Acute Traumatic Aortic Transection Research Articles

Uncomplicated vaginal delivery 5 years after acute traumatic aortic transection and transluminal endovascular aortic repair

We describe the case of a 40-year-old patient who sustained an aortic transection in 2016 following a road traffic accident and had two subsequent full-term pregnancies. This case adds to the literature on pregnancy after endovascular aortic repair.

Surgical Repair of Acute Traumatic Aortic Transection Using Partial or Left Heart Bypass: Our Experience of Six Cases

Aortic transection following blunt trauma chest is one of the main life-threatening situations requiring early intervention. The endovascular approach is now preferred; however, in some conditions, an open approach is warranted. We describe our experience of dealing with acute traumatic transection in six such patients over the past 3 years.

Aortic Isthmus Narrowing after Endovascular Repair of Acute Traumatic Aortic Transection.

PurposeThe traumatic transection is located in the normal sized aortic isthmus where the angle is curved. We found a reversal of upper and lower blood pressure differences among patients who underwent thoracic endovascular aortic repair (TEVAR) for transection of the thoracic aorta. We investigated the isthmus stenosis in patients who underwent TEVAR for aortic injury using computed tomography.Materials and MethodsSixteen patients who underwent TEVAR for transection were divided in two groups: the aortic narrowing (AN) group and the non-aortic narrowing (NAN) group. AN was defined as stent graft folding more than 5 mm at the isthmus confirmed by computed tomography. The length of aorta at isthmus, pseudoaneurysm, and angle of isthmus were measured.ResultsAN was noted in five patients (31.3%). The area index in the NAN group (2.16±0.35 cm2/m2) was larger than that in the AN group (1.74±0.77 cm2/m2). The size of the pseudoaneurysm in the NAN group (31.9±4.2 mm) was smaller than that in the AN group (37.4±7.5 mm). The distance from the subclavian artery in the NAN group (15.7±9.3 mm) was longer than that in the AN group (8.4±3.2 mm) but not statistically significant. The angle of the isthmus in the NAN group (131±6 degrees) was larger than that in the AN group (107±3 degrees), and this was the only statistically significant difference (P=0.002).ConclusionAN by stent graft folding should be considered when performing TE-VAR in aortic injury with an acute angle of the isthmus less than 110 degrees.

Transluminal endovascular aortic repair and pregnancy: a case report

Acute Traumatic Aortic Transection (ATAT) is a dramatic event related to extremely high mortality. Transluminal Endovascular Aortic Repair (TEVAR) is currently the preferred Strategy for such lesions and offers an alternative to open surgical repair. In this article we discuss the case of a 21-year old woman who suffered from an ATAT of the aortic isthmus along with multiple fractures and visceral lesions during a car accident. Three years after the endovascular repair of the aorta our patient became pregnant. The pregnancy evolved without any complications, but since no spontaneous labour occurred, and the patient refused labour induction, we decided to perform an elective caesarean section at 41 week. To our knowledge, this is the first case described in literature of a patient undergoing a caesarean section after TEVAR for ATAT.

Endovascular repair in acute traumatic aortic transection: a case report

A thirty-eight-year-old male patient who suffered from 10th and 11th thoracal vertebrae fractures, paraplegia and acute traumatic aortic transection because of accidental fall was referred to our hospital. Open surgical repair carried a very high risk due to severe coexisting injuries. Transection was treated with 30x100 mm Valiant thoracic endograft, which was deployed just distal to the ostium of the left carotid artery. The patient was transferred to the neurosurgery clinic for treatment of paraplegia after an uneventful recovery. Endovascular repair of acute transection confers substantial advantages in mortality and morbidity compared to surgical repair. However, the long-term durability of thoracic endografts remains unknown. If the long-term results are as satisfactory as the promising mid-term results, this technique may become the gold standard approach for the treatment of acute transection.

