Trend of management of traumatic thoracic aortic injuries in a single center

Abstract

The purpose of this study was to review the shift in the trend of management and mid-term outcomes of all patients who sustain thoracic aortic injury. A Retrospective analysis was performed of all patients sustaining blunt thoracic aortic trauma admitted to our unit. Forty-seven patients were presented with injury to the thoracic aorta following blunt chest injury. Ten patients underwent open surgical repair of their thoracic aortic injury. The mean age ± SD (range) was 29.4 ± 7.9 years (18–41) with a mean Injury Severity Score (ISS) of 41 ± 14.7 (25–75). Fifteen patients underwent thoracic endovascular repair for blunt aortic transections with a mean age of 35.1 ± 14.5 years (17–65), mean ISS of 40.8 ± 13.9 (20–75) and an average length of hospital stay of 25.6 ± 14.5 days (3–77). The mean aortic diameter proximal to the aortic injury was 23.46 ± 3.02 mm (19–28) with a mean aortic angulation of 58.46° ± 17.73 (44–80°). The mean oversizing was 24.4 ± 5.4% (17–32%). At our institution, there has been a paradigm shift in the emergent repair of blunt thoracic aortic injury from open surgery to endovascular repair. Oversizing of the stent-graft did not translate to a poorer outcome.

Keywords

blunt thoracic aortic injury stent-graft thoracotomy endoleak paraplegia

Background

Injuries to the thoracic aorta sustained secondary to blunt chest trauma results in devastating consequences for the multi-trauma victim. A five-year retrospective review of the North American National Trauma Databank identified 3114 blunt aortic injuries among 1.1 million trauma presentations (0.3%).¹ Though thoracic aortic injury (TAI) is relatively uncommon among trauma presentations, these injuries have been noted to occur in up to one-third of fatalities from blunt trauma with 80% of deaths occurring at scene.²

In 1997, the American Association of Trauma published a prospective study demonstrating that conventional open repair had an overall mortality of 31%.³ However, the mortality and complication rate from aortic trauma has fallen over recent years, particularly with the advent of endovascular approaches to aortic repair.⁴ Results from our center have also reflected the trend of increasing endovascular repair over the past decade for traumatic aortic injuries.

The purpose of this study was to review the shift in the trend of management and the mid-term outcomes at our State Major Trauma Center of all multitrauma patients who sustained blunt thoracic aortic injury over an 11-year period.

Patients and methods

Patients

The State Major Trauma Center at the Royal Perth Hospital (RPH) is the only Level 1 trauma center in Western Australia. Thoracic aortic injury was diagnosed in multitrauma patients via computed tomography angiogram (CTA) of the thoracic aorta with intravenous contrast administration. A prospectively updated State Trauma Registry Database was used to identify all consecutive patients admitted with blunt thoracic aortic injury between June 2000 and April 2012. Medical records, discharge summaries, radiological documentation and surgical documentation were also used as complementary sources. A written institutional informed consent was obtained from all patients if feasible, undergoing repair of the thoracic aortic trauma.

Demographic information was collected, including patient age, gender and the Injury Severity Score (ISS). The ISS is an anatomical scoring system that provides an overall score for patients with multiple injuries. Aortic arch angle was measured either on CTA and/or on lateral aortogram was also quantified. This was defined as the angulation between the ascending and the descending aorta where the lines joined at the highest point (A) of the transverse aorta, as shown in Figure 1.⁵ Postoperative information was obtained, including intensive care unit (ICU) admission, length of hospital stay, the type of repair (open or endovascular) as well as the need for conversion to open repair and in-hospital mortality and complications. For endovascular procedures, the type of endograft and its manufacturer were also noted.

Figure 1

The aortic arch angle was measured at the intersection between AB and AC, as shown by the white arrow

The decisions regarding type of repair and device selection and sizing in endovascular repair cases were made at the discretion of the primary operating surgeon. Appropriateness for endovascular repair was based on anatomic features and patient medical co-morbidities. Outcome measures in this study were restricted to those during the index hospitalization.

Procedure characteristics

Aortic injury was managed either operatively (open or endovascular repair), non-operatively (close follow-up in the absence of intervention) or the injuries sustained by the patient were of a nature to be incompatible with life and intervention was not undertaken. Experienced cardiothoracic surgeons performed all open repairs via a left thoracotomy and single-lung ventilation in a conventional operating theatre. The ‘clamp and sew’ technique was used in types II and III, while in type IV injury, the partial left heart bypass method was used. The aortic injury was exposed through a posterolateral left thoracotomy incision. The left lung was collapsed using either a double-lumen endotracheal tube or a left main bronchial blocker. The femoral artery and atrial appendage was catheterized and connected by appropriate tubing to a Bio-Medicus pump (Bio-Medicus, Minneapolis, MN, USA) with minimal systemic heparinization. The distal aortic pressures was maintained around 60–100 mmHg. After obtaining proximal and distal control with the shortest inter-clamp distance, the torn aortic edges were trimmed and the interposition graft anastomosed. On completion the patient was slowly weaned off bypass.

