0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review Article |

Thoracic Aortic Endografting for Trauma:  A Current Appraisal FREE

Brandon W. Propper, MD; W. Darrin Clouse, MD
[+] Author Affiliations

Author Affiliations: Department of Surgery, Wilford Hall Medical Center, Lackland Air Force Base, Texas (Dr Propper); Department of Surgery, David Grand USAF Medical Center, Travis Air Force Base, California (Dr Clouse); Division of Vascular and Endovascular Surgery, University of California, Davis, Sacramento (Dr Clouse); and Uniformed Services University of the Health Sciences, Bethesda, Maryland (Dr Clouse).


Arch Surg. 2010;145(10):1006-1011. doi:10.1001/archsurg.2010.194.
Text Size: A A A
Published online

Objective  To explore this newer treatment modality's benefits, technical concerns, and complications as currently understood during the management of patients with blunt aortic injury (BAI).

Data Sources  Data sources included relevant articles from published medical journals and current published texts.

Study Selection  Assimilation of the pertinent world's literature into a select representation of the current status of thoracic aortic endografting for trauma's (TAET) performance and outcomes.

Data Extraction  Comprehensive review of the current literature on BAI.

Data Synthesis  Comparison and critical evaluation of the current literature.

Conclusions  Endografting is the most frequently used method for repair of BAI. The use of TAET has led to reductions in operative mortality and spinal cord ischemia. Although experience seems promising, a new array of early and late complications must be considered. The positive experience with TAET thus far has provided impetus for endograft engineering and clinical trials specifically for BAI therapy. The ultimate late durability of TAET remains to be defined.

Figures in this Article

Blunt aortic injury (BAI) continues to harbor major morbidity and mortality. It remains the second leading cause of death among patients with trauma, secondary only to head injury.13 Although less than 0.5% of patients with trauma sustain BAI, 75% to 90% die in the prehospital setting.410 Of those who survive transport, only 50% survive beyond 24 hours without initiation of therapy. Injury occurs most commonly distal to the left subclavian artery (Figure 1), and two-thirds of these deaths are from aortic rupture.9 As imaging technology improves, the diagnosis of BAI seems to be increasing, and more subtle injuries are presenting difficult therapeutic dilemmas for patients and surgeons. During the past decade, the approach to individuals who sustain a traumatic injury of the thoracic aorta has also been conflicted by the development and implementation of newer, less-invasive endovascular therapies. The purpose of this article is to explore this newer treatment modality's benefits, technical concerns, and complications as currently understood during the management of patients with BAI.

Place holder to copy figure label and caption
Figure 1.

Various locations of blunt aortic injury.

Graphic Jump Location

Aortography has been the historical method for diagnosing BAI; however, the diagnostic modality of choice has shifted to computed tomography (CT) during the past 10 to 15 years.11 Debate regarding the sensitivity and specificity of CT was heated during the early part of the past decade. However, newer multidetector, highly resolute systems and volumetric reconstruction have essentially put this argument to rest (Figure 2). Demetriades et al11 authored an American Association for the Surgery of Trauma (AAST) Aortic Injury Study Group communication examining changing perspectives in BAI evaluation and treatment between 1997 and 2007. Use of aortography for diagnosis decreased from 87.0% to 8.3%, whereas use of CT for diagnosis increased from 34.8% to 93.3%.11 Today, aortography is essentially used as the initial evaluation portion of the endografting procedure (Figure 3).

Place holder to copy figure label and caption
Figure 2.

Computed tomographic images (A and B) showing blunt aortic injury.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Aortic angiogram of blunt aortic injury (BAI). A, Standard left anterior oblique arch aortogram showing BAI at the aortic isthmus. B, Completion aortogram after thoracic aortic endografting for trauma (TAET) to repair this BAI. Currently, most use of aortography is for landmark and injury definition before TAET.

Graphic Jump Location

In addition to CT and aortography, other methods of BAI diagnosis and imaging include transesophageal echocardiography, intravascular ultrasonography, and magnetic resonance angiograghy.9,12,13 All these modalities are specific for identifying BAI in patients with suspected injury. Intravascular ultrasonography and transesophageal echocardiography can also provide helpful real-time information regarding aortic size and seal zone morphologic features during thoracic aortic endografting for trauma (TAET). A classic series of abnormal findings on routine anteroposterior chest radiography have been identified that suggest BAI; however, although routine screening chest radiography has its proponents, it has been reported to miss 7% to 44% of BAI.3,1416 Given this high rate of missed injury on chest radiography, CT has been widely recommended for all patients who sustain significant blunt trauma.

