thrombosis

8 34 M RT CFA LT CFA 24 28 · 100 Total –

9 29 M RT CFA LT CFA 23 28 · 100 Total –

10 35 M RT CFA LT CFA 25 28 · 100 Non Endoleak type 1a

11 33 M RT CFA LT CFA 27 31 · 100 Total –

12 26 M RT CFA LT CFA 22 26 · 100 Total –

13 45 M RT CFA LT CFA 26 31 · 100 Non –

14 16 M RT CFA LT CFA 17 21 · 100 Partial –

a This patient is subjected to re-intervention with overlapping stent (Fig. 6).b Stent size was 10–20% larger than diameter of proximal landing zone.c Left SCA was totally covered in 9 cases with evidence of refilling in all cases.

Endovascular repair of acute traumatic injury of thoracic aorta 195

are attached to the base of the flares, serving as a guide duringdeployment and in graft surveillance. A trilobed balloon isused to inflate the aortic stent graft while allowing continuousantegrade blood flow during balloon inflation (Fig. 3) (13,14).

The last patient in this series was 16 years old in whom a21 mm C-Tag endoprosthesis (C = Conformable) was used(Fig. 4).

Plain X-ray chest was done on the second day to confirmstent position and contour. Follow up CT scan was done at1 month after procedure unless it is indicated earlier e.g. if

endoleak is noted at time of intervention (Fig. 7) or for otherreasons e.g. to exclude pulmonary embolism.

4. Results

Study included 14 patients, they were RTA victims, 13 males

and 1 female, age ranged from 16 to 55 years. ATAI was con-firmed on CT scan, patterns of injury included deformities ofthe aortic contour, intimal flaps, transection, thrombus or

debris into the aortic lumen, adventitial hematoma, pseudoan-eurysm and periaortic hematoma.

EVR was done in all cases with no peri-procedural mortal-

ity. There was no conversion to open surgery, post-interven-tion paraplegia or significant blood loss. Complicationsencountered are: inadvertent stent jump (1 case, Fig. 5),

Figure 2 Summarizes the steps of EVR in a 25YOM, RTA victim with ATAI. (A) CTA MPCR shows location of aortic injury and

relation to LSCA. (B) Aortography through 5F pigtail catheter in 55� LAO projection, confirmed aortic injury. The C-arm angle was pre-

defined on CT scan. (C) Confirms stent position before deployment, the stent and wire should follow the outer curve of aorta. (D&E) After

release of stent; a trilobe balloon is inflated to touch the distal and proximal landing zone respectively. (E) Completion angiogram to

confirm stent position, coverage of injured segment and absence of endoleak. The LSCA was partially covered with stent flares.

196 A.H. Abou-Issa et al.

endoleak type 1 (1 case, Fig. 6), endoleak type 3 (1 case,Fig. 7), and left common iliac artery thrombosis for whichthrombectomy was done (Table 1).

5. Discussion

Despite significant advances in critical care medicine and refine-ment in surgical techniques; morbidity and mortality rates of

open surgical repair of ATAI are still high. Postoperativeparaplegia is of major concern with an incidence up to 25.5%and 30-day mortality ranging from 8% to 30% (15). Some

authors have advocated that open repair remains the first linetherapy for blunt aortic injury in patients <18 years of ageand those with an outer wall aortic diameter <18 mm for rea-

sons of oversizing but in many centers it has now become theinitial procedure of choice, even in young or low-risk patients.

Figure 3 (A) Diagram shows components of Gore TAG endoprosthesis, (B) Trilobe balloon (13,14).

Figure 4 16YOM RTA victim with ATI of descending aorta incidentally discovered on CT scan (arrow in A). (B) EVR with C-TAG

21X100 mm. (C) Follow up CT scan shows exclusion of injured segment and partial coverage of LSCA. No endoleak.

Endovascular repair of acute traumatic injury of thoracic aorta 197

As for the timing of repair, in the case of aorta-related hemody-

namic instability (massive mediastinal hematoma, activebleeding, or left hemothorax), emergency endovascular treat-ment must be performed. In the case of non-aorta-related

hemodynamic instability, the other life-threatening injuriesshould be treated first, and endovascular treatment of the aorticinjury can be performed within 24 h (16). In our institution,

EVR is now the treatment option for patients with acute injuryof the thoracic aorta. Surgery was performed before the intro-duction of this technique. EVR is associated with clear reduc-

tion in peri-operative mortality and morbidity. No paraplegiawas encountered in all (14) cases. Due to the introduction of

new C-TAG device (C = Conformable) we were able to do

EVR for a 16 year old patient whose aorta was 17 mm indiameter (Fig. 4). Although we did not have immediatecomplications yet, long term follow up and use in more cases

will show the future of these devices in small aorta and youngages.