Experienced vascular surgeons performed endovascular repair predominantly, with a single repair performed by two consultant interventional radiologists. All endovascular procedures were carried out in a hybrid endoluminal-operating suite with angiographic capabilities. General anesthesia was used in all patients by a team of anaesthetists. Spinal drains were not used as most of these patients had multiple associated injuries and were not always hemodynamically stable. Common femoral artery access was established after arterial exposure with an oblique skin incision. In addition, the contralateral common femoral artery was obtained via percutaneous puncture. A third access site was used at the surgeon's discretion and included either the left brachial artery (majority) or rarely the right brachial artery. Patients received heparin anticoagulation if intracerebral or subarachnoid bleeding was excluded. Endovascular cases were performed with one of the following endografts: Valiant® Thoracic Stent (Medtronic, Santa Rosa, CA, USA), and Zenith TX1® and Zenith TX2® Pro-Form endovascular stent-graft (Cook, Inc, Bloomington, IN, USA). Endovascular grafts were inserted over a stiff wire (Lunderquist or Amplatz Wire, Cook, Inc) and deployed during pharmacological manipulation of the blood pressure and heart rate by the anesthetist. The level of hypotension was left to the discretion of the anaesthetist and operating surgeon. A moulding balloon was not used unless there was evidence of a type I endoleak. Completion angiography was performed using a rapid frame rate (6–7.5 frames per second) with the contract injector set at 10–15 mL/s with a total volume of 15–20 mL per run to differentiate cardiac motion from contrast extravasation.

Follow-up

Standard follow-up postendoluminal graft repair was via clinical review in the vascular outpatient clinic with a CTA performed within the first month of graft insertion with further clinical follow-up and CTA at six and 12 months for the first year and annually thereafter. Morphological changes on the CTA were reported in adherence to the reporting standards for endovascular thoracic repair.

Statistical analysis

The primary outcome measure assessed was in-hospital mortality in each of the endovascular and open repair groups. Secondary outcomes included ICU admission and length of hospital stay. Statistical analyses were performed if required using SPSS software (SPSS, Chicago, IL, USA). Data are presented as mean ± standard deviation of the mean (SD).

Results

A total of 47 patients presented to RPH with injury to the thoracic aorta following blunt chest injury over an 11-year period. This represented nearly 1% of all major trauma alerts (n = 4790) admitted during this same time period at the State Trauma Center. Forty patients were admitted secondary to a motor vehicle accident, two were admitted following a fall from a height greater than 3 m, four patients sustained crush injuries secondary to a motor bike accident and one patient was a pedestrian struck by a car.

Endovascular group

Fifteen patients underwent thoracic endovascular repair for blunt aortic transections (Table 1). The mean age of the patients was 35.1 ± 14.5 years (17–65) with a mean ISS of 40.8 ± 13.9 (20–75) and an average length of hospital stay of 25.6 ± 14.5 days (3–77) (Table 2). Ten (67%) were male. Two patients had grade I thoracic aortic injury associated with uncontrollable hypertension, four patients had grade II injury, eight patients had grade III injury and one patient had grade IV thoracic aortic injury.^6,7 Five patients (33.3%) required coverage of the left subclavian artery (LSA) for adequate proximal seal with only one of these undergoing a carotid–subclavian bypass at a later stage for persistent left arm ischemic weakness. One patient (6.7%) had intraoperative stenting of the left common carotid artery as it was felt that partial shuttering of this vessel had occurred during stent-graft deployment. None of the patients developed either cerebral ischemic infarcts, embolic infarcts or neurological complications (e.g. paraplegia) (Table 3). The mean follow-up of these patients was seven years with CT scan and chest X-ray.

