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Eur J Cardiothorac Surg 2001;19:739-745
© 2001 Elsevier Science NL

Endovascular treatment of acute bleeding complications in traumatic aortic rupture and aortobronchial fistula

B. Dorweilera, C. Dueberb, A. Neufanga, W. Schmiedta, M.B. Pittonb, H. Oelerta

a Department of Cardiothoracic and Vascular Surgery, University Hospital, Johannes-Gutenberg University, Langenbeckstrasse 1, 55101 Mainz, Germany
b Department of Radiology, University Hospital, Johannes-Gutenberg University, Langenbeckstrasse 1, 55101 Mainz, Germany

Received 22 November 2000; received in revised form 21 March 2001; accepted 22 March 2001.

Corresponding author. Tel.: +49-6131-173208; fax: +49-6131-173626
e-mail: dorweiler{at}htg.klinik.uni-mainz.de


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Objective: Herein we report our experience in placement of endovascular stentgrafts in the descending aorta in patients with acute bleeding complications due to traumatic rupture or aortobronchial fistula. Methods: Six patients (one woman, five men, mean age 47±19 years) were treated from September 1995 to February 2000 by implantation of endovascular stentgrafts in the descending aorta. Indications included traumatic ruptures of the aortic isthmus (n=3) and aortobronchial fistulas (n=3). All procedures were performed under general anaesthesia. The implants were introduced under fluoroscopic guidance via the aorta (n=1), the iliac (n=4) or femoral (n=2) artery, respectively. Results: All aortobronchial fistulas and ruptures were sealed up successfully. There was no perioperative morbidity and no procedure-related morbidity except one patient who received aortofemoral reconstruction because of iliac occlusive disease. All patients are alive and well after a mean follow-up of 31 months (range 6–60). Two patients had recurrent hemoptysis, in one case, the patient received a second implant (distal extension), the other patient was managed conservatively. Conclusion: Endovascular treatment by a stentgraft is a safe and reliable procedure in the management of acute bleeding complications in patients with aortic rupture or aortobronchial fistulas.

Key Words: Traumatic aortic rupture • Aortobronchial fistula • Endovascular treatment


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Endovascular techniques were firstly introduced in 1991 for the treatment of infrarenal aortic aneurysm, based on the results obtained in a dog model and the experience of several clinical cases [1]. Since then, significant developments have been made in terms of device fabrication and durability as well as the implantation procedure for elective treatment of infrarenal aortic aneurysms. This is reflected by the mortality rates that decreased from 10% in earlier reports [2] to 2.6% in the large EUROSTAR-Study [3]. The advantage of minimal operative trauma and quick recovery of patients warrants further investigation of endovascular treatment techniques in emergency cases of aortic rupture or aortobronchial fistula where conventional surgery is still endowed with high mortality.

Therefore, the objective of this study was to examine the feasibility and reliability of endovascular stentgrafts in the treatment of acute bleeding complications originating from the descending aorta due to traumatic rupture or aortobronchial fistula.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
From September 1995 to February 2000, six patients (one woman, five men) with a mean age of 47±19 years (range 23–77 years) received endovascular treatment for acute bleeding complications after traumatic rupture of the descending aorta or aortobronchial fistula (ABF) at our institution. In the subsequent report, patients were divided into an aortic rupture group (Pat 1–3) and an ABF group (Pat 4–6, Table 1). At our institution, endovascular treatment is managed by an interdisciplinary approach with a team of two vascular surgeons and two interventional radiologists. Informed consent was obtained either by the patients themselves (4 and 5) or by the relatives for the remaining cases. The implantation procedures were performed in an angio-suite equipped with digital subtraction angiography. All cases were operated with standby for cardiopulmonary bypass available, in case a conversion to open procedure would be necessary. The patients were positioned either in a decubitus position or in a modified Crawford position (upper body at 60° lateral angle). All operations were performed under general anaesthesia and ABF patients were intubated with a double lumen tube.