TIMING TO SURGICAL INTERVENTION

The time from diagnosis to surgical intervention has changed significantly in the past 10 years. Since 1960, immediate surgical repair has been advocated.3,4 Yet, the widespread use of antihypertensive agents and β-blockers culminating in sheer stress reduction therapy have proved effective in halting subacute progression of BAI.17 The benefits of delay to definitive treatment until the patient's physiologic improvement has been recognized. In 1997, mean time from aortic injury to surgical intervention was 16.5 hours, and it increased to almost 55 hours by 2007.11 Recent multicenter evaluations by the AAST study group11,18,19 regarding time to repair have delineated this benefit more clearly. Regardless of repair method, delay beyond 24 hours after injury emerged as significantly advantageous regarding operative mortality (early vs delayed: odds ratio, 7.8; P = .008).18,19 Thus, with the usual physiologic compromise that can occur with severe blunt trauma, these current data and recommendations favor delayed aortic repair in patients suitable for ongoing blood pressure and sheer stress control.11,18,2023

CLASSIC OPEN SURGICAL INTERVENTION

Open surgical intervention has remained the mainstay for BAI repair for approximately 50 years. Surgical intervention involves double-lumen endotracheal intubation to facilitate single-lung ventilation of the right lung and aortic clamping via left thoracotomy, providing access to the injured aorta. Once the injured aorta is identified, the operating surgeon must choose between “clamp-and-sew” and alternative perfusion methods. When using clamp-and-sew, the aorta is doubly clamped and an interposition graft is inserted expeditiously. Analysis of this technique has revealed significant mortality of 16% and paraplegia of almost 20%.3,24 In fact, the clamp-and-sew technique has been impugned as an independent predictor of paraplegia when open aortic repair is undertaken.9

As such, distal perfusion techniques are commonly used during open repair.3,11 These techniques encompass a spectrum that includes left-sided heart bypass methods, femoral-femoral bypass, standard cardiopulmonary bypass, and, when necessary, even hypothermic circulatory arrest. Advantages of distal perfusion may include visceral and spinal cord protection. The AAST report11 suggests a significant reduction in spinal cord ischemic injury using contemporary operative techniques vs historical comparisons (2.9% vs 8.7%, P < .001). This included a substantial increase in the use of bypass modalities over the clamp-and-sew technique. Several systematic meta-analyses2527 have indicated that recent outcomes with open repair include operative mortality of 10% to 20%, paraplegia of 2% to 10%, and stroke of 4% to 6%. However, some researchers have argued that in young patients with trauma, the physiologic burden of open repair is well tolerated and outweighs the risk given the unknown long-term durability of stent grafts.

THORACIC ENDOGRAFTNG FOR TRAUMA

Endografting for thoracic aortic disease was first reported in 1994.24 Initial use of endografts was reserved for age-related and aneurysmal disease. A few years later, in 1997, Semba et al28 reported on the placement of covered stents for the treatment of 10 patients with traumatic aortic injuries. Since 1997, endovascular technology has evolved significantly, and TAET is a highly visible treatment method for BAI. In fact, recent evidence shows that it has become the most commonly used method of addressing this formidable injury today.11 Use of endografts is especially appealing in patients with large physiologic burdens from other injuries. Thoracic aortic endografting for trauma does not require single-lung ventilation, thoracotomy, or aortic cross-clamping. In addition, the devices can be deployed without the use of anticoagulation, which is especially advantageous in patients with concomitant head and solid organ trauma. Finally, TAET provides more flexibility for the trauma team and has been implemented in less than ideal environments, including the deployed military setting during Operation Iraqi Freedom.29

Naturally, TAET carries a new set of complications and challenges. Aside from operative mortality and paraplegia, endoleak, access vessel problems, stroke, and inadvertent arch-branch occlusion may occur.11 Currently, endoleak rates are reported to be 4.2% to 14% early and approximately 1% late.25,30 Early endoleak has been suggested to have a role in early death.26 Graft collapse is a severe complication and may potentially lead to aortic rupture and thrombosis and, ultimately, death.30 Additional complications, including stent fracture, migration, and ongoing aortic expansion, have been described.