Table 1

Patient demographics and baseline characteristics

Variable	Open repair (n = 10)	Endovascular repair (n = 15)	P value
Mean age ± SD (range)	29.4 ± 7.9 (18–41)	35.1 ± 14.5 (17–65)	0.157
Sex (M/F)	8/2	10/5	–
ISS ± SD (range)	41 ± 14.7 (25–75)	40.8 ± 13.9 (20–75)	0.157
Co-morbidities
Diabetes mellitus	1 (10%)	1 (6.7%)	0.157
Hypertension	2 (20%)	3 (20%)	0.160
Coronary artery disease	0	2 (13.3%)	–
Peripheral arterial disease	0	1(6.7)	–
Aortic injury morphology* (%)
Type I (intimal tear)	0	2 (13.3%)	0.04
Type II (intramural hematoma)	1 (10%)	4 (26.7%)	0.160
Type III (pseudoaneurysm)	6 (60%)	8 (53.3%)	0.150
Type IV (rupture)	3 (30%)	1 (6.7%)	0.147

ISS, Injury Severity Score; SD, standard deviation

Values in parentheses are ranges

Significant at P < 0.05

Table 2

Intraoperative data

Variables	Open repair	Endovascular repair	P value
Operating Time (minutes)	232.3 ± 125 (140–554)	115.7 ± 56.7 (60–259)	0.03
LOS	22.7 ± 11.6 (12–45)	25.6 ± 19.5 (3–77)	0.170
Radiation dose	N/A	1093.823 (69.972–7568.500)	–
Screening time (minutes)	N/A	21.9 ± 18.4 (7.3–82.4)	–
Contrast volume (mL)	N/A	181.9 ± 57.7 (72–328)	–

LOS, length of hospital stay (in days)

Values in parentheses are ranges

Operating time was defined as the time from surgical skin incisions to the closure of the surgical incisions

Table 3

Postoperative complications

Variables	Open repair	Endovascular repair	P value
Intrathoracic nerve damage	0	N/A	N/A
Paraplegia	0	0	N/A
Paraparesis	0	0	N/A
Pneumonia/lung collapse	2	0	0.247
TIA	0	1	0.157
Access site complications	0	1	0.157
Cardiac tamponade	1	0	0.157
Left hand weakness	0	1	0.157
AKI*	0	0	N/A

TIA, transient ischemic attack

*Patients were classified as having AKI when baseline serum creatinine was below the threshold and subsequently rose by a factor of 1.5 or more or the estimated glomerular filtration rate was reduced by 25% or more

The mean aortic diameter (adventitia-to-adventitia), proximal to the aortic injury, was 23.46 ± 3.02 mm (19–28) with a mean aortic angulation of 58.46° ± 17.73 (44–80°). Eleven (73.33%) patients were repaired using a Zenith TX2® Pro-Form endovascular stent-graft (Cook, Inc) with two patients repaired with the first-generation thoracic stent-graft device (Zenith TX1®) and one patient was repaired with a thoracic extension device. Only one patient had a Valiant Thoracic stent-graft (Medtronic) inserted. No abdominal aortic extension cuff was used. The mean over-sizing was 24.4 ± 5.4% (17–32%).

Technical success, defined as safe delivery of the endograft to the intended site of injury and successful deployment, was 100%. All patients were repaired under general anesthesia, with a mean procedure time of 115.7 ± 56.7 minutes, a mean fluoroscopy time of 21.9 ± 18.4 minutes and mean contrast volume of 181.9 ± 57.7 mL (Table 3). No patient had a spinal drain placed before the endovascular repair, and there were no instances of new paraplegia or paraparesis (one patient was paraplegic preoperatively because of a spinal cord injury sustained during the initial trauma). Completion angiography demonstrated no endoleak in all patients. There were no thoracic aortic injury-related deaths in this group of patients. The only death in the group was secondary to progression of a severe traumatic brain injury (ISS = 38). A retrievable inferior vena cava filter was inserted when clinically indicated in seven patients and all were retrieved within three weeks of deployment.

Open surgery group

Ten patients underwent open surgical repair of their thoracic aortic injury. Grade III (pseudoaneurysm) was identified in six patients while a grade IV (thoracic aortic rupture) occurred in three patients (Table 1). The mean age ± SD (range) was 29.4 ± 7.9 years (18–41) with a mean ISS of 41 ± 14.7 (25–75) and an average length of hospital stay of 22.7 days (12–45) (Table 2). Three complications recorded were cardiac tamponade, pneumonia and lung collapse (Table 3). The reasons for open repair included severe hemodynamic instability, delayed diagnosis of the aortic injury at the time of exploratory laparotomy and, although not clearly documented in the medical records, the reasons likely involved some combination of surgeon preference and unavailability of suitable technical endovascular devices. There were no deaths reported in this group.