Graft was oversized by 10–20% based on the inner diame-

ter of the landing zone except in the first case where a 26 mmstent used in 20 mm aorta (30% oversizing) because C-TAGwas not available at that time. However, no endoleak or col-

lapse was encountered in this case. The minimum length oflanding zone required for EVR was 1 cm from the origin of

Figure 5 28YOF, RTA victim, referred for EVR. (A) 3DVR CTA, (B) Conventional angiography confirmed complex aortic injury distal

to LSCA. Common trunk for LCCA and IA noted. Note the short distance between LSCA and the common trunk and the short landing

zone as well.(C) Angio after stent release shows inadvertent proximal jump of the stent so it partially covers the common trunk and

encroaches on LCCA. (D) Follow up CTA shows encroachment on the common trunk and retrograde filling of LSCA. Patient recovered

without ischemic or neurologic complications. Comment: RT brachial access would be preferred in such cases, if bailout stenting is

required.

198 A.H. Abou-Issa et al.

LSCA otherwise; the LSCA will be covered. The LSCA wascovered totally in 9 and partially in 2 patients. This decisionwas based on CT measures and reviewed during angiography.

Sizing catheters was used in 3 patients to allow more accurateassessment before deployment.

Intentional covering of LSA may lead to higher incidence

of extremity ischemia and stroke. The evidence in the literature

is sparse with a low number of events and the outcomes arepoorly described in many cases although it needs to be weighedagainst many factors, such as urgency of repair or patient

anatomy (17,18). In our study, LSCA covering was well toler-ated without signs or symptoms of peripheral limb ischemia orneurological manifestations. All cases showed refilling of

LSCA on follow up CTA (Figs. 2,4–7).

Figure 6 35YOM, RTA victim with ATAI. (A) 3DVR CTA shows injury distal to LSCA. (B) Completion angiogram after stent

deployment shows bird peak sign (arrow) however, no endoleak noted. The LSCA was not covered. (C&D) follow up after 1 month shows

endoleak type I with collapsed stent. (E) Re-intervention with insertion of a larger stent proximally. (F) Follow up CTA shows complete

exclusion of the injured segment with no endoleak however, the LSCA is totally covered now.

Endovascular repair of acute traumatic injury of thoracic aorta 199

Complications after endograft repair can manifest imme-diately or in a delayed fashion. The most commonly re-

ported complications (many of which are rare) includeendoleak, graft collapse, branch vessel complications includ-ing stroke and left upper extremity ischemia, endograft

infection, graft material failure, missed injury or stent migra-tion, paraplegia, and complications related to the access site(19).

Endoleak is the most common complication after endo-vascular repair with a prevalence ranging from 3.2% to14.4% (9,11). Endoleaks are important to recognize becausethey result in exposure of the excluded pseudoaneurysm to

systemic arterial pressure. Small endoleaks are sometimesmanaged conservatively with imaging follow-up, but mostrequire rapid intervention with either additional overlapping

stent placement or conversion to open surgical repair(20,21).

In our series, we reported 1 case with inadvertent jump dur-

ing deployment (Fig. 5). Immediately after stent release, thepatient developed a sudden drop of blood pressure and circu-latory collapse but was successfully resuscitated. Although the

graft encroaches on LCCA yet, there were no neurological orischemic manifestations on follow up. Endoleak was reported

in 2 cases. The first one was type 1 and resulted in collapse ofthe graft and refilling of the pseudoaneurysm (Fig. 6). Endo-leak was expected in this patient due to presence of bird beak

sign on completion angiogram. This sign was due to lack ofapposition between the stent and inner surface of the aortawhich allows passage of blood between them with eventual col-

lapse of the stent. Re-intervention with overlapping largerstent was performed. The second patient had type 3 endoleak(Fig. 7); there was immediate filling of the aneurysm on com-pletion angiogram. CTA showed contrast filling of the aneu-

rysm at inner curve of the stent in relation to focal contourirregularity of the stent suggesting fracture or disruption ofthe stent. Access complications in our series included 1 patient

in whom thrombosis of the left iliac and common femoralarteries occurred. Thrombectomy was done and antegradeflow regained. Due to new trend toward EVR of ATAI, we

prepare for total percutaneous repair with the use of closuredevices to minimize surgical access complication and shortenthe overall procedure time.

Figure 7 55YOM, RTA victim subjected to EVR for ATAI. (A) Catheter angiography shows injured segment distal to LSCA. There is a

common trunk for IA & LCCA. (B) Completion angiography shows endoleak (arrow). (C,D&E) CTA after 1 week shows endoleak (type

3) related to small defect in the graft.

200 A.H. Abou-Issa et al.

6. Conclusion

Endovascular repair of acute traumatic injury to the thoracic

aorta can be performed with less risk than emergency surgicaltreatment. It is a less invasive therapeutic option that can beperformed even in young and low risk patients. This procedure

is well tolerated, can be performed rapidly with minimal bloodloss with subsequent shorter convalescent periods. However,close follow up is important to exclude risks of late

complications.

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