1DepartmeTock Seng Hos

2DepartmeTock Seng Hos

3DepartmeSeng Hospital,

CorrespondM Med (SurgHospital, 11E-mail: glennt

Ann Vasc SurgDOI: 10.1016/� Annals of VPublished onli

Management of Blunt Traumatic ThoracicAorta Injuries With EndovascularStent-Grafts in a Tertiary Hospitalin an Urban Asian City

Glenn Wei Leong Tan,1 Chong Han Pek,1 Daniel Wong,2 Sundeep Punamiya,2

Ming Terk Chiu,3 Vijayan Appasamy,3 Kok Hoong Chia,1 and Chee Wei Lee,1 Singapore

Background: Thoracic aortic injury from blunt trauma is a life-threatening condition with signif-icant mortality and morbidity with open surgical repair. Endovascular means of treatment isemerging as an attractive and less invasive option. We report our experience with endovascularstent-graft repair for blunt traumatic thoracic aorta injury.Methods: Between January 2003 and August 2009, six patients underwent endovascular repairof blunt traumatic thoracic aorta injury. Data from the medical records of these patients wereanalyzed.Results: All patients had deceleration injury resulting in thoracic aorta pseudoaneurysm at theaortic isthmus just distal to the left subclavian artery. Four patients were motorcyclists who hadbeen involved in road-traffic accidents and two had fallen from a height. The mean InjurySeverity Score was 33.8 (range, 21-43). All procedures were performed within 48 hours ofadmission and technical success was 100%. Five patients (83.3%) had the left subclavian arteryintentionally covered by the stent-graft to achieve adequate proximal landing zone. None of themhad any left upper limb ischemic complications or cerebrovascular events after the procedure.One patient had preservation of the left subclavian artery because intraoperative vertebralangiogram showed a hypoplastic right vertebral artery. No other procedural complications,paraplegia, or deaths were reported. Mean follow-up was 18.8 months (range, 1.5-42 months).Conclusions: Our early experience of endovascular stent-grafting for blunt traumatic thoracicaorta injury suggests that this emerging technique is safe for treatment of such pathology in ourinherently Asian population. Left subclavian artery may be sacrificed if adequate proximallanding zone is required for the stent-graft; and when vertebral angiogram was performed whichdid not show a dominant left vertebral artery.

nt of General Surgery, Vascular Surgery Service, Tanpital, Singapore.

nt of Radiology, Interventional Radiology Service, Tanpital, Singapore.

nt of General Surgery, Trauma Surgery Service, Tan TockSingapore.

ence to: Glenn Wei Leong Tan, MB, ChB, MRCS (Glasg),ery), Department of General Surgery, Tan Tock SengJalan Tan Tock Seng, Singapore 308433, Singapore,an@doctors.org.uk

2011; 25: 605-611j.avsg.2010.12.009ascular Surgery Inc.ne: March 24, 2011

INTRODUCTION

Traumatic aortic injury is a life-threatening condi-

tion with high prehospital mortality rates to

a maximum of 85%.1 Most of the patients die at

the scene of the injury. The postulated mechanisms

of blunt great vessel injury include shear forces

caused by relative mobility of a portion of the vessel

adjacent to a fixed portion, compression of the vessel

between bony structures, and profound intralumi-

nal hypertension during the severe traumatic event.

Themost common portion of the aorta to be affected

is the proximal descending thoracic aorta.

605

606 Glenn Tan et al. Annals of Vascular Surgery

Descending thoracic aortic injuries often occur at

the isthmus just distal to the left subclavian artery

because of the fixation of the descending thoracic

aorta at the ligamentum arteriosum. The traditional

management of descending thoracic aortic injury is

open surgery with some form of bypass shunt or

cardiopulmonary bypass or, for centers without

facilities for bypass, simple clamp-and-repair

technique. Mortality rates for open surgery can be

as high as between 15% and 30%.2,3 Recently,

endovascular techniques with low mortality and

morbidity rates have become popular in the treat-

ment of traumatic thoracic aortic injuries.4,5 Most

of the large series of endovascular stenting for blunt

traumatic aortic injuries have emerged from

Western centers, with only a small series from the

Far East.6 We report our experience with this tech-

nique in a tertiary hospital in an urban Asian city.