Individuals who sustain traumatic aortic injury, in general, are younger, with relatively smaller aortas, than those treated for degenerative diseases. Many aortic diameters adjacent to the injury are smaller than 20 mm and taper in the descending component. Thus, the use of available, larger devices designed for degenerative diseases has unmasked serious troubles with graft infolding, graft collapse, aortic thrombosis, and failure when thoracic endografts are significantly oversized.12,3133 Therefore, it has become evident that oversizing thoracic grafts by only 10% is ideal. Specifically owing to the concern of aortic size in trauma, smaller and tapered endografts have been developed. Dedicated trials for the treatment of traumatic injury using these smaller grafts are under way and allow for TAET in aortas as small as 16 mm. Specifically, trials using smaller TAG (WL Gore & Associates Inc, Flagstaff, Arizona) and TALENT (Medtronic AVE Inc, Santa Rosa, California) thoracic endografts have been designed and are enrolling participants.

Arterial access via the iliofemoral system may also present challenges, particularly compared with the older population undergoing endografting for aneurysm and dissection. In TAET, the femoral and iliac vessels usually do not have significant calcification or thrombus burden. Instead, they are smaller and narrowing, with a higher risk of iatrogenic injury, such as perforation, tearing, thromboembolism, and rupture. Commercially available thoracic endografts are mounted on delivery systems with 20- to 26-French inner diameters (7.6- to 9.1-mm outer diameter). Thus, realistically, a continuous iliac system at least 8 mm in diameter throughout is necessary.

When iliofemoral access is not appropriate, graft conduits can be placed along the iliac arterial system, usually the common iliac, or the terminal aorta.33,34 These placements are accomplished via relatively small retroperitoneal incisions. The graft can be amputated after the procedure, and the stump can be oversewn in a straightforward manner. In patients in whom the iliofemoral system is adequate, reasonable results have been achieved by performing TAET via a totally percutaneous approach.35

Brachial access can help with TAET when arch angulation seems problematic. Arteriography via the brachial artery can help delineate proximal seal zones and decrease contrast load. In addition, a stiff wire snared between brachial and groin access sites can help decrease arch angulation and increase graft pushability and device tracking. The need for brachial access has been less common in trauma because significant angulation usually is associated with degenerative disease in older patients. When proximal seal zones were not adequate, subclavian coverage has been used.31,36 If the subclavian is covered, patients must be monitored for vertebrobasilar insufficiency and problematic upper extremity ischemia. European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair registry data, largely based on thoracic endografting for degenerative diseases, have revealed that intentional coverage of the subclavian artery without revascularization is a significant predictor of spinal cord ischemia, and this has been substantiated by a meta-analysis.32,37 Whether this may also be a distinct dilemma in patients with trauma undergoing TAET remains to be clarified.

WHAT ARE THE DATA?

Studies3843 aimed at comparing open surgical repair and TAET were initially single-institution trials, and these have continued to mature. In a representative study, Rousseau et al44 compared 29 patients undergoing TAET with a cohort of 35 patients repaired via the open technique in 2005. They found open repair mortality of 21%, with paraplegia of 7%. The TAET group experienced no mortality or paraplegia. This skilled group recently described their ongoing experience with endografting for trauma. Although there continued to be no perioperative deaths, 1 temporary paraparesis was noted. At mean follow-up of almost 3 years, no aortic reinterventions were required in individuals undergoing TAET.45

The largest singular cohort comes from the multicenter BAI data stemming from the AAST aortic injury study group reports.11 The initial report from this group, in 1997, provided important information regarding open repair (AAST1).9 As mentioned previously herein, the most recent communications have provided more pertinent information on BAI therapy. A total of 193 patients (68 open repair and 125 TAET) were enrolled in AAST2 between 2005 and 2007. During this time, 64.8% of BAI was repaired via TAET. Not only has the newer AAST2 study contrasted contemporary open vs endovascular repair experiences in a multicenter manner, but it illustrated the changing perspectives developing since 1997.11 Operative mortality has remained constant at 16% in open repair and is significantly lower with TAET (9%, P = .001). After adjusting for systemic injury degree and extrathoracic injury, mortality and pulmonary complications remained significantly lower with TAET.19 Nevertheless, repair site complications, usually from device delivery access, have been recognized to be more prevalent in TAET.11

