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Surgical and endovascular repair of blunt thoracic aortic injury

Author
David G Neschis, MD
Section Editors
Joseph L Mills, Sr, MD
John F Eidt, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Blunt aortic injury is a life-threatening condition that will require repair in most patients and is second only to head injury as a cause of death in injured patients. Only about 20 percent of individuals survive long enough following injury to be transported to the hospital and treated [1-3]. The most significant advance in the past 50 years for the treatment of thoracic aortic disease is endovascular stent-grafting. Compared with other etiologies that are treated with thoracic endovascular stenting, such as thoracic aneurysm, patients with blunt aortic injury tend to be younger with anatomic features that can present challenges for the placement of endograft devices, which were not designed for this indication.  

The surgical and endovascular options for repair of the traumatic thoracic aortic disruption will be reviewed. The diagnosis and management of blunt thoracic aortic injury is discussed separately. (See "Blunt thoracic aortic injury".)

INDICATIONS FOR AND TIMING OF REPAIR

Aortic repair for blunt aortic injury is indicated for patients with injury Grades II, III, and IV. The diagnosis, grading and indications for repair, as well as timing of repair, are discussed elsewhere. Aortic repair is generally not indicated for patients with Type I injury (intima only), but may become necessary if the injury progresses. Aortic repair may be delayed in patients with a high surgical risk, due to comorbidities, challenging aortic anatomy, or coexistent injuries. (See "Blunt thoracic aortic injury", section on 'Aortic injury grading' and "Blunt thoracic aortic injury", section on 'Approach to management'.)

ENDOVASCULAR VERSUS OPEN SURGICAL REPAIR

The most significant surgical advance in the past 50 years for the treatment of thoracic aortic disease is endovascular stent grafting [4]. Based upon observational data that demonstrate improved perioperative outcomes [5-14], we agree with major trauma society and vascular society guidelines that suggest endovascular rather than open surgical repair for patients with indications for aortic repair and anatomy that is suitable for thoracic stent grafting [15,16]. This preference places a higher value on preventing perioperative mortality and morbidity, such as spinal cord ischemia, compared with endograft complications that lead to reintervention and uncertain long-term outcomes. It is important to keep in mind, though, that patients with blunt aortic injury may be more suited for one approach or another depending on local institutional resources and other issues such as the presence, location, and type of associated injuries, the location of the aortic injury and diameter of the aorta, the patient’s life expectancy, and likelihood of cooperation with long-term follow-up in the event of endovascular repair. (See 'Issues to consider' below.)  

Comparative morbidity and mortality — It is unlikely that randomized trials will ever be performed comparing open and endovascular repair for treatment of blunt aortic injury. Comparisons of the rates of major perioperative morbidity and mortality from retrospective reviews and pooled data suggest a benefit for endovascular repair [5-14,17,18].    

                 

