Endovascular treatment of thoracic aortic pseudoaneurysm: case report

Brito, Luis Carlos Mendes de; Martins, João de Toledo; Furlani Júnior, Ovanil; Oliveira Júnior, Sérgio Penteado de Camargo; Chagury, Azis Arruda; Tavares, Karina Ribeiro Cavalcante

doi:10.1590/S1677-54492010005000002

Abstracts

A 31-year-old car accident victim was admitted with progressive inspiratory dyspnea, followed by intense dissecting thoracic pain, without any irradiation. The patient’s Glasgow score was 15, while his ISS was 26 (16 + 9 + 1). Laboratory and radiographic results were normal. One day after hospital admission, the patient underwent surgery due to a fractured tibia, being discharged from hospital 3 days later. However, worsening shortness of breath and thoracic pain were observed and he returned to the hospital 2 days later. A helical computed tomography was done revealing a thoracic aortic pseudoaneurysm. Endovascular surgery with endoprosthesis implantation was the treatment of choice.

Pseudoaneurysm; thoracic aorta; thoracic injuries

Paciente de 31 anos vítima de acidente automobilístico apresentou falta de ar inspiratória progressiva acompanhada de dor dissecante no tórax, de forte intensidade, sem irradiação; Glasgow 15 e ISS 26 (16 + 9 + 1); exames laboratoriais e radiográficos compatíveis com a normalidade. Foi operado de fratura de tíbia 1 dia depois, tendo recebido alta 3 dias depois da entrada no serviço. No entanto, foi piorando da falta de ar e da dor torácica, retornando para nova consulta 2 dias após a alta hospitalar. Foi realizada tomografia computadorizada helicoidal que revelou pseudoaneurisma de aorta torácica. Optou-se por tratamento endovascular com implante de endoprótese.

Pseudoaneurisma; aorta torácica; traumatismos torácicos

CASE REPORT

^ICirurgião vascular, Radiologia Vascular Intervencionista, Sorocaba, SP, Brazil

^IICirurgião vascular, Sorocaba, SP, Brazil

^IIICirurgião torácico, Sorocaba, SP, Brazil

^IVAcadêmicos de Medicina, Centro de Ciências Médicas e Biológicas, Pontifícia Universidade Católica de São Paulo, Sorocaba, SP, Brazil

Correspondence

ABSTRACT

A 31-year-old car accident victim was admitted with progressive inspiratory dyspnea, followed by intense dissecting thoracic pain, without any irradiation. The patient's Glasgow score was 15, while his ISS was 26 (16 + 9 + 1). Laboratory and radiographic results were normal. One day after hospital admission, the patient underwent surgery due to a fractured tibia, being discharged from hospital 3 days later. However, worsening shortness of breath and thoracic pain were observed and he returned to the hospital 2 days later. A helical computed tomography was done revealing a thoracic aortic pseudoaneurysm. Endovascular surgery with endoprosthesis implantation was the treatment of choice.

Keywords: Pseudoaneurysm, thoracic aorta, thoracic injuries.

Introduction

Trauma has been considered as the main cause of death in young adult population in the world, and thoracic traumatism, in particular, is being highlighted due to factors associated to technological advances, progressively faster means of transportation, and increase in urban violence.^1-3 Thoracic trauma may be classified as blunt or penetrating trauma depending on the pleural cavity being open or not. Any of the organs contained in the thoracic cavity may be injured during trauma, depending on its mechanism, trajectory, and magnitude.⁴ A severe consequence of thoracic trauma is the pseudoaneurysm or false aortic aneurysm, a clinical entity caused by the disruption of one of the arterial wall layer, which may be retained by neighboring tissues.

The authors present a case report on blunt thoracic traumatism and sudden slowing down caused by car collision culminating in a thoracic aorta pseudoaneurysm, with endovascular treatment with endoprosthesis implant as the treatment of choice, at the Sorocaba Hemodynamics Service. The interest of this case lies in the rarity of incidence and life expectancy of the patients with this type of lesion, given that most of the patients die before hospital treatment, and in the treatment's positive result due to the use of new minimally invasive technique in comparison to conventional treatment techniques.