Broader understanding of the place of TAET in aortic injury therapy has been further exemplified by recent meta-analyses. Tang et al25 evaluated 33 communications between 2001 and 2006. Three hundred twenty-nine patients were found who underwent open repair and 370 who underwent TAET. There were no differences in age, injury severity score, or technical success between the 2 strategies. Follow-up averaged 4 years in those with open repair but only approximately 2 years in those having TAET. Nevertheless, perioperative mortality (7.6% vs 15.2%), spinal cord ischemia (0% vs 5.6%), and stroke (0.85% vs 5.3%) were all statistically less frequent in the endografting group. Comparable findings have been reported by Xenos et al27 combining 17 studies from 2003 to 2007. In yet another systematic review by Hoffer et al,26 similar reductions in mortality and paraplegia were identified comparing TAET with open repair. They also compiled 667 reported TAET procedures regardless of open comparison. In this group, they identified early endoleak in 4.2% and late endoleak in 0.9%. Migration was negligible. Although seemingly adequate, almost 1 in 10 early deaths were attributed to endoleak and, essentially, treatment failure. In these systematic meta-analyses, the technical success of TAET was estimated to be greater than 96%, thus establishing its applicability as a reasonable treatment option.

Without prospective data to lead us, these collective evaluations are perhaps the most compelling discussion in favor of TAET currently. The developing body of literature is captivating, and a paradigm shift toward endovascular repair continues. Proponents point out that in light of these data, TAET seems to provide superior immediate results, and, at best, it is definitive treatment. At worst, it may provide a bridge to a later, elective procedure when the patient is physiologically optimized, or even recovered, from concomitant injuries.

DOES EVERYONE NEED REPAIR?

Prolonged medical therapy using sheer stress reduction without ultimate repair is debated but not currently commonplace. In 2001, the University of Tennessee at Memphis retrospectively evaluated data for patients with BAI between 1994 and 2000.12 A new definition of minimal aortic injury was used to describe injury with less than 1 cm of intimal flap and no periaortic hematoma. Nine patients were identified, and 6 of the 9 were observed. Of those, 3 developed pseudoaneurysm; however, none of the observed patients died as a result of aortic injury.12 Other studies exist regarding observation for minimal aortic injury. Fisher et al46 observed 3 patients with no deaths and reported 10 other such cases in the literature. With improvements in imaging technology, particularly CT, and its increased use, these minimal injuries are now frequently diagnosed. With quick and effective blood pressure control, the need for surgical repair is unclear.47 In a subset of patients, some have advocated for selective repair.47,48 No definitive conclusions can be made regarding the need for repair in those with minimal aortic injury currently, but it is likely that this debate will intensify as technology and medical therapy continue to improve. Based on current data, in centers where imminent endovascular capability for TAET is available, Figure 4 suggests an algorithm for the management of BAI.

Place holder to copy figure label and caption
Figure 4.

Treatment algorithm for thoracic injury. ASC indicates ascending aorta; BAI, blunt aortic injury; CRX, chest radiograph; CT, computed tomography; PSA, pseudoaneurysm; SCA, subclavian artery; and TAET, thoracic aortic endografting for trauma.

Graphic Jump Location

In summary, TAET has undergone significant changes since its introduction more than 10 years ago. Commercially made devices have improved, and ongoing modifications to enhance TAET are occurring. Endografting is now the most common method for repair of aortic injury and is becoming more commonplace. Although experience seems promising, this new technology provides a new array of early and late complications that must be considered, and the ultimate late durability of TAET remains to be defined. However, given the significant multisystem trauma sustained by most patients with BAI in conjunction with the newer evidence indicating reductions in mortality and spinal cord ischemia compared with open repair, TAET provides surgeons with an excellent additional option for addressing this difficult injury.

Correspondence: W. Darrin Clouse, MD, Department of Surgery, David Grant USAF Medical Center, 101 Bodin Cir, Travis AFB, CA 94535 (william.clouse@us.af.mil).

Accepted for Publication: November 13, 2009.

Author Contributions:Study concept and design: Propper and Clouse. Acquisition of data: Propper and Clouse. Analysis and interpretation of data: Propper and Clouse. Drafting of the manuscript: Propper and Clouse. Critical revision of the manuscript for important intellectual content: Propper and Clouse. Obtained funding: Clouse. Administrative, technical, and material support: Propper and Clouse. Study supervision: Propper and Clouse.

Financial Disclosure: None reported.