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  		Table 1. Perioperative Patient Dataa

 
Measurements for selection of the appropriate stentgraft were based upon preoperative CT scan (Figs. 1 and 4A). The length of the device is determined by the length of the defect and a minimum of 2 cm length of the proximal and distal landing zone that is required for secure fixation. The diameter of the graft is calculated from the largest diameter of either proximal or distal landing zone and an oversizing factor of 20–25% (4–6 mm).



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  		Fig. 1. 2D reconstruction of preoperative contrast enhanced CT scan locates the rupture at the aortic isthmus in patient 2 that was injured during a high-speed deceleration trauma.

 
The arterial access vessel was chosen accordingly to the diameter of the introducer sheath (Table 2). After surgical exposure of the access vessel and intravenous administration of 5000 I.U. of heparine, a 5F pigtail catheter was introduced via a vascular sheath in the contralateral groin and positioned in the aortic arch for angiographic evaluation. Subsequently, a stiff guide-wire (Amplatz) was introduced in the access vessel using a 9F sheath and, after removal of the sheath and transverse arteriotomy, the introducer system of the stentdevice was advanced under fluoroscopic guidance. Additionally, a long guide-wire (Terumo) that was introduced from the contralateral groin parallel to the pigtail catheter was used in two cases (Pat. 1 and 3) to mark the orifice of the left subclavian artery. The stent device was deployed at the target position and a balloon was used to model the leading and trailing parts of the stentgraft to the aortic wall. To prevent the windsock effect during deployment of the graft, either nitroprusside was administered intravenously to lower systolic blood pressure to 60–80 mmHg or a occluding balloon was positioned in the ascending aorta to reduce blood flow. Finally, the introducer sheath was removed and the arteriotomy was closed. Completion angiography was obtained using the 5F sheath, which was kept in place in the contralateral groin.


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  		Table 2. Stent-graft details

 
The follow-up protocol encompassed a spiral CT scan with early and late phase series, a magnetic resonance imaging scan (MRI) and a chest X-ray after 1, 3, 6 and 12 months with annual repetitions afterwards.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 Appendix A. Conference...
 References
 
According to the above described method we have implanted eight stentgrafts in the descending aorta in a series of six patients (Table 2). The mean operative time for the procedures including surgical arterial access and arterial closure was 124±54 min (range 65–200 min). For patient 5, operative time was prolonged to 315 min because of difficult access and aortofemoral reconstruction. All patients survived the procedure resulting in a mortality of 0%. The procedure related morbidity was found to be one out of six patients: In Patient 5, conversion from femoral to iliac and finally to aortic access had to be performed because of extensive iliac occlusive disease that was not anticipated on the preoperative angiography. For introduction of the stent device, a 10 mm PTFE-graft in side-port technique was used and completed to an aortofemoral bypass at the end of the procedure. In two cases (Pat. 1 and 3), the proximal, uncovered part of the stent was placed across the origin of the left subclavian artery. Thrombosis, embolization or clinical manifestations of impeded blood flow could not be detected. In Patient 3, an additional proximal stentgraft was necessary due to a distal migration of the initial graft during the deployment process (windsock phenomenon). As this was not considered a technical failure, the technical success rate of the implantation procedure can be considered 100%.

During the implantation procedures, care was taken to salvage intercostal arteries, nevertheless, one pair of intercostal arteries had to be over-stented in patient 5 for the distal extension of the stent graft. For the aortic ruptures, complete sealing without continuing extravasation could be documented in serial CT scans, thus ruling out relevant back-bleeding from intercostal arteries.

Concerning neurological complications, neither postoperative stroke nor paraplegia was noted. Completion angiograms confirmed satisfactory position of the implanted stentgraft in each case and showed no sign of endoleakage or dislocation (Figs. 2B and 5B). All patients were transferred to the ICU for postoperative monitoring. The trauma patients displayed a substantially longer need for mechanical ventilation with 3, 15 and 19 days for patients 1,2 and 3, respectively. The overall duration of intensive care treatment is listed in Table 1. Concerning the ABF-group, prolonged duration of mechanical ventilation (9 days) was only necessary for patient 6 due to cardiopulmonary arrest and underlying chronic obstructive pulmonary disease. Patients were either discharged home (1,3,4), retransferred to the referring hospital (5) or discharged into rehabilitation (2, 6). All patients with ABF received a prophylactic antibiotic treatment perioperatively that was continued for 6 weeks postoperatively.