Non-operative group

Twenty-two patients were deemed to have either died prior to arrival at RPH or did not survive the initial resuscitation attempts in the emergency department. The presence of a thoracic aortic injury was confirmed during postmortem. The mean age of this group of patients was 36.35 years (20–68) with a mean ISS of 47.88 (range 24–75) (statically significant compared with the endovascular group).

Discussion

Although blunt thoracic aortic injury accounts for <1% of adult level I trauma center admissions, it represents the second most common cause of death due to blunt injury, after head trauma.⁸ The most common etiological cause of TAI is sudden deceleration from road traffic accidents and falls from a height of more than 10–15 feet.^9–11 Occasionally, crush injuries produce similar injuries, but in general these involve a longer length of aorta and cause extensive intramural hematoma. Traction, torsion and hydrostatic forces as a consequence of differential slowing of thoracic structures have all been implicated in sudden deceleration injury.¹² Horizontal shear forces result from the aortic arch being fixed anatomically by the great vessels.^13,14 It has been proposed that the aorta distal to the left subclavian artery is most commonly injured because the major neck branches fix the superior aortic arch in place and the descending aorta is closely apposed to the spine by the intercostal vessels and the ligamentum arteriosum. The intervening proximal descending aorta is fixed in position and cannot move away, causing it to be pinched front to back. The isthmus is the most common site of rupture (50–70%), followed by the ascending aorta or aortic arch (18%) and the distal thoracic aorta (14%).^15,16

The natural history of untreated blunt thoracic aortic injury is grave. Early reports suggested that 80–85% of TAI die at the scene. For those who initially survive, the prognosis remains poor; nearly 30% will die within the first six hours and 50% will not live beyond the first 24 hours.¹⁷

Despite advances in modern trauma care, emergency surgery for blunt TAI is associated with significant cardiac, pulmonary, neurological and hemodynamic complications.¹⁸ The most significant morbidity is paraplegia from spinal cord ischemia, which occurs in 2.3–14% of patients.¹¹ Mortality rates from open surgery have been reported to be between 5 and 28%.¹¹ In our institution, there has been a tremendous shift from open repair to endovascular repair due to increased awareness among the emergency staff and cardiothoracic team involved in these patients management (Figure 2).

Figure 2

Progression in the management option of thoracic aortic injury (TAI) at our institution, with the trend shifting toward endovascular repair if suitable

Endovascular stent-grafting has become increasingly the treatment of choice for traumatic TAI.^19–21 Standard commercially available stent-grafts range in diameter from 26 to 46 mm. Current devices were primarily designed and developed to treat aneurysmal disease. The shortest possible length of device (typically 10–12 cm) is used because the injury is focal and this minimizes the risk of paraplegia. Over-sizing the device diameter by 10–15% is recommended. Some young patients may have aortic diameters of <20 mm, which is too small for standard devices. In these cases, proximal extension cuffs for abdominal aortic stent-grafts may be used, but the delivery systems can be too short for thoracic deployment (typically a shaft length of ∼60 cm) even with the use of retroperitoneal common iliac access to maximize the usable length.¹¹ Patients in their teens and early twenties commonly have an aortic arch with a tight radius of curvature. In such cases, the apposition on the inner curve of the aortic arch may be suboptimal due to insufficient device flexibility. In addition, we do not know how the devices will withstand 50 years, or more, of postimplantation stress or the normal aortic dilation associated with aging.

Femoral artery access is a potential challenge when considering thoracic aortic repair, particularly in young trauma patients. Currently available thoracic endograft devices require a minimum 18F introducer sheath. The common femoral or external iliac arteries may be too small (<6–8 mm depending on the device being used) to insert the device. This problem is over-represented in TAI patients compared with other thoracic stent-grafting procedures due to the higher percentage of younger patients and particularly young and female patients who have generally smaller vessels. This can be overcome by the use of retroperitoneal access to the common iliac artery (CIA) via a Rutherford Morrison incision. In slim patients, direct access to the vessels may be used; otherwise a conduit of an 8–10 mm diameter surgical graft is sutured onto the CIA.²² Where the CIA is also too small or diseased (stenosed or calcified), the stent-graft can be inserted directly into the abdominal aorta via the aortic bifurcation. White et al.²³ highlighted in their study that there was a 27% rate of access complications (iatrogenic femoral artery injury) associated with thoracic endovascular repair procedures. However, as endovascular devices undergo continued refinement and miniaturization with smaller introducer sheaths, the incidence of iatrogenic access complications is likely to decrease.