Clancy  TVGary Maxwell  JCovington  DLBrinker  CCBlackman  D A statewide analysis of level I and II trauma centers for patients with major injuries. J Trauma 2001;51 (2) 346- 351
PubMed Link to Article
Smith  RSChang  FC Traumatic rupture of the aorta: still a lethal injury. Am J Surg 1986;152 (6) 660- 663
PubMed Link to Article
Neschis  DGScalea  TMFlinn  WRGriffith  BP Blunt aortic injury. N Engl J Med 2008;359 (16) 1708- 1716
PubMed Link to Article
Parmley  LFMattingly  TWManion  WCJahnke  EJ  Jr Nonpenetrating traumatic injury of the aorta. Circulation 1958;17 (6) 1086- 1101
PubMed Link to Article
Plummer  DPetro  KAkbari  CO’Donnell  S Endovascular repair of traumatic thoracic aortic disruption. Perspect Vasc Surg Endovasc Ther 2006;18 (2) 132- 139
PubMed Link to Article
von Oppell  UODunne  TTDe Groot  MKZilla  P Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994;58 (2) 585- 593
PubMed Link to Article
Jamieson  WRJanusz  MTGudas  VMBurr  LHFradet  GJHenderson  C Traumatic rupture of the thoracic aorta: third decade of experience. Am J Surg 2002;183 (5) 571- 575
PubMed Link to Article
Lin  PHBush  RLZhou  WPeden  EKLumsden  AB Endovascular treatment of traumatic thoracic aortic injury: should this be the new standard of treatment? J Vasc Surg 2006;43(suppl A)22A- 29A
PubMed Link to Article
Fabian  TCRichardson  JDCroce  MA  et al.  Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma 1997;42 (3) 374- 383
PubMed Link to Article
Kwon  CCGill  ISFallon  WF  et al.  Delayed operative intervention in the management of traumatic descending thoracic aortic rupture. Ann Thorac Surg 2002;74 (5) S1888- S1898
PubMed Link to Article
Demetriades  DVelmahos  GCScalea  TM  et al.  Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma 2008;64 (6) 1415- 1419
PubMed Link to Article
Malhotra  AKFabian  TCCroce  MAWeiman  DSGavant  MLPate  JW Minimal aortic injury: a lesion associated with advancing diagnostic techniques. J Trauma 2001;51 (6) 1042- 1048
PubMed Link to Article
Gavelli  GCanini  RBertaccini  PBattista  GBnà  CFattori  R Traumatic injuries: imaging of thoracic injuries. Eur Radiol 2002;12 (6) 1273- 1294
PubMed Link to Article
Mirvis  SEBidwell  JKBuddemeyer  EU  et al.  Value of chest radiography in excluding traumatic aortic rupture. Radiology 1987;163 (2) 487- 493
PubMed
Demetriades  DGomez  HVelmahos  GC  et al.  Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma patients. Arch Surg 1998;133 (10) 1084- 1088
PubMed Link to Article
Woodring  JH The normal mediastinum in blunt traumatic rupture of the thoracic aorta and brachiocephalic arteries. J Emerg Med 1990;8 (4) 467- 476
PubMed Link to Article
Fabian  TCDavis  KAGavant  ML  et al.  Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg 1998;227 (5) 666- 677
PubMed Link to Article
Demetriades  DVelmahos  GCScalea  TM  et al.  Blunt traumatic thoracic aortic injuries: early or delayed repair—results of an American Association for the Surgery of Trauma prospective study. J Trauma 2009;66 (4) 967- 978
PubMed Link to Article
Demetriades  DVelmahos  GCScalea  TM  et al. American Association for the Surgery of Trauma Thoracic Aortic Injury Study Group, Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma 2008;64 (3) 561- 571
PubMed Link to Article
Pierangeli  ATurinetto  BGalli  RCaldarera  LFattori  RGavelli  G Delayed treatment of isthmic aortic rupture. Cardiovasc Surg 2000;8 (4) 280- 283
PubMed Link to Article
Symbas  PNSherman  AJSilver  JMSymbas  JDLackey  JJ Traumatic rupture of the aorta: immediate or delayed repair? Ann Surg 2002;235 (6) 796- 802
PubMed Link to Article
Pacini  DAngeli  EFattori  R  et al.  Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005;129 (4) 880- 884
PubMed Link to Article
Pate  JWFabian  TCWalker  W Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995;19 (1) 119- 126
PubMed Link to Article
Dake  MDMiller  DCSemba  CPMitchell  RSWalker  PJLiddell  RP Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331 (26) 1729- 1734
PubMed Link to Article
Tang  GLTehrani  HYUsman  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 (3) 671- 675
PubMed Link to Article
Hoffer  EKForauer  ARSilas  AMGemery  JM Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc Interv Radiol 2008;19 (8) 1153- 1164
PubMed Link to Article
Xenos  ESAbedi  NNDavenport  DL  et al.  Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008;48 (5) 1343- 1351