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  		Fig. 2. Periprocedural digital subtraction angiography of patient 2 performed with a graduated pigtail catheter allows secure and precise deployment of the implant (A) and documents the postoperative result with complete sealing of the rupture (B).

 


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  		Fig. 5. Digital subtraction angiography documents irregularity of the aortic wall due to mural thrombus without an active fistula (A) in patient 5. Completion angiography shows satisfactory results after stentgraft placement (B).

 
Two patients from the ABF-group had recurrent episodes of hemoptysis, which was considered to be rather an expectoration of bits of older blood clots consistent with solubilized hematoma than fresh red blood, reflecting persistent communication between the aneurysm sac and the bronchial system. Patient 5 presented 5 months after the initial procedure where a spiral CT scan with early and late series failed to demonstrate any endoleak, dislocation or material fatigue and bronchoscopy revealed no sign for active bleeding. On 2D reconstruction of CT scan, overlap of the distal stentgraft in the landing zone was considered too short, therefore we decided to implant a second stentgraft as a distal extension for safety reasons. Patient 6 also had recurrent hemoptysis and was readmitted to our service 2 weeks after discharge. CT scan and angiogram showed no signs of endoleakage, stent dislocation or aortobronchial fistula and, additionally, the mediastinal hematoma had decreased in size. In this case, we omitted any further invasive procedures. Interestingly, both patients continued to expectorate bits of hematoma for 2 weeks, then no further episodes of expectoration were noted.

After a mean follow up of 31 months (Range 6–60 months), all patients are alive and well. According to our follow-up protocol, serial CT scans and plain radiography of the chest confirmed satisfactory placement of the implanted stentgrafts in each patient without evidence for endoleakage or dislocation (Figs. 3 and 4B). Complete resolution of the periaortic hematoma was noted in all rupture cases. For the ABF patients, resolution of the aneurysm sac was seen in one and considerable shrinkage in the remaining two patients.



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  		Fig. 3. Six months postoperatively, 2D reconstruction of MRI presents results after stentgraft placement without signs for endoleakage or migration in patient 2.

 


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  		Fig. 4. Pre- and postoperative contrast enhanced CT scan imaging studies of patient 5 with ABF delineate the aneurysm of the descending aorta with protrusion to the left dorsolateral side and proximity to the left lower segment bronchus (A). One year postoperatively, exclusion and shrinkage of the aneurysm is documented on a follow-up CT scan (B). Meanwhile, the patient had received an additional implant as distal extension.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
Appendix A. Conference...
 References
 
Whereas elective surgical correction of thoracic aortic aneurysms (TAA) is performed with a mortality of 5.1% [4], conventional surgery of ruptured TAA is still endowed with a substantially higher mortality varying from 15% in a single center study [5] to 21.3% in a large metaanalysis of traumatic ruptures [6]. Based on the results obtained in elective endovascular treatment of TAA with a reported mortality of 9% [7], we decided to apply the armament of endovascular techniques in the emergency treatment of acute aortic bleeding complications that either resulted from traumatic rupture of the thoracic aorta or aortobronchial fistula.

We adhere to the principle that thoracic aortic injuries should be treated surgically with minimal delay [8] but in patients where serious associate injuries mandate immediate attention, medical management is used until delayed surgical repair can be performed [9]. Patients 1 and 2 of our series had only minor fractures and were scheduled for endovascular treatment within a time frame of approximately 8 h which was necessary to obtain the stent device. In patient 3, endovascular treatment was delayed 56 h in order to perform laparotomy and resection of the spleen followed by an external fixation of the pelvis for massive hemorrhage from splenic rupture and a pelvic fracture.