The most widely used systems are Valiant Thoracic stent-graft (Medtronic), TAG stent-graft (W.L. Gore, Flagstaff, AZ), and Zenith TX2 grafts (Cook, Inc). In our study, we have used mostly the Zenith TX2 proximal extensions pieces (diameter size from 28 to 42 mm with length variable of 77, 80 and 81 mm) and Zenith TX2 Proximal components with Pro-form (diameter size from 28 to 42 mm with length variable from 120 to 216 mm). One interesting finding in the study was there was no usage of infrarenal abdominal aortic extension cuffs, even in patients with a small thoracic aorta. This cuff has been used in some published series¹⁹ with some using it exclusively.²⁴ However, we have over-sized some patients more than 15% from the normal thoracic aorta. This has resulted to some patient's stent developing a minor step deformity of several of the metal Z-struts involving the inferior aspect of the proximal portion of the graft, as well as a second step deformity at the junction with the mid-section. However, these foci of angular deformity have not resulted in any significant compromise of luminal diameter, but a poor apposition of the stent-graft along the inner curve of the aortic arch was noted with the stent-graft protruding into the lumen of the aorta (Figures 3a and b). Furthermore, a severely angulated proximal aortic neck was always observed.

Figure 3

CT angiography of the aortic arch. Axial CT angiography (a) and sagittal multiplanar reformation reconstruction (b, 2 years later) demonstrating poor apposition of the stent-graft along the inner curve of the aortic arch with the stent-graft protruding into the lumen of the aorta (broad arrow), resulting in wedge-shaped gap between undersurface of the stent-graft and aortic wall and a step wise deformation of the mid-part of the graft to accommodate the angulation in the descending thoracic aorta (small arrow). CT, computed tomography

Manipulation of endografts in the vicinity of the ascending aorta is not only technically difficult but also carries a high risk of stroke. This should be minimized as much as possible by reducing the mean arterial blood pressure to approximately 70 mmHg, or less, for precise stent-graft deployment. This will decrease the distal displacement forces on the stent-graft and aid accurate positioning. This is particularly useful because it reduces the power of the ‘windsock effect’ to which some devices are prone.

There is a variable approach to the proximal sealing (drop or landing) zone or neck. For aneurysmal disease, at least 20 mm is the usual recommendation. Thoracic aortic injuries are by definition often closer to the left subclavian artery. Different approaches to this have been adopted. Placing the stent-graft distal to the left common carotid artery and intentionally covering the LSA can increase the proximal sealing zone. This is usually well tolerated and acute arm ischemia is rare.²⁵ Prior revascularization of the LSA has previously been advocated but experience has shown it is not necessary and increases the procedural complexity and morbidity. In TAI, unlike in aneurysmal disease, the aorta is usually histologically normal apart from the injured segment. We had a liberal approach to the coverage of the LSA with only one case requiring a subclavian artery revascularization and the rest had no follow-up complications.

We have adopted a vigilant clinical and imaging follow-up of our patients. However, the patients are understandably concerned about the long-term risks of irradiation, particularly the younger ones. The device will likely have many years of hemodynamic stress to endure. This makes annual CTA follow-up difficult and not accepted by all patients. Magnetic resonance angiography (MRA) is an alternative where MR-compatible devices have been used, although its poorer spatial resolution could lead to a lowered sensitivity for subtle complications and will not detect stent-graft migration. In the vast majority of patients, the injury site is apparently completely healed, or perhaps just sealed, on the early follow-up CTAs with a small bulge in the stent-graft at the site of the TAI but no thrombus or wall thickening. Under these circumstances there is no potential for endoleak, so a CTA follow-up may not be necessary. Stent-graft migration could potentially occur as a late complication, but at least some of these will be detected if standardized centering and projections are used for the plain films. We currently do not know if there remains a late risk of chronic pseudoaneurysm formation, although intuitively this seems unlikely. So despite hi-definition, low-dose CT scanning and MRA, follow-up remains challenging and should be clearly explained to the patients and relatives.

Limitations

This study has the standard limitations of being a retrospective, observational study where treatment choice is at the discretion of the physician. Furthermore, the number patients treated in each group is small to suggest strong recommendations of treatment.

Conclusion

This study addresses the challenges of managing patients with traumatic thoracic aortic injury and the evolution in the treatment options. One interesting finding in the study was that there was no usage of infrarenal abdominal aortic extension cuffs. We found that there was no need for this, as a variety of sizes of the Zenith TX2® Pro-Form endovascular stent-graft and Valiant® Thoracic stent-grafts were readily available at our institution.

Footnotes

Acknowledgements

All thanks to all staff from the trauma unit at royal Perth Hospital for the data capture and entry in the registry database.

Conflicts of interest: None.

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