PubMed Link to Article
Semba  CPKato  NKee  ST  et al.  Acute rupture of the descending thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8 (3) 337- 342
PubMed Link to Article
Propper  BWAlley  JBGifford  SMBurkhardt  GERasmussen  TE Endovascular treatment of a blunt aortic injury in Iraq: extension of innovative endovascular capabilities to the modern battlefield. Ann Vasc Surg2009;23(5):687, e19-e22
PubMed
Feezor  RJHess  PJ  JrMartin  TD  et al.  Endovascular treatment of traumatic thoracic aortic injuries. J Am Coll Surg 2009;208 (4) 510- 516
PubMed Link to Article
Rehders  TCPetzsch  MInce  H  et al.  Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance. J Endovasc Ther 2004;11 (6) 659- 666
PubMed Link to Article
Cooper  DGWalsh  SRSadat  UNoorani  AHayes  PDBoyle  JR Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and meta-analysis. J Vasc Surg 2009;49 (6) 1594- 1601
PubMed Link to Article
Clouse  WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad In press
Criado  FJ Iliac arterial conduits for endovascular access: technical considerations. J Endovasc Ther 2007;14 (3) 347- 351
PubMed Link to Article
Peterson  BGMatsumura  JSMorasch  MDWest  MAEskandari  MK Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005;59 (5) 1062- 1065
PubMed Link to Article
Neschis  DGMoaine  SGutta  R  et al.  Twenty consecutive cases of endograft repair of traumatic aortic disruption: lessons learned. J Vasc Surg 2007;45 (3) 487- 492
PubMed Link to Article
Buth  JHarris  PLHobo  R  et al.  Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. a study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007;46 (6) 1103- 1111
PubMed Link to Article
Ott  MCStewart  TCLawlor  DKGray  DKForbes  TL Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004;56 (3) 565- 570
PubMed Link to Article
Andrassy  JWeidenhagen  RMeimarakis  GLauterjung  LJauch  KWKopp  R Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta: a single-center experience. J Trauma 2006;60 (4) 765- 772
PubMed Link to Article
Doss  MBalzer  JMartens  S  et al.  Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience. Ann Thorac Surg 2003;76 (5) 1465- 1470
PubMed Link to Article
Kasirajan  KHeffernan  DLangsfeld  M Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management. Ann Vasc Surg 2003;17 (6) 589- 595
PubMed Link to Article
Amabile  PCollart  FGariboldi  VRollet  GBartoli  JMPiquet  P Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004;40 (5) 873- 879
PubMed Link to Article
Stampfl  PGreitbauer  MZimpfer  D  et al.  Mid-term results of conservative, conventional and endovascular treatment for acute traumatic aortic lesions. Eur J Vasc Endovasc Surg 2006;31 (5) 475- 480
PubMed Link to Article
Rousseau  HDambrin  CMarcheix  B  et al.  Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair. J Thorac Cardiovasc Surg 2005;129 (5) 1050- 1055
PubMed Link to Article
Marcheix  BDambrin  CBolduc  JP  et al.  Endovascular repair of traumatic rupture of the aortic isthmus: midterm results. J Thorac Cardiovasc Surg 2006;132 (5) 1037- 1041
PubMed Link to Article
Fisher  RGOria  RAMattox  KLWhigham  CJPickard  LR Conservative management of aortic lacerations due to blunt trauma. J Trauma 1990;30 (12) 1562- 1566
PubMed Link to Article
Pate  JWFabian  TCWalker  W Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995;19 (1) 119- 125, discussion 125-126
PubMed Link to Article
Pate  JWGavant  MLWeiman  DSFabian  TC Traumatic rupture of the aortic isthmus: program of selective management. World J Surg 1999;23 (1) 59- 63
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Various locations of blunt aortic injury.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Computed tomographic images (A and B) showing blunt aortic injury.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Aortic angiogram of blunt aortic injury (BAI). A, Standard left anterior oblique arch aortogram showing BAI at the aortic isthmus. B, Completion aortogram after thoracic aortic endografting for trauma (TAET) to repair this BAI. Currently, most use of aortography is for landmark and injury definition before TAET.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Treatment algorithm for thoracic injury. ASC indicates ascending aorta; BAI, blunt aortic injury; CRX, chest radiograph; CT, computed tomography; PSA, pseudoaneurysm; SCA, subclavian artery; and TAET, thoracic aortic endografting for trauma.