Case presentation

A 31-year-old male patient, victim of car accident, presented with progressive inspiratory dyspnea and no improvement factors accompanied by high intensity thoracic dissecting pain with no irradiation. In physical exam he showed to be in a regular general state, slightly pale and with vesicular murmur, no adventitious sounds. Fracture in left tibia. Laboratory and radiographic exams were within normality. Receiving an operation for tibia fracture 1 day after, being discharged 3 days after arriving at the service. However, dyspnea and thoracic pain worsened, so he returned for a new consultation 2 days after discharge from hospital. Helicoidal computed tomography (Figure 1) was performed, revealing aortic arch with focal dilation and signs of localized dissection with saccular image formation in the descending aorta with 3cm diameter and 2cm extension, double light.

On the same day, endovascular treatment was chosen. Initially the left common femoral artery was punctured and a 5F valve introducer was installed. The centimetered guided Pig Tail catheter was used and an angiography was performed, confirming the diagnosis of thoracic aorta pseudoaneurysm (Figure 2A). Right inguinotomy was performed with isolation of common femoral artery and, soon after that, a puncture of the right common femoral artery and a 0,038'', 260 cm Lunderquist^® guidewire was passed, positioning it in the aortic arch. Through this wire the Talent^® 34/34/115 mm endoprosthesis was positioned and liberated (Figure 2B) and endoprosthesis with latex balloon was accomodated. After that, an angiography, after the endoprosthesis implant, evidenced the exclusion of pseudoaneurysm and revealed the pervious thoracic aorta in its whole extension.

The patient was discharged 3 days after the procedure, with a new tomography being performed, which demonstrated exclusion of the false light and stabilization of the clinical picture. The patient was followed up and returned in 30 days (Figure 3A), and in 90 days (Figure 3B) for control TC, which revealed the complete disappearance of the pseudoaneurysm and also of the previously cited symptoms.

Discussion

Conventional surgical treatment for aorta aneurysm requires thoracotomy and substitution of thoracic aorta for a prosthesis. With the endovascular treatment, thoracotomy is prevented and, with incisions in the inguinal region, the endoprosthesis may be implanted by means of a less invasive procedure. The endoprosthesis is advanced backward through guides, through the common femoral artery, iliac artery pathways, to the abdominal aorta and, consequently, thoracic aorta. Once it is adequately positioned, it is immediately released. This way, the blood loss is lower than that produced in conventional surgery, the aorta does not need to be clamped, and the patient's recovery is quicker. Various prospective and randomized studies are being conducted in the sense of comparing conventional to endovascular technique.^5-10 Two of them, EVAR1¹¹ and DREAM,¹² demonstrated a tendency toward lower surgical mortality, even in low risk patients, offering a viable alternative and with less morbidity in relation to conventional surgery. Besides that, Ott et al. reported a lower risk of post-operatory complications, as myocardial infarction, sepsis, mechanical ventilation time and acute respiratory discomfort syndrome, in patients with traumatic lesions in the aorta treated with the endovascular method. In this study, with the open method, 17% of mortality was obtained (n = 2), 16% paraplegia (n = 2), and 8.3% (n = 1) of laryngeal-recurrent nerve lesion; with endovascular surgery none of these complications occurred.¹³.

In another study, with 1904 patients, better indexes of endovascular treatment were observed in relation to open surgery in data related to mortality in 30 days (3.1% vs. 5.6%, p = 0.01), mortality after 1 year (8.7 vs. 12.1%) and perioperative risks (15.5 vs. 27.7%).¹⁴ In Brazil, although there are not many multicenter comparative studies, there was a significant improvement in morbidity and post-operative complications in thoracic trauma since the adoption of endovascular treatment.^15,16 In the last years, the use of stents has enabled a new perspective in treatment of aorta dissections and aneurysms. The use of this technique permitted a shorter time of hospitalization, decrease in surgical mortality and better post-operative recovery, in addition to the decrease in hospital costs.^17,18.