Emergency treatment of traumatic ruptures of the thoracic aorta by endovascular approach has been reported in several case reports with promising results: Successful sealing of the lesion was achieved in four patients as immediate procedure [10–12] and within 3–7 days after the initial injury for another two patients [13]. Additionally, successful endovascular exclusion of a posttraumatic pseudoaneurysm of the thoracic aorta as delayed treatment was reported for one patient with an interval of 3 months [14], for nine patients with an interval of 1 month to 32 years [15] and for ten patients with an interval of 17 days to 50 years [16]. In summary of these seven reports, all patients survived with satisfying mid-term results. Our series provides additional results in the immediate therapy of traumatic aortic ruptures as three patients could be successfully treated with the endoluminal procedure within 8–56 h.

Although indispensible in the treatment of aortobronchial fistulas, the mortality of conventional surgical repair remains high (24%) [17].

To date, six cases of endovascular treatment of an aortobronchial fistula were reported with a mortality of one out of six (nonrelated cause), the remaining five patients recovered uneventfully [10,18–21]. Our series adds three consecutive patients that could be salvaged with satisfying result. All of the patients survived, and there was no procedure related morbidity. Of note, no focal neurological deficits or paraplegia were detected. Therefore, our results compare well to the promising results in the above-mentioned reports. Interestingly, two of our cases demonstrated recurrent expectoration of blood clots in the postoperative period. In both patients we were not able to detect any endoleak, stent migration or fistulous communication despite all diagnostic efforts. This led us to the hypothesis, that the resorption of residual mediastinal hematoma contributes to the expectoration of blood-tainted sputum or bits of blood clots despite successful sealing of the aortobronchial fistula. Based on that knowledge, we managed the second patient conservatively, and expectoration stopped by itself after 3 weeks. The indication for endovascular treatment of trauma cases was based upon the assumption of minimal additional operative trauma and reduced operative time. Additionally, avoidance of a left thoracotomy in the presence of pulmonary contusion and serial left rib fractures was thought to support recovery of the patients. Furthermore, endovascular repair eludes the need for prolonged heparinization of the trauma patient which would otherwise be necessary in surgical repair with distal perfusion in order to decrease the risk of postoperative paraplegia [6]. Of note, no advantage in terms of length of ICU-treatment and overall length of hospital stay resulted from the endovascular treatment. The decision towards endovascular treatment of the ABF cases resulted from previous thoracic surgery in patient 4 and significant comorbidity (ASA IV) in patients 5 and 6. Despite initial success of the implantation procedure, patients have to be rescheduled for serial follow-up examinations. Endovascular stent implantation remains a procedure limited to centers with close patient surveillance in the follow-up period in order to gain more knowledge concerning long-term performance and durability of the implanted grafts. Possible late failures include endoleakage due to migration of the stent, collateral flow from intercostal arteries and structural defects of the stentgraft itself.

In summary, we were able to successfully manage acute bleeding complication from the descending thoracic aorta due to traumatic rupture or ABF in a series of six patients applying endovascular treatment techniques with satisfying perioperative and mid-term results. Consequently, endovascular stentgrafts can be seen as safe and reliable tools complementing the armament of surgical techniques in the emergency treatment of aortic bleeding complications. In our experience, recurrent hemoptysis presenting as expectoration of mediastinal hematoma, may be expected despite successful sealing of an ABF and can be managed conservatively. The relatively small number of patients in this series does not allow to report definite mortality and morbidity rates. On the other hand, endovascular treatment of acute lesions of the thoracic aorta is an emerging field where few cases have been reported. Nevertheless, our series of three patients with a successful endovascular treatment of an aortobronchial fistula constitutes one third of cases published to date. It is realized, that these promising results, however, mandate further meticulous observation of patients because the long-term performance of the implanted graft material remains to be elucidated.


   Footnotes
 
Presented in part at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.


