Endovascular treatment of traumatic descending thoracic aortic rupture

Abstracts

Paciente do sexo feminino, 55 anos de idade, vítima de atropelamento, foi admitida em unidade de emergência, onde se realizou o diagnóstico clínico, radiológico e tomográfico de ruptura traumática da aorta torácica descendente. Diante do achado, a paciente foi encaminhada para tratamento endovascular com colocação de endoprótese auto-expansível (stent) pela artéria femoral. O tratamento obteve sucesso, evidenciado pela exclusão da lesão localizada previamente no istmo aórtico. O tratamento endovascular tem sido indicado nas afecções de aorta torácica descendente com bons resultados iniciais. Na ruptura traumática de aorta, a terapêutica endovascular representa uma alternativa aceitável, especialmente devido aos riscos do tratamento operatório convencional.

Aorta lesões; aorta cirurgia; radiografia intervencionista; instrumentação

CASE REPORT

Endovascular treatment of traumatic descending thoracic aortic rupture

João Roberto Breda; Ana Silvia Ragognetti Breda; Eliane Yumi Fujii; João Antonio Corrêa; Adriano Meneghini; Jaime Ignácio Jaramilo; Dirceu Rodrigues de Almeida; Adilson Casemiro Pires

Cardiovascular Surgery, Faculdade de Medicina do ABC, Santo André, SP, Brazil

^{Correspondence}

ABSTRACT

A 55-year-old, female patient who was run over by a motor vehicle was admitted at an emergency room. Clinical, radiological and tomographic diagnosis of traumatic descending aortic thoracic rupture was performed. The patient was referred for endovascular treatment with placement of a self-expandable stent through the femoral artery. Treatment was successful, with exclusion of the lesion previously located in the aortic isthmus. Endovascular treatment has been indicated in the treatment of descending thoracic aortic diseases, with good initial results. In case of traumatic aortic rupture, endovascular treatment is a feasible alternative, especially due to risks offered by the conventional surgical treatment.

Keywords: Aortic injuries, aortic surgery, interventional radiography, instrumentation.

Introduction

Use of self-expandable stents in the treatment of descending thoracic aorta diseases has become a reality over the past years, especially with the advent of the approach through the femoral artery in the hemodynamic laboratory.¹

The search for and use of this therapeutic alternative are justified by reduction in surgical morbidity and mortality rates, when compared with traditional techniques.² Thus, endoluminal treatment has become an acceptable alternative in the treatment of dissections and true aneurysms of the descending thoracic aorta. In traumatic aortic ruptures, endovascular treatment aims at reducing morbidity and mortality associated with conventional surgical treatment.

This study aims at reporting an indication of endovascular treatment of traumatic descending aortic thoracic rupture, located in the aortic isthmus, in a patient who was run over, with thoracic trauma and mechanism of lesion due to deceleration.

Case report

A 55-year-old female patient was referred to the emergency room, after being run over, with diagnosis of multiple trauma. Recommended and standardized primary care procedures were performed. After her status was stabilized and during secondary assessment, widening of the mediastinum was diagnosed. Status of clinical stability was maintained, and the patient underwent thoracic computed tomography.

Thoracic tomography confirmed the diagnosis of traumatic descending thoracic aortic rupture, with lesion located in the aortic isthmus, besides presence of bilateral pleural effusion (Figure 1).

With this diagnosis, the patient was sent to the hemodynamic laboratory and submitted to aortography. Due to the angiographic finding and severity of lesion, we chose the endovascular treatment at the hemodynamic laboratory, by placing an aortic stent. We used an aortic stent currently manufactured by Braile-Biomédica, which is developed at Escola Paulista de Medicina (Universidade Federal de São Paulo).

The procedure was performed using general anesthesia. Monitoring involved continuous oximetry, mean blood pressure and surface electrocardiogram. Angiography was used to control stent placement in the aortic lumen. Surgical isolation of the left femoral artery was performed, which was chosen for stent placement and, after endovenous administration of 5,000 U of heparin, femoral arteriotomy was performed between two vascular clamps.