In relation to post-surgical effects, a recent study showed that after 2 years and 6 months of emergency surgery, in patients with aorta trauma, there was no interference related to the quality of life and depression and anxiety levels.¹⁹

In respect to the selection of prosthesis for the procedure, studies show that there is no significant difference among used models (Talent^®, Excluder^® e Zenith^®).^10,20

Finally it is important to refine the technique in order to permit the placement of the stent through smaller introducers and catheters, as important as the surgeon's ability. On the other hand, with this method we can prevent complications inherent to the conventional surgical manipulation as, for instance, respiratory and renal failure, coagulopathies, post-operative pain, paraplegia, hematoma near the prosthesis and pseudoaneurysms near the zones of sutures and localized and systemic infections.

Conclusion

The victims of blunt thoracic trauma with aortic compromised evidence high morbidity and mortality indexes in the whole world. Its diagnosis is difficult to be performed and a well-trained and prepared team is needed to treat these victims.

With the improvement of endovascular surgery and of the surgeon's ability, this technique has been progressively presenting better results in short and medium terms, being able to be performed quickly, safely, and with low morbidity. Besides that, it permits the treatment of other associated lesions, decreases post-operative complications and shortens hospitalization time.

References

1. Giannini JÁ, Soldá SC, Saad Júnior R. Trauma de tórax. In: Coimbra RSM, Soldá SC, Casaroli AA, et al. Emergências traumáticas e não traumáticas. São Paulo: Atheneu; 2001. p. 57-69.
2. LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. 1989;69:15-9.
3. Calhoon JH, Trinkle JK. Pathophysiology of chest trauma. Chest Surg Clin N Am. 1997;7:199-211.
4. Cuba RM, Bezerra JA. Traumatismo torácico: estudo retrospectivo de 168 casos. Rev Col Bras Cir. 2005;32:57-9.
5. Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras. 2007;6:64-73.
6. Buz S, Zipfel B, Mulahasanovic S, Pasic M, Weng Y, Hetzer R. Conventional surgical repair and endovascular treatment of acute traumatic aortic rupture. Eur J Cardiothorac Surg. 2008;33:143-9.
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;47:671-5.
8. 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;47:1094-8.
9. Moainie SL, Neschis DG, Gammie JS, et al. Endovascular stenting for traumatic aortic injury: an emerging new standard of care. Ann Thorac Surg. 2008;85:1625-9.
10. Orend KH, Zarbis N, Schelzig H, Halter G, Lang G, Sunder-Plassmann L. Endovascular treatment (EVT) of acute traumatic lesions of the descending thoracic aorta: 7 years' experience. Eur J Vasc Endovasc Surg. 2007;34:666-72.
11. EVAR Trial Participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysms (EVAR 1 Trial): Randomized controlled trial. Lancet. 2005;365:2179-86.
12. Blankensteijn JD, de Jong SE, Prinssen M, et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2005;352:2398-405.
13. 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.
14. Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg. 2002;89:714-30.
15. Aun R. Ruptura traumática da aorta por traumatismo torácico fechado. J Vasc Bras. 2007;6:5-6.
16. Mioto Neto B, Aun R, Estenssoro AE, Puech-Leão P. Tratamento das lesões de aorta nos traumatismos torácicos fechados. J Vasc Bras. 2005;4:217-26
17. Bush RL, Johnson ML, Collins TC, et al. Open versus endovascular abdominal aortic aneurysm repair in VA hospitals. J Am Coll Surg. Apr 2006;202:577-87.
18. Saratzis N, Melas N, Saratzis A, Lazaridis J, Kiskinis D. Minimally invasive endovascular intervention in emergent and urgent thoracic aortic pathologies: single center experience. Hellenic J Cardiol. 2008;49:312-9.
19. Dick F, Hinder D, Immer FF, et al. Outcome and quality of life after surgical and endovascular treatment of descending aortic lesions. Ann Thorac Surg. 2008;85:1605-12.
20. Mohan IV, Hitos K, White GH, et al. Improved outcomes with endovascular stent grafts for thoracic aorta transections. Eur J Vasc Endovasc Surg. 2008;36:152-7.