   Appendix A. Conference discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
References
 
Dr A. Arbulu (Detroit, MI, USA): In the trauma cases, I have a comment and question related to the time from the patient's arrival to the emergency room to completion of the intervention. In our experience we found that either femoral-femoral bypass or left heart bypass is shorter and cheaper. Would you comment also on what are the costs?

Dr Dorweiler: The trauma patients have a staying interval on the intensive care unit which is quite long, up to about 10–19 days. So this makes the whole hospital stay expensive. Compared to the ICU treatment, which is in our case about 2500 marks a day, the costs for a stent device are rather low.

Dr J. Bachet (Paris, France): I have two questions. First, in the patients with a traumatic rupture, did you use this technique because it's the trend now or did the patients have a total contraindication to surgery?

Dr Dorweiler: The patients were severely injured. All of them had pulmonary contusions, which also reflects the need for mechanical ventilation, and all of the patients had cerebral contusions, and this is a situation where we decided to go ahead to endovascular treatment.

Dr Bachet: As I understand, the device is quite stiff and difficult to place properly. Aren't you afraid that in those patients rupture could be a frequent and very definitive complication?

Dr Dorweiler: We sure have to think about rupture, and this is the reason why all measures for a conventional operation are present during this procedure. In our experience, deployment and modeling of the graft to the aortic wall is without complications. Also for our endovascular infrarenal cases we haven't seen any ruptures, and we have about 100 cases to-date.

Dr W. Harringer (Hannover, Germany): Could you comment on the risk of infection in your patients who had aortobronchial fistulas, and did you take any specific precautions to prevent it?

Dr Dorweiler: I think this is an important remark. All of our patients with aortobronchial fistulas received antibiotic treatment during the procedure and for 6 weeks afterwards. On follow-up examinations, including MRI and CT scan, we haven't seen any signs of infection to-date in this group.

Dr L.K. von Segesser (Lausanne, Switzerland): What is your preferred technique for pressure control during unloading? Do you prefer pharmacological control or inflow occlusion?

Dr Dorweiler: We do pharmacologic treatment and lower the blood pressure during deployment to about 60–80 mmHg. We had one patient where we also used a balloon in the ascending aorta for partial occlusion.

Dr M. Turina (Zurich, Switzerland): I have a question and a comment. Do you use this now in all procedures, or what is the proportion of the patients who received open repair? The reason why I ask you that question is that we have in Zurich now 17 patients with descending thoracic aorta covered stents, and we lost one because the patient had a very large extravasation on CT scan, and although the graft was properly placed, this patient ruptured 24 h later and exsanguinated before we could do anything. So in our present guidelines for traumatic rupture, we will perform stenting in all of those except the major extravasation. If they have a major extravasation, they will go to surgery. What is your policy now?

Dr Dorweiler: Well, we use stent grafts in all the patients where we think there is a significant risk during a conventional operation. I have not worked up the cases of conventional thoracic aortic replacement during the last 5 years in detail, but there are approx. 20 cases including 6 cases of emergency operation amongst them one for traumatic rupture.

Dr Turina: And would you be putting in one of these grafts in a patient with a major extravasation if he has a big mediastinal hematoma which you can see opacification?

Dr Dorweiler: I have shown you one slide of an old lady with massive bleeding and a large mediastinal hematoma, and in this case we were not afraid to place the stent graft because of the comorbid conditions. This lady was in shock and she had to be resuscitated, and with the endovascular technique, I think the result is better than if we had operated the patient conservatively.

Dr S. Takamoto (Tokyo, Japan): I also have some comments about the big, huge extravasation of the descending aorta. The stent graft does not prevent bleeding. If we insert the stent graft in the descending aorta, it decreases the bleeding, but it doesn't prevent bleeding completely. I have one case, it's a perforation to the esophagus, and the stent graft did not prevent bleeding to the esophagus. Active bleeding still continued, although we could decrease the bleeding by the stent graft. If active bleeding exists continuously, it doesn't prevent all bleeding. The indication of this stent graft is confined for small amounts of bleeding around the descending aorta. If it's a large and active bleeding to the free space, it is not an indication.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 

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