Graphic Jump Location

Tables

References

Clancy  TVGary Maxwell  JCovington  DLBrinker  CCBlackman  D A statewide analysis of level I and II trauma centers for patients with major injuries. J Trauma 2001;51 (2) 346- 351
PubMed Link to Article
Smith  RSChang  FC Traumatic rupture of the aorta: still a lethal injury. Am J Surg 1986;152 (6) 660- 663
PubMed Link to Article
Neschis  DGScalea  TMFlinn  WRGriffith  BP Blunt aortic injury. N Engl J Med 2008;359 (16) 1708- 1716
PubMed Link to Article
Parmley  LFMattingly  TWManion  WCJahnke  EJ  Jr Nonpenetrating traumatic injury of the aorta. Circulation 1958;17 (6) 1086- 1101
PubMed Link to Article
Plummer  DPetro  KAkbari  CO’Donnell  S Endovascular repair of traumatic thoracic aortic disruption. Perspect Vasc Surg Endovasc Ther 2006;18 (2) 132- 139
PubMed Link to Article
von Oppell  UODunne  TTDe Groot  MKZilla  P Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994;58 (2) 585- 593
PubMed Link to Article
Jamieson  WRJanusz  MTGudas  VMBurr  LHFradet  GJHenderson  C Traumatic rupture of the thoracic aorta: third decade of experience. Am J Surg 2002;183 (5) 571- 575
PubMed Link to Article
Lin  PHBush  RLZhou  WPeden  EKLumsden  AB Endovascular treatment of traumatic thoracic aortic injury: should this be the new standard of treatment? J Vasc Surg 2006;43(suppl A)22A- 29A
PubMed Link to Article
Fabian  TCRichardson  JDCroce  MA  et al.  Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma 1997;42 (3) 374- 383
PubMed Link to Article
Kwon  CCGill  ISFallon  WF  et al.  Delayed operative intervention in the management of traumatic descending thoracic aortic rupture. Ann Thorac Surg 2002;74 (5) S1888- S1898
PubMed Link to Article
Demetriades  DVelmahos  GCScalea  TM  et al.  Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma 2008;64 (6) 1415- 1419
PubMed Link to Article
Malhotra  AKFabian  TCCroce  MAWeiman  DSGavant  MLPate  JW Minimal aortic injury: a lesion associated with advancing diagnostic techniques. J Trauma 2001;51 (6) 1042- 1048
PubMed Link to Article
Gavelli  GCanini  RBertaccini  PBattista  GBnà  CFattori  R Traumatic injuries: imaging of thoracic injuries. Eur Radiol 2002;12 (6) 1273- 1294
PubMed Link to Article
Mirvis  SEBidwell  JKBuddemeyer  EU  et al.  Value of chest radiography in excluding traumatic aortic rupture. Radiology 1987;163 (2) 487- 493
PubMed
Demetriades  DGomez  HVelmahos  GC  et al.  Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma patients. Arch Surg 1998;133 (10) 1084- 1088
PubMed Link to Article
Woodring  JH The normal mediastinum in blunt traumatic rupture of the thoracic aorta and brachiocephalic arteries. J Emerg Med 1990;8 (4) 467- 476
PubMed Link to Article
Fabian  TCDavis  KAGavant  ML  et al.  Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg 1998;227 (5) 666- 677
PubMed Link to Article
Demetriades  DVelmahos  GCScalea  TM  et al.  Blunt traumatic thoracic aortic injuries: early or delayed repair—results of an American Association for the Surgery of Trauma prospective study. J Trauma 2009;66 (4) 967- 978
PubMed Link to Article
Demetriades  DVelmahos  GCScalea  TM  et al. American Association for the Surgery of Trauma Thoracic Aortic Injury Study Group, Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma 2008;64 (3) 561- 571
PubMed Link to Article
Pierangeli  ATurinetto  BGalli  RCaldarera  LFattori  RGavelli  G Delayed treatment of isthmic aortic rupture. Cardiovasc Surg 2000;8 (4) 280- 283
PubMed Link to Article
Symbas  PNSherman  AJSilver  JMSymbas  JDLackey  JJ Traumatic rupture of the aorta: immediate or delayed repair? Ann Surg 2002;235 (6) 796- 802
PubMed Link to Article
Pacini  DAngeli  EFattori  R  et al.  Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005;129 (4) 880- 884
PubMed Link to Article
Pate  JWFabian  TCWalker  W Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995;19 (1) 119- 126
PubMed Link to Article
Dake  MDMiller  DCSemba  CPMitchell  RSWalker  PJLiddell  RP Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331 (26) 1729- 1734
PubMed Link to Article
Tang  GLTehrani  HYUsman  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 (3) 671- 675