MATERIALS AND METHODS

Between January 2003 and August 2009, a search

was made for traumatic thoracic aorta injuries

from the prospective trauma registry in Tan Tock

SengHospital (TTSH), Singapore. The registry is staf-

fed by two permanent trauma coordinators and is

regularly audited for accuracy. The trauma registry

includes all patients admitted to TTSH for trauma.

TTSH is a tertiary hospital located in the central

part of Singapore housing the busiest trauma center

in the island country with an estimated population

of five million. It is well accessible with good

motorway links to the rest of the country.

During the study period of 80months, 45 patients

were identified as having traumatic thoracic aorta

injury. A total of 31 patients died in the Accident

and Emergency Department during resuscitation

before any intervention or investigations could be

performed, and the thoracic aortic injury was only

discovered at the postmortem examination. Of the

remaining 14 patients, only six underwent endolu-

minal stenting of the thoracic aorta. The other eight

died from their injuries. Of these, three patients

were brought to the operation theater for resuscita-

tion with surgery planned to achieve hemostasis:

only one patient was stable enough to undergo

thoracotomy and the remaining two died before

thoracotomy could be performed. However, the

patient who underwent thoracotomy died intrao-

peratively before aortic repair was performed. The

remaining five patients had ongoing resuscitation

in the intensive care unit but were never stable

enough to be transported to the operation theater

for surgery and subsequently died. The medical

records were reviewed for the six patients who

underwent endovascular stenting.

All trauma patients are brought to the Accident

and Emergency Department’s Resuscitation room

on arrival and stabilized by the Accident and Emer-

gency staff and General Surgery and Trauma

Surgery services according to Advanced Trauma

Life Support protocols. Multidetector computed

tomographic scan of the thorax with 1-mm fine

cuts was performed for all trauma patients who

demonstrated a widened mediastinum on chest

X-ray, which was part of the trauma series of

X-rays performed in the Accident and Emergency

Department. All but one patient had a widened

mediastinum on the chest X-ray. The patient

who had a normal chest X-ray had to undergo

a computed tomographic (CT) scan of the thorax

because of the severity of the mechanism of the

injury (fall from the fourth storey of a building),

which incidentally showed the pseudoaneurysm of

the thoracic aorta. On diagnosis of the thoracic

aortic pathology, the vascular surgery service was

consulted for all cases and decision and timing for

surgery was discussed and agreed on between the

trauma and vascular surgery teams. All the patients

who were confirmed to have a traumatic thoracic

aorta injury on CT scan were offered endovascular

stenting. Life-threatening and more severe injuries

were treated first before endovascular stenting of

the thoracic aorta could be performed (Figs. 1 and 2).

The general criteria used to determine anatomic

suitability for endovascular repair in this series was

a proximal and distal aortic neck of a minimum of

20 mm in diameter. The left subclavian artery was

sacrificed and covered in cases when adequate

landing zone was required. The endografts were

oversized by approximately 20% for our study

group. Iliac vessels also had to be>7mm in diameter

to accommodate the delivery system. All devices

used were one of the following two types: the Talent

or Valiant endovascular stent-graft (Medtronic Inc.).

In 2006, the Talent thoracic stent-graft was replaced

by the Valiant thoracic stent-graft at our center.

Both endovascular devices are straight stent-

grafts consisting of an external nitinol wire support

structure with an outer polyester covering. The

Talent device was used in the first three patients,

whereas the subsequent patients had the Valiant

variety. The Talent graft was available in only 100-

mm lengths, with diameters ranging from 24 to 46

mm, whereas the Valiant devices have lengths

ranging from 100 to 150 mm and diameters ranging

from 22 to 46 mm. There is a bare portion of prox-

imal stent-graft of 12 mm in the Valiant and 15

mm in the Talent.

Fig. 1. Sagittal image of computed tomographic aorto-

gram showing thoracic aorta pseudoaneurysm just distal

to the left subclavian artery.

Fig. 2. Angiographic film of thoracic aorta pseudoaneur-

ysm just distal to the left subclavian artery.