Uncomplicated vaginal delivery 6 years after stent graft repair of an acute traumatic aortic transection

Acute traumatic transection of the aorta (ATAT) is a devastating event. Transluminal endovascular aortic repair (TEVAR) has meanwhile become an excellent alternative for such lesions. A 27-year old woman sustained a multiple trauma in a car accident including ATAT which was treated by aortic stent graft placement. Six years after the endovascular repair, our patient had only noticed, just shortly after an annual computed tomography (CT) check-up, that she was pregnant and in the 9th week of gestation. The CT was considered as unproblematic for the foetus since direct radiation of the uterus had been avoided. Our patient clearly preferred a vaginal delivery over a caesarean section. The pregnancy was uneventful with uncomplicated vaginal delivery at term. This case shows that vaginal delivery is possible if the stent graft is in regular position without signs of endoleaks and the rest of the aorta is free from dissection or aneurysm formation. It indicates that TEVAR is a sound and durable treatment modality in ATATs and that aortic stent grafts can resist increased intravascular volume and elevated aortic pressure levels as encountered in pregnancy and during vaginal delivery. This particular case also shows that it is possible to respect a patient's right of self-determination.

Endovascular Repair in Chronic Aortic Transection: A Report of Three Cases

Open repair of acute traumatic aortic transection has a very high risk of morbidity and mortality due to the frequent occurrence of other severe coexisting injuries. For this reason, endovascular repair has become the primary treatment modality [[1], [2]]. However, the management of the chronic form caused by undiagnosed rupture is controversial. In this paper, we present three cases of chronic aortic transection treated with endovascular repair.

Blunt traumatic aortic transection: the endovascular experience

BackgroundThoracic aortic transection resulting from blunt trauma is usually fatal. It is almost always associated with multiple, complex, nonaortic injuries that could be adversely affected by standard surgical repair of the aorta. Endovascular stenting techniques offer these patients a less physiologically disruptive treatment option. We studied the feasibility and safety of endovascular stent graft placement for treatment of acute traumatic aortic transection. MethodsBetween 1994 and 2001, 9 patients were treated emergently for aortic transections with stent graft placement. The first patient had a custom-made prototype, and the other 8 patients had the Cook-Zenith thoracic stent graft implanted. All were polyester-covered Z-stent construction and deployed through a femoral 20- to 24-F delivery sheath. ResultsStent graft placement successfully sealed the aorta in all patients. One patient died as a result of a cerebrovascular accident. One patient required a brachial thrombectomy to relieve arm ischemia. The remaining eight patients were alive and without complications during the follow-up period (mean 21 months). ConclusionsEndovascular repair for acute aortic transection is a safe, effective, and timely treatment option. It may be the treatment of choice in patients with extensive associated injuries.

Surgery for Acute Aortic Transection

Traumatic transection of the thoracic aorta is a lethal condition that results in ininietliate death approximately 8S% of the time.' Injury results from rapid deceleration secondary to a fall from a height or high-speed motor vehicle accident. Profound intraluminal hypertension, with pressures in excess of 2,500 mm Hg, are needed to generate a traumatic rupture2 in an area where the aorta is relatively fixed in position. Greater than 90% of the injuries arise in the descending thoracic aorta at the level of the ligamentum arteriosum. An additional 5% of patients will sustain an aortic transection in the ascending aorta, just above the sinotubular junction, whereas the remaining 5% of patients sustain one in the distal descending thoracic aorta or aortic arch.< Patients surviving the initial insult are found to have a partial thickness tear of the aorta or a full thickness tear with the hematoma being contained by intact parietal pleura. The need for urgent intervention is highlighted by the fact that 46% of patients will expire in the 2 weeks after the injury. Nearly 98% of patients will not survive beyond 1 month. The small percentage of patients who evade initial detection are still at high risk for death. Approximately 20% of patients will rupture a traumatic pseudoaneurysm within 5 years of d e t e ~ t i o n . ~ The mere presence of the injury should be an indication for repair. The only exception to this is if the patient has other, life-threatening injuries that require immediate attention. These patients should be managed with aggressive beta-blockade and afterload reduction in an effort to decrease dP/dt and minimize intralumiiial wall tension.' However, this is a calculated risk and repair should be undertaken as soon as the patient is able to tolerate the procedure. The radiographic detection of a traumatic transection is a rapidly evolving field. Angiography remains the gold standard for confirming the presence of an aortic transection with an accuracy of nearly 10070. Angiograms also provide precise anatomic detail that allow for more careful planning of operative intervention. This test remains the diagnostic tool of choice in our practice. Three less invasive modalities, computed tomographic (CT) scanning, transesophageal echocardiography (TEE), and magnetic resonance imaging (MRI), have also been applied to this tenuous patient population. CT has gained popularity because it is noninvasive and wiclely available. It is often used in the trauma patient to evaluate intracranial or intraabdoniinal injury. The addition of il chest wan does not greatly increase the amount of time spent in the radiology suite and the appeal of a single diagnostic procedure before surgical intervention cannot be discounted. To date, however, the accuracy of CT scans are only 90% in the best and most experienced hands and only when strict interpretation criteria are applietL6 Reliahle interpretation must become more standardized hefore widespread application in the setting of acute aortic transection can be advocated. Aortic imaging using TEE has proven its use as a highly accurate method of diagnosing aortic dissection.' In limited reports, the accuracy has been shown to exceed that of CT scans in traumatic transections.' It is an attractive method because of its ready availability in both the emergency department and the operating rooms. However, interpretation can be obscured by the tracheal air column behind the distal aortic arch. Hypertension associated with the procedure may also precipitate rupture. Further experience with TEE may ultimately make it the modality of choice in this setting. MRI, although highly accurate, cannot be advocated for diagnosis of acute transections at the present time. Radiological interpretation is highly variable as is the quality of the machines. More importantly, it is time consuming and patients cannot be adequately evaluated and monitored while the procedure is being performed. The preferred method of surgical repair has been a hotly debated issue for decades. The simplest method remains the clamp and sew technique. Advantages include the elimination of anticoagulation ancl an operative field free of the tubing and cannulae needed with an extracorporeal circuit or shunt. Advocates of this method have consistently shown low rates of paraplegia when the cross-clamp time can be kept to 30 minutes or less.y Some of the earliest repairs in the literature were performed using an extracorporeal circuit. ' Since then many methods have been advocated for repair of traumatic transections. These include partial left-heart bypass with and without heparin, femoral-femoral cardiopulmonary bypass with full dose heparin and passive shunts into the descending thoracic aorta from both the ascending aorta and the left ventricular apex. In 1992, a large meta-analysis reviewed over 1,700 cases of acute traumatic aortic transection repaired with a variety of the aforementioned techniques. This analysis suggests improved neurological outcome with the use of distal