Therefore, the catheter containing the stent was delicately introduced into the iliac-femoral system. Progression of the device was controlled by radioscopy. Once the correct position of the stent was determined inside the aorta, the stent was released was moving the catheter sheath backward with control of mean blood pressure (between 60 and 70 mmHg), placing the device under the ostium of the left subclavian artery.

After stent release, a new aortography was performed to assess the result, with complete exclusion of aortic rupture site, confirming a successful procedure. There was no total occlusion of the subclavian artery (Figure 2). Pleural drainage to the right was performed after the procedure, due to a large pleural effusion with pulmonary restriction and ventilatory difficulty associated with the patient's status, with output of hemorrhagic fluid. The patient was then sent to the Postoperative Unit, where she remained under monitoring and strict control of her vital signs.

In the postoperative period, before being discharged, the patient underwent control computed tomography, which showed treatment success due to absence of contrast extravasation in the aortic isthmus (Figure 3). There was presence of a large bilateral pleural effusion, despite pleural drainage to the right. We discussed the need of exploratory thoracotomy to clean and remove cavity clots. However, due to severity of this case, we chose expectant management and due to good clinical progress, adjuvant surgical treatment was not indicated at that moment. The patient was sent for outpatient follow-up.

Comments

Treatment of aortic aneurysms using endoluminal stents started with the concept put forward by Dotter in 1969. In 1991, Parodi et al. widely advertised the percutaneous treatment, publishing their success obtained by using balloon-expanded stents in the treatment of abdominal aortic aneurysms.² In 1994, Dake et al. published their experience in repairing descending thoracic aortic aneurysms using self-expandable stents.¹

Aortic stents are an option for the treatment of aneurysms and dissections of the descending thoracic aorta. For that reason, several centers worldwide have studied and published their results using this therapeutic option.²

At Hospital de Ensino da Faculdade de Medicina do ABC, we started our experience in 1996 and, since then, we have used this technique in the treatment of dissections and aneurysms of the descending thoracic aorta.³ Traumatic descending thoracic aortic rupture, reported in this paper, was not part of the diagnoses that have motivated indication of endovascular treatment in our institution so far.

In the literature, there are reports of unusual indications of endovascular treatment for diseases of the descending thoracic aorta. Shimono et al. reported the endovascular treatment of a single case of acute descending aortic dissection with intimal tear in the descending aorta. A stent was placed, occluding the intimal orifice in the descending portion, resulting in a successful treatment, which was demonstrated by thrombosis of the false lumen, both in the ascending aorta and in the descending aorta, with satisfactory clinical progress of the patient.⁴

Descending aortic rupture after thoracic trauma has immediate mortality between 75 and 90% of cases and, despite the advances in conventional surgical treatment, mortality rates can reach 50% of diagnosed cases.⁵ Therefore, less invasive alternatives have been proposed for the treatment of this severe clinical situation.^6,7 In a retrospective study, Rosseau et al., assessed 70 patients with traumatic aortic rupture, comparing the results obtained between three therapeutic modalities (conservative, conventional surgery and aortic stent placement). The authors showed less mortality and lower risk of paraplegia in the group submitted to endovascular treatment.⁶ Similarly, Agostinelli et al. reported cases of 15 patients submitted to immediate endovascular treatment after diagnosis of traumatic aortic rupture, concluding that this procedure represents a safe option in this severe clinical status.⁷

Therefore, the endovascular treatment may represent an option in this situation, with good initial outcomes. However, more studies are needed to confirm the role of stents in the prevention of late aortic rupture, as well as the follow-up of possible complications of stents in young individuals and with reduced aortic diameter.

References

Manuscript received January 14, 2007, accepted April 9, 2007.

This study was carried out at Hospital Estadual Mário Covas, São Paulo, Brazil.

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• 4. Shimono T, Kato N, Tokui T, et al. Endovascular stent-graft repair for acute type A aortic dissection with an intimal tear in the descending aorta. J Thorac Cardiovasc Surg. 1998;116:171-3.
• 5. Williams JS, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicular trauma. Ann Thorac Surg. 1994;57:726-30.
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Publication Dates

• Publication in this collection
  20 Sept 2007
• Date of issue
  June 2007

History

• Accepted
  09 Apr 2007
• Received
  14 Jan 2007