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Literature review current through: Nov 2016. | This topic last updated: Tue Dec 01 00:00:00 GMT+00:00 2015.
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References
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  1. Sevitt S. The mechanisms of traumatic rupture of the thoracic aorta. Br J Surg 1977; 64:166.
  2. Smith RS, Chang FC. Traumatic rupture of the aorta: still a lethal injury. Am J Surg 1986; 152:660.
  3. Schulman CI, Carvajal D, Lopez PP, et al. Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 2007; 62:664.
  4. Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med 2008; 359:1708.
  5. Murad MH, Rizvi AZ, Malgor R, et al. Comparative effectiveness of the treatments for thoracic aortic transection [corrected]. J Vasc Surg 2011; 53:193.
  6. Xenos ES, Abedi NN, Davenport DL, et al. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008; 48:1343.
  7. Tang GL, Tehrani HY, Usman A, et al. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. J Vasc Surg 2008; 47:671.
  8. Xenos ES, Minion DJ, Davenport DL, et al. Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis. Eur J Cardiothorac Surg 2009; 35:282.
  9. Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc Interv Radiol 2008; 19:1153.
  10. Takagi H, Kawai N, Umemoto T. A meta-analysis of comparative studies of endovascular versus open repair for blunt thoracic aortic injury. J Thorac Cardiovasc Surg 2008; 135:1392.
  11. Jonker FH, Trimarchi S, Verhagen HJ, et al. Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm. J Vasc Surg 2010; 51:1026.
  12. Walsh SR, Tang TY, Sadat U, et al. Endovascular stenting versus open surgery for thoracic aortic disease: systematic review and meta-analysis of perioperative results. J Vasc Surg 2008; 47:1094.
  13. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma 1997; 42:374.
  14. Demetriades D, Velmahos GC, Scalea TM, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma 2008; 64:561.
  15. Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 78:136.
  16. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011; 53:187.
  17. Khoynezhad A, Azizzadeh A, Donayre CE, et al. Results of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Vasc Surg 2013; 57:899.
  18. Khoynezhad A, Donayre CE, Azizzadeh A, et al. One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Thorac Cardiovasc Surg 2015; 149:155.
  19. Demetriades D, Velmahos GC, Scalea TM, et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma 2008; 64:1415.
  20. Azizzadeh A, Charlton-Ouw KM, Chen Z, et al. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. J Vasc Surg 2013; 57:108.
  21. Estrera AL, Miller CC 3rd, Guajardo-Salinas G, et al. Update on blunt thoracic aortic injury: fifteen-year single-institution experience. J Thorac Cardiovasc Surg 2013; 145:S154.
  22. Patel HJ, Hemmila MR, Williams DM, et al. Late outcomes following open and endovascular repair of blunt thoracic aortic injury. J Vasc Surg 2011; 53:615.
  23. Estrera AL, Gochnour DC, Azizzadeh A, et al. Progress in the treatment of blunt thoracic aortic injury: 12-year single-institution experience. Ann Thorac Surg 2010; 90:64.
  24. Riesenman PJ, Brooks JD, Farber MA. Acute blunt traumatic injury to the descending thoracic aorta. J Vasc Surg 2012; 56:1274.
  25. Di Eusanio M, Folesani G, Berretta P, et al. Delayed management of blunt traumatic aortic injury: open surgical versus endovascular repair. Ann Thorac Surg 2013; 95:1591.
  26. Watson J, Slaiby J, Garcia Toca M, et al. A 14-year experience with blunt thoracic aortic injury. J Vasc Surg 2013; 58:380.
  27. Marone EM, Kahlberg A, Tshomba Y, Chiesa R. Single-center experience with endovascular treatment of acute blunt thoracic aortic injuries. J Cardiovasc Surg (Torino) 2013; 54:123.
  28. Asaid R, Boyce G, Atkinson N. Endovascular repair of acute traumatic aortic injury: experience of a level-1 trauma center. Ann Vasc Surg 2014; 28:1391.
  29. Leong Tan GW, Pek CH, Wong D, et al. Management of blunt traumatic thoracic aorta injuries with endovascular stent-grafts in a tertiary hospital in an urban Asian city. Ann Vasc Surg 2011; 25:605.
  30. Arthurs ZM, Starnes BW, Sohn VY, et al. Functional and survival outcomes in traumatic blunt thoracic aortic injuries: An analysis of the National Trauma Databank. J Vasc Surg 2009; 49:988.
  31. Garcia-Toca M, Naughton PA, Matsumura JS, et al. Endovascular repair of blunt traumatic thoracic aortic injuries: seven-year single-center experience. Arch Surg 2010; 145:679.
  32. Mansour MA, Kirk JS, Cuff RF, et al. Endovascular repair of traumatic thoracic aortic tears. Am J Surg 2012; 203:401.
  33. Azizzadeh A, Ray HM, Dubose JJ, et al. Outcomes of endovascular repair for patients with blunt traumatic aortic injury. J Trauma Acute Care Surg 2014; 76:510.