Traumatic aortic transections: Eight-year experience with the “Clamp-Sew” technique

Because traumatic aortic transection is associated with high mortality rates, great debate exists about the appropriate operative technique for treatment of patients who have acute traumatic aortic transection. To determine the safety and efficacy of the "clamp-sew" method, we retrospectively reviewed our 8-year experience treating 75 patients who had aortic injuries secondary to blunt trauma. Seventy-one of these patients were treated surgically. The clamp-sew method was used in all of these operations. Aortic cross-clamp time averaged 24 minutes (range, 14 to 36 minutes), with 4/71 having times in excess of 30 minutes. One patient (clamp time, 28 minutes) became paraplegic. Significant associated injuries were seen in 51/75 patients (48/71 patients with operation), including intrathoracic (35 patients), orthopedic (28 patients), intraabdominal (24 patients), and central nervous system (17 patients) damage. No patient died within 24 hours of operation. Overall 30-day mortality was 12% (9/75), with 7/9 having two or more aforementioned associated injuries. Of these 7, 5 had central nervous system injuries. Two of 9 died within 30 days without two or more associated injuries: 1 Jehovah's Witness of low hemoglobin, and 1 patient of sepsis. Although any of several maneuvers may be appropriate in managing traumatic aortic injuries, the simple "clamp-sew" technique is a safe and effective method for the treatment of traumatic aortic transections.

Repair of aortic transection associated with ductal diverticular aneurysm

A 14-year-old girl involved in a motor vehicle accident sustained an acute traumatic aortic transection at the site of a congenital ductal diverticular aneurysm. Aortic transection is a lethal injury that is uncommon in children. A ductal diverticular aneurysm is a rare congenital lesion, formed when the ductus arteriosus fails to close with aneurysmal formation at the aortic isthmus. Diagnosis, management, and pathophysiology of both lesions are discussed.

Incremental risk factors for spinal cord injury following operation for acute traumatic aortic transection

Of 35 patients operated upon for acute traumatic transection of the upper descending thoracic aorta between 1967 and March 31, 1980, 33 had sufficient information for us to analyze the incidence of spinal cord injury (paraplegia or paresis). This event occurred in eight patients. Multivariate analyses indicated that spinal cord injury was more likely to occur with long aortic cross-clamp times (p = 0.08) when no shunt was employed to perfuse the distal aorta during cross-clamping. The data suggest that if an aortic cross-clamp time exceeding about 30 minutes is anticipated, a shunt should be employed during aortic cross-clamping.