PubMed Link to Article
Hoffer  EKForauer  ARSilas  AMGemery  JM Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc Interv Radiol 2008;19 (8) 1153- 1164
PubMed Link to Article
Xenos  ESAbedi  NNDavenport  DL  et al.  Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008;48 (5) 1343- 1351
PubMed Link to Article
Semba  CPKato  NKee  ST  et al.  Acute rupture of the descending thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8 (3) 337- 342
PubMed Link to Article
Propper  BWAlley  JBGifford  SMBurkhardt  GERasmussen  TE Endovascular treatment of a blunt aortic injury in Iraq: extension of innovative endovascular capabilities to the modern battlefield. Ann Vasc Surg2009;23(5):687, e19-e22
PubMed
Feezor  RJHess  PJ  JrMartin  TD  et al.  Endovascular treatment of traumatic thoracic aortic injuries. J Am Coll Surg 2009;208 (4) 510- 516
PubMed Link to Article
Rehders  TCPetzsch  MInce  H  et al.  Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance. J Endovasc Ther 2004;11 (6) 659- 666
PubMed Link to Article
Cooper  DGWalsh  SRSadat  UNoorani  AHayes  PDBoyle  JR Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and meta-analysis. J Vasc Surg 2009;49 (6) 1594- 1601
PubMed Link to Article
Clouse  WD Endovascular repair of thoracic aortic injury: current thoughts and technical considerations. Sem Int Rad In press
Criado  FJ Iliac arterial conduits for endovascular access: technical considerations. J Endovasc Ther 2007;14 (3) 347- 351
PubMed Link to Article
Peterson  BGMatsumura  JSMorasch  MDWest  MAEskandari  MK Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005;59 (5) 1062- 1065
PubMed Link to Article
Neschis  DGMoaine  SGutta  R  et al.  Twenty consecutive cases of endograft repair of traumatic aortic disruption: lessons learned. J Vasc Surg 2007;45 (3) 487- 492
PubMed Link to Article
Buth  JHarris  PLHobo  R  et al.  Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. a study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007;46 (6) 1103- 1111
PubMed Link to Article
Ott  MCStewart  TCLawlor  DKGray  DKForbes  TL Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004;56 (3) 565- 570
PubMed Link to Article
Andrassy  JWeidenhagen  RMeimarakis  GLauterjung  LJauch  KWKopp  R Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta: a single-center experience. J Trauma 2006;60 (4) 765- 772
PubMed Link to Article
Doss  MBalzer  JMartens  S  et al.  Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience. Ann Thorac Surg 2003;76 (5) 1465- 1470
PubMed Link to Article
Kasirajan  KHeffernan  DLangsfeld  M Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management. Ann Vasc Surg 2003;17 (6) 589- 595
PubMed Link to Article
Amabile  PCollart  FGariboldi  VRollet  GBartoli  JMPiquet  P Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004;40 (5) 873- 879
PubMed Link to Article
Stampfl  PGreitbauer  MZimpfer  D  et al.  Mid-term results of conservative, conventional and endovascular treatment for acute traumatic aortic lesions. Eur J Vasc Endovasc Surg 2006;31 (5) 475- 480
PubMed Link to Article
Rousseau  HDambrin  CMarcheix  B  et al.  Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair. J Thorac Cardiovasc Surg 2005;129 (5) 1050- 1055
PubMed Link to Article
Marcheix  BDambrin  CBolduc  JP  et al.  Endovascular repair of traumatic rupture of the aortic isthmus: midterm results. J Thorac Cardiovasc Surg 2006;132 (5) 1037- 1041
PubMed Link to Article
Fisher  RGOria  RAMattox  KLWhigham  CJPickard  LR Conservative management of aortic lacerations due to blunt trauma. J Trauma 1990;30 (12) 1562- 1566
PubMed Link to Article
Pate  JWFabian  TCWalker  W Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995;19 (1) 119- 125, discussion 125-126
PubMed Link to Article
Pate  JWGavant  MLWeiman  DSFabian  TC Traumatic rupture of the aortic isthmus: program of selective management. World J Surg 1999;23 (1) 59- 63
PubMed Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Balloon control for ruptured AAAs: when and when not to use? J Cardiovasc Surg (Torino) 2014;55(2):161-7.
[Aortitis due to Salmonella]. Dtsch Med Wochenschr 2014;139(16):835-8.