  34. Harris DG, Rabin J, Kufera JA, et al. A new aortic injury score predicts early rupture more accurately than clinical assessment. J Vasc Surg 2015; 61:332.
  35. Echeverria AB, Branco BC, Goshima KR, et al. Outcomes of endovascular management of acute thoracic aortic emergencies in an academic level 1 trauma center. Am J Surg 2014; 208:974.
  36. Steuer J, Wanhainen A, Thelin S, et al. Outcome of endovascular treatment of traumatic aortic transection. J Vasc Surg 2012; 56:973.
  37. Chen SW, Wang SY, Liao CH, et al. Timing of Intervention in Blunt Traumatic Aortic Injury Patients: Open Surgical versus Endovascular Repair. Ann Vasc Surg 2015; 29:1559.
  38. Neschis DG, Moainie S, Flinn WR, et al. Endograft repair of traumatic aortic injury-a technique in evolution: a single institution's experience. Ann Surg 2009; 250:377.
  39. Moainie SL, Neschis DG, Gammie JS, et al. Endovascular stenting for traumatic aortic injury: an emerging new standard of care. Ann Thorac Surg 2008; 85:1625.
  40. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991; 5:491.
  41. Volodos NL, Karpovich IP, Troyan VI, et al. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa Suppl 1991; 33:93.
  42. Semba CP, Kato N, Kee ST, et al. Acute rupture of the descending thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol 1997; 8:337.
  43. Canaud L, Joyeux F, Berthet JP, et al. Impact of stent-graft development on outcome of endovascular repair of acute traumatic transection of the thoracic aorta. J Endovasc Ther 2011; 18:485.
  44. Mitchell ME, Rushton FW Jr, Boland AB, et al. Emergency procedures on the descending thoracic aorta in the endovascular era. J Vasc Surg 2011; 54:1298.
  45. D'Souza S, Duncan A, Aguila F, et al. TEVAR for non-aneurysmal thoracic aortic pathology. Catheter Cardiovasc Interv 2009; 74:783.
  46. Cannon RM, Trivedi JR, Pagni S, et al. Open repair of blunt thoracic aortic injury remains relevant in the endovascular era. J Am Coll Surg 2012; 214:943.
  47. Kölbel T, Dias N, Resch T, et al. In situ bending of thoracic stent grafts: clinical application of a novel technique to improve conformance to the aortic arch. J Vasc Surg 2009; 49:1613.
  48. Torsello GB, Torsello GF, Osada N, et al. Midterm results from the TRAVIATA registry: treatment of thoracic aortic disease with the valiant stent graft. J Endovasc Ther 2010; 17:137.
  49. http://www.goremedical.com/contentTypeDetail.jsp?action=contentDetail&N=8083 8239&contenttype=8327&R=1276629378975 (Accessed on March 21, 2012).
  50. Farber MA, Mendes RR. Endovascular repair of blunt thoracic aortic injury: techniques and tips. J Vasc Surg 2009; 50:683.
  51. Peterson BG, Longo GM, Matsumura JS, et al. Endovascular repair of thoracic aortic pathology with custom-made devices. Surgery 2005; 138:598.
  52. Peterson BG, Matsumura JS, Morasch MD, et al. Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005; 59:1062.
  53. Lee WA, Brown MP, Nelson PR, et al. Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique. J Vasc Surg 2008; 47:919.
  54. Lachat M, Pfammatter T, Witzke H, et al. Acute traumatic aortic rupture: early stent-graft repair. Eur J Cardiothorac Surg 2002; 21:959.
  55. Hoornweg LL, Dinkelman MK, Goslings JC, et al. Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multicenter analysis of 28 cases in The Netherlands. J Vasc Surg 2006; 43:1096.
  56. Rahimi SA, Darling RC 3rd, Mehta M, et al. Endovascular repair of thoracic aortic traumatic transections is a safe method in patients with complicated injuries. J Vasc Surg 2010; 52:891.
  57. Sepehripour AH, Ahmed K, Vecht JA, et al. Management of the left subclavian artery during endovascular stent grafting for traumatic aortic injury - a systematic review. Eur J Vasc Endovasc Surg 2011; 41:758.
  58. Antonello M, Menegolo M, Maturi C, et al. Intentional coverage of the left subclavian artery during endovascular repair of traumatic descending thoracic aortic transection. J Vasc Surg 2013; 57:684.
  59. Gilani R, Ochoa L, Wall MJ Jr, et al. Endovascular repair of traumatic aortic injury using a custom fenestrated endograft to preserve the left subclavian artery. Vasc Endovascular Surg 2011; 45:549.
  60. Kurimoto Y, Asai Y, Nara S, et al. Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury. J Trauma 2009; 66:974.
  61. Alberta HB, Secor JL, Smits TC, et al. Comparison of thoracic aortic diameter changes after endograft placement in patients with traumatic and aneurysmal disease. J Vasc Surg 2014; 59:1241.
  62. Forbes TL, Harris JR, Lawlor DK, Derose G. Aortic dilatation after endovascular repair of blunt traumatic thoracic aortic injuries. J Vasc Surg 2010; 52:45.
  63. Katsargyris A, Verhoeven EL. Part Two: Against the motion. All TEVAR patients do not require lifelong follow-up by annual CTA/MRA.[Con]. Eur J Vasc Endovasc Surg 2012; 44:538.
  64. Wong S, Mastracci TM. Part One: For the motion. All TEVAR patients must be followed lifelong by annual CTA/MRA. [Pro]. Eur J Vasc Endovasc Surg 2012; 44:534.
