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Editorial comment

Management of traumatic aortic rupture: endovascular is the winner

Department of Cardiovascular Surgery, University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland

^_* Corresponding author. Tel.: +41 26 426 7185; fax: +41 26 426 7314. (Email: martyb{at}h-fr.ch).

Massive deceleration either horizontal or vertical can cause rupture of the aorta typically at the level of the ligamentum arteriosum (the aortic isthmus) distal to the origin of the left subclavian artery. The moment of inertia displaces the relatively mobile heart together with the aortic arch, while the descending aorta tethered to the spine via the intercostals pedicles remains fixed. With the vast majority of these injuries incurred through car crashes, nearly 80% of the victims die at scene of the accident as a result of complete aortic transection including the adventitia and attached connective tissue [1]. Approximately 20% reach the hospital alive due to an incomplete disruption of the tunica intima and media. Tensile strength is provided by the intact adventitia, and the parietal pleura contain the hematoma. However, if left untreated, 5–20 % of these patients are at risk of secondary rupture and intrapleural exsanguination within the first week [2]. In surgically untreated survivors, the natural course of aortic rupture is false aneurysm formation with secondary rupture after months or years.

For decades the treatment of choice has been immediate repair by a left thoracotomy, aortic cross clamping and direct suturing, or prosthetic graft interposition. The outcome has been constantly improved and in particular, the risk of paraplegia resulting from open surgery has been decreased to 2% by the use of partial cardiopulmonary bypass, active distal perfusion, and heparin-bonded circuits. However, mortality remains high with 12–26% due to associated injuries [3,4].

Since the first report of an endovascular treatment of traumatic aortic rupture in 1997 [5], numerous studies including our own experience [6,7] demonstrate a high degree of technical success and low complication rates, although based on a small number of patients. The recent report of Buz and co-workers [8] represents the largest series to date, and corroborates the results of the previous studies. It gives, once again, supporting evidence of an improved early outcome following endovascular repair. The literature gives clear proof of a shift in the management from open surgical to endovascular repair. Although endovascular aneurysm repair was first introduced 16 years ago, and a decade from the first stent graft repair of an acute traumatic rupture, no prospective randomized trial has been performed so far. Endovascular repair has several obvious advantages over open repair:

Increased efficiency: operative trauma load is minimal with a relatively short operating time of 60–90 min.

Improved outcomes: overall early mortality seems to be lower by 3–6%, as well as procedure-related morbidity including pulmonary complications. Heparin administration, even if necessary, is minimized and, therefore, less dangerous in patients with cerebral injuries. The endovascular repair is usually performed in a supine position, which is preferable in the presence of instable spine fractures.

Lower risk: paraplegia as an inherent and tragic complication of open repair, is not associated with endovascular repair, as aortic cross clamping is avoided.

Minimized delay: the endovascular approach removes the issue of delaying the repair due to its minimal invasiveness.

While the techniques and technology used in endovascular repair will continue to improve, there are a number of challenges that remain, namely:

Design improvement: there is a demand for smaller device diameters (20 or 22 mm) in these mostly younger patients with a small aorta and a tight aortic arch. Improvements of the devices are likely to mitigate device-related complications such as endoleaks and device collapse. Enhanced flexibility in order to better accommodate the steep inner curve of the aortic arch and a covered flap at the proximal end of the device designed to fully appose the inner aortic curve, will enable tight sealing of the aortic tear. A scallop at the outer proximal end of the device could avoid covering the left subclavian artery orifice. However, its covering by the actually available devices is necessary in about one third of the cases, and is rarely associated with impaired perfusion of the extremity. Finally the risk of iliac artery laceration could be decreased by smaller introducer sheaths.

Embolization risk: an inherent risk is the possibility of cerebral embolization resulting from manipulations within the aortic arch, although most of these trauma victims are young and their aortas free of atheroma.

Repair suitability: certain types of lesions are not favorable to an endovascular repair. There is such a circumferential disruption with pseudocoarctation because of the risk of dissection of the aortic arch by endovascular manipulations, or an impending instability of the device because of insufficient anchorage. An aortic disruption with extension into the arch also requires an open repair.

Device durability: the main argument against the endovascular repair, or indeed in favor of a randomized trial, is the unknown outcome in the long term. There are some concerns about device collapse, compression of the left main stem bronchus or aortoesophageal fistula, however, they seem to be very rare, and mid-term results are encouraging [9,10].

In summary, reduced early mortality and procedure-related morbidity, combined with the absence of paraplegia, are strong arguments in favor of an endovascular repair. Although early results are favorable, long-term outcome is still lacking. Considering the very encouraging experience we have to date, it is difficult to recommend prospective randomized trials. In the challenging management of traumatic rupture of the aorta, the endovascular approach with a record of improved outcomes, is a winning strategy.

	References

Top References

 

1. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ. Nonpenetrating traumatic injury of the aorta. Circulation 1958;XVII:1086-1101.
2. Pate JW, Fabian TC, Walker W. Traumatic rupture of the aortic isthmus: An emergency?. World J Surg 1995;19:119-126.[CrossRef][Medline]
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4. Jahromi AS, Kazemi K, Safar HA, Doobay B, Cina CS. Traumatic rupture of the thoracic aorta: Cohort study and systematic review. J Vasc Surg 2001;34:1029-1034.[CrossRef][Medline]
5. Kato N, Dake, MD, Miller DC, Semba CP, Mitchell RS, Razavi MK, Kee ST. Traumatic thoracic aortic aneurysm: Treatment with endovascular stent-grafts. Radiology 1997;205:657-662.[Abstract/Free Full Text]
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7. Marty B, Tozzi P, Ruchat P, Huber C, Doenz F, von Segesser LK. An IVUS-based approach to traumatic aortic rupture, with a look at the lesion from inside. J Endovasc Ther 2007;14:689-697.[CrossRef][Medline]
8. 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;33:143-149.[Abstract/Free Full Text]
9. Hoornweg LL, Dinkelman MK, Goslings C, Reekers JA, Verhagen HJM, Verhoeven EL, Schurink GWH, Balm R. Endovascular management of traumatic ruptures of the thoracic aorta: A retrospective multicenter analysis of 28 cases in The Netherlands. J Vasc Surg 2006;43:1096-1102.[CrossRef][Medline]
10. Marcheix B, Dambrin C, Bolduc J-P, Arnaud C, Hollington L, Cron C, Mugniot A, Soula P, Bennaceur M, Chabbert V, Otal P, Cérène A, Rousseau H. Endovascular repair of traumatic rupture of the aortic isthmus: Midterm results. J Thorac Cardiovasc Surg 2006;132:1037-1041.[Abstract/Free Full Text]

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