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Letters to the Editor

Endovascular treatment of acute traumatic aortic rupture: radical solution or postponement of the problem?

Cardiothoracic Surgery Department of University of Patras, 14 Zaimi Street, 26500, Rion Patras, Greece

Received 15 April 2008; accepted 19 June 2008.

^_* Corresponding author. Tel.: +30 2610 999779/999847; fax: +30 2610 994535. (Email: stratisapostolakis{at}yahoo.gr).

Key Words: Traumatic aortic rupture • Spinal cord ischemia • Subclavian occlusion • Conventional surgery of aortic rupture • Endovascular stent-graft • Aortic endo-stent

Endovascular stent-grafting of the traumatic thoracic aortic rupture constitutes an alternative treatment option to conventional surgical repair. The advantages of endovascular treatment over conventional surgical repair include the avoidance of thoracotomy (in the majority of patients), cardiopulmonary bypass and related complications (SIRS, ARDS), systemic heparinization complications, ischemia of spinal cord during aortic cross-clamping, and finally distal arterial ischemia [1]. While, endovascular treatment seems to have an advantage over conventional surgical repair concerning early results, this technique has in our opinion, two major drawbacks: (A) its superiority concerning early results is not as significant as reported, and (B) its late results still remain unknown and may be underestimated. In fact, reading this excellent study [1] and several others [2,3] we could note the following: (A1) Although the mortality is higher in the surgical group in comparison to the stenting group (21.2% vs 7.7%), this difference is not statistically significant. (A2) Concerning the incidence of paraplegia there were no statistically significant differences between two groups. In addition, the reported two cases of paraplegia were not related to the surgical procedure itself. (A3) The accidental occlusion of left subclavian artery, reported in a high percentage (51%) of stented patients, constitutes a serious complication, especially for young patients such as those in this study (average age = 36 years) [1]. However, it should be noted the fact that the majority of patients were young, consequently this complication becomes much more meaningful as it is related to the future professional return, and the potential use of IMA. Indeed, 25% of the patients with the above complication had ischemic complications of the arm and underwent re-operation with low heparinization. Moreover, it would be interesting for us to have clarification if the two patients with the late neurological problem belong to the subgroup with the accidental occlusion of the LSA. (A4) Conversion to conventional surgery was needed in three cases.

(B1) The mean follow-up time was significantly shorter in the endovascular stent-graft group compared to surgical group: 2.2 years vs 6 years, a fact that will no doubt influence positively the late results of the endovascular stent-graft technique. (B2) The quality of the follow-up was greatly different in the two groups: only 25% of patients belonged to endovascular stent-graft group evaluated with CT-scan. As a consequence, further complications of this group may not have been reported. The reported two deaths in following 18 months due to late sequelae or severe cerebrospinal trauma might be related to the stent technique. In conclusion, endovascular stent technique in unstable patients with polytrauma and simultaneous craniocerebral trauma attenuates the surgeon's stress as it offers a temporary solution to a difficult situation, rendering the surgeon a winner according to Marty [4]. However, this technique in a great number of patients may simply postpone the problem (possibly with different clinical appearance) to the future. A more reliable and also longer follow-up is needed in order to clarify if the endovascular stenting is the real winner.

Footnotes

The authors of the original paper [1] were also invited to reply to this Letter to the Editor but they did not respond.

References

1. 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;33:143-151.[Abstract/Free Full Text]
2. Rousseau H, Damprin C, Richeux L, Mazerolles M, Cron C, Watkinson A, Mugniot A, Soula P, Chabbert V, Canevet G, Roux D, Massabuau P, Meites G, Tran Van T, Otal P. Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair. J Thorac Cardiovasc Surg 2005;129:1050-1055.[Abstract/Free Full Text]
3. Zipfel B, Hammerschmidt R, Krabatsch T, Buz S, Weng Y, Hetzer R. Maxwell Chamberlain memorial paper for adult cardiac surgery: stent-grafting of the thoracic aorta by the cardiothoracic surgeon. Ann Thorac Surg 2007;83:441-449.[Abstract/Free Full Text]
4. Marty B. Management of traumatic aortic rupture: endovascular is the winner. Eur J Cardiothorac Surg 2008;33:149-151.[Free Full Text]

This article has been cited by other articles:

				B. Marty Reply to Apostolakis et al. Eur. J. Cardiothorac. Surg., September 1, 2008; 34(3): 701 - 702. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dimitrios Dougenis Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Apostolakis, E. Articles by Dougenis, D. Search for Related Content PubMed Articles by Apostolakis, E. Articles by Dougenis, D. Related Collections Great vessels