  65. Rocchi G, Lofiego C, Biagini E, et al. Transesophageal echocardiography-guided algorithm for stent-graft implantation in aortic dissection. J Vasc Surg 2004; 40:880.
  66. von Oppell UO, Dunne TT, De Groot MK, Zilla P. Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994; 58:585.
  67. Szwerc MF, Benckart DH, Lin JC, et al. Recent clinical experience with left heart bypass using a centrifugal pump for repair of traumatic aortic transection. Ann Surg 1999; 230:484.
  68. Moore EE, Burch JM, Moore JB. Repair of the torn descending thoracic aorta using the centrifugal pump for partial left heart bypass. Ann Surg 2004; 240:38.
  69. Attar S, Cardarelli MG, Downing SW, et al. Traumatic aortic rupture: recent outcome with regard to neurologic deficit. Ann Thorac Surg 1999; 67:959.
  70. Gammie JS, Shah AS, Hattler BG, et al. Traumatic aortic rupture: diagnosis and management. Ann Thorac Surg 1998; 66:1295.
  71. Kodali S, Jamieson WR, Leia-Stephens M, et al. Traumatic rupture of the thoracic aorta. A 20-year review: 1969-1989. Circulation 1991; 84:III40.
  72. Katz NM, Blackstone EH, Kirklin JW, Karp RB. Incremental risk factors for spinal cord injury following operation for acute traumatic aortic transection. J Thorac Cardiovasc Surg 1981; 81:669.
  73. Guvendik L, Davis NR, Starr A. Repair of traumatic aortic transection: a management protocol and review of twenty-one patients. Thorac Cardiovasc Surg 1988; 36:198.
  74. O'Connor JV, Byrne C, Scalea TM, et al. Vascular injuries after blunt chest trauma: diagnosis and management. Scand J Trauma Resusc Emerg Med 2009; 17:42.
  75. Cardarelli MG, McLaughlin JS, Downing SW, et al. Management of traumatic aortic rupture: a 30-year experience. Ann Surg 2002; 236:465.
  76. Verdant A. Contemporary results of standard open repair of acute traumatic rupture of the thoracic aorta. J Vasc Surg 2010; 51:294.
  77. Park D, Rajakumar C, Forbes TL. Endovascular salvage of complications following initial open repair of blunt traumatic thoracic aortic injuries. Vasc Endovascular Surg 2011; 45:183.
  78. Dake MD, White RA, Diethrich EB, et al. Report on endograft management of traumatic thoracic aortic transections at 30 days and 1 year from a multidisciplinary subcommittee of the Society for Vascular Surgery Outcomes Committee. J Vasc Surg 2011; 53:1091.
  79. Lee WA, Daniels MJ, Beaver TM, et al. Late outcomes of a single-center experience of 400 consecutive thoracic endovascular aortic repairs. Circulation 2011; 123:2938.
  80. Kaya A, Heijmen RH, Overtoom TT, et al. Thoracic stent grafting for acute aortic pathology. Ann Thorac Surg 2006; 82:560.
  81. Wheatley GH 3rd, Gurbuz AT, Rodriguez-Lopez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses: single center experience. Ann Thorac Surg 2006; 81:1570.
  82. Orford VP, Atkinson NR, Thomson K, et al. Blunt traumatic aortic transection: the endovascular experience. Ann Thorac Surg 2003; 75:106.
  83. Clough RE, Modarai B, Topple JA, et al. Predictors of stroke and paraplegia in thoracic aortic endovascular intervention. Eur J Vasc Endovasc Surg 2011; 41:303.
  84. Cooper DG, Walsh SR, Sadat U, et al. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and meta-analysis. J Vasc Surg 2009; 49:1594.
  85. Chung J, Kasirajan K, Veeraswamy RK, et al. Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death. J Vasc Surg 2011; 54:979.
  86. Idu MM, Reekers JA, Balm R, et al. Collapse of a stent-graft following treatment of a traumatic thoracic aortic rupture. J Endovasc Ther 2005; 12:503.
  87. Lioupis C, MacKenzie KS, Corriveau MM, et al. Midterm results following endovascular repair of blunt thoracic aortic injuries. Vasc Endovascular Surg 2012; 46:109.
  88. Steinbauer MG, Stehr A, Pfister K, et al. Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease. J Vasc Surg 2006; 43:609.
  89. Neschis DG, Moaine S, Gutta R, et al. Twenty consecutive cases of endograft repair of traumatic aortic disruption: lessons learned. J Vasc Surg 2007; 45:487.
  90. Tadros RO, Lipsitz EC, Chaer RA, et al. A multicenter experience of the management of collapsed thoracic endografts. J Vasc Surg 2011; 53:1217.
  91. van Prehn J, van Herwaarden JA, Muhs BE, et al. Difficulties with endograft sizing in a patient with traumatic rupture of the thoracic aorta: the possible influence of hypovolemic shock. J Vasc Surg 2008; 47:1333.
  92. Wallace GA, Starnes BW, Hatsukami TS, et al. Intravascular ultrasound is a critical tool for accurate endograft sizing in the management of blunt thoracic aortic injury. J Vasc Surg 2015; 61:630.
  93. Malhotra AK, Fabian TC, Croce MA, et al. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. J Trauma 2001; 51:1042.
  94. Gavelli G, Canini R, Bertaccini P, et al. Traumatic injuries: imaging of thoracic injuries. Eur Radiol 2002; 12:1273.