Vol. 25, No. 5, July 2011 Management of blunt traumatic thoracic aorta injuries 607

All procedures were performed under general

anesthesia in the angiography suite by a vascular

surgeon and an interventional radiologist under

fluoroscopic guidance. Patients were positioned

supine, prepped, and draped as for thoracotomy in

case of stent-graft failure. Lumbar drains were not

used. In all cases, the right common femoral artery

was surgically exposed for direct puncture, sheath

placement, and subsequent delivery of the stent-

graft. Percutaneous puncture of the left common

femoral artery was also performed. For all our

patients, the ileofemoral artery was>7mm in diam-

eter and none required a conduit for stent-graft

delivery. An aortography was performed initially

to confirm the aortic pathology before proceeding

with stent-graft deployment. A selective vertebral

angiogram was also performed intraoperatively for

all patients for assessment of posterior circulation

to the brain to ensure patency of the vertebral

arteries in case there was a need to preserve the

left subclavian artery when it was the dominant

supply to the basilar artery. Sizing of the stent-

graft was determined by the preoperative CT scan

and intraoperative aortogram. A completion aorto-

gram at the end of the procedure was also carried

out in all cases to ensure accurate placement and

no endoleaks. Surgical arterial closure was per-

formed for the right groin arterial cutdown (Figs. 3

and 4).

Technical success was defined as deployment of

the endograft in the correct position to exclude the

aortic pathology and to ensure the absence of endo-

leak on completion aortogram.

Follow-up of the patients was carried out with

clinical examination and repeat CT planned at

6-month intervals for the first year, then every

12 months or earlier if necessary. Plain chest radiog-

raphy was also performed to monitor for stent

position and fractures in cases when CT scan was

not performed at follow-up. All patients were given

antiplatelet therapy after endovascular stenting.

RESULTS

All the patients had undergone high impact acci-

dents with some form of deceleration injury result-

ing in a traumatic pseudoaneurysm of the thoracic

aorta just distal to the left subclavian artery. Mech-

anism of injury in the case of two patients was fall

from a height: one patient fell from the seventh

storey of a building in a suicide attempt and another

was a domestic helper who fell from the fourth

storey while cleaning windows. The other four

patients were motorcyclists who were involved in

road-traffic accidents and were flung to a distance

from their vehicles. There were four men and two

women. All patients were of Asian descent (three

Chinese, two Malay, and one Indian). The mean

age was 45 years (range, 24-72 years). All patients

had a variety of associated injuries, including frac-

tures of long bones, ribs, and pelvis; head injuries;

Fig. 3. Angiographic film showing a hypoplastic right

vertebral artery.Fig. 4. Angiographic film of normal caliber right verte-

bral artery.

608 Glenn Tan et al. Annals of Vascular Surgery

abdominal injuries; spine injuries; pulmonary

injuries; and other various orthopedic injuries, as

a result of the severity of the trauma. The mean

Injury Severity Score was 33.8 (range, 21-43).

None of the patients had any severe comorbidities

(hypertension, diabetes mellitus, ischemic heart

disease, cerebrovascular disease, renal impairment,

pulmonary disease, or hyperlipidemia), with the

exception of patient #2 who was a chronic smoker.

The length of intensive care unit stay and hospital

stay was prolonged mainly because of the severity of

the associated injuries from the trauma. The length

of hospital stay was prolonged in patients who had

severe orthopedic limb injuries or amputations

requiring rehabilitation and intensive physiotherapy.

The traumatic aorta injurywasnot themain reason in

any of the patients for the prolonged hospital stay.

All patients had stent-graft insertion within 48

hours of admission. The mean time from admission

to stent-graft insertion was 21.8 hours (range, 6-48

hours). The patients’ injuries were treated according

to the risk of threat to the life of the patient, which

explains the delay from admission before some of

these patients received their stent-grafts. This assess-

ment was made jointly and with close collaboration

between the trauma surgeons and vascular

surgeons. All patients had high surgical risk, as

reflected by the American Society of Anesthesiolo-

gists (ASA) score ranging between 3 and 4. The

mean operating time was 129.2 minutes (range,

105-180 minutes). A summary of the procedural

information is displayed in Table I.

All patients had a traumatic thoracic aorta pseu-

doaneurysm occurring just distal to the left subcla-

vian artery. The average diameter of the thoracic

aorta was 23 mm (range, 20-28 mm). All patients

had a landing zone of �20 mm between the left

subclavian artery and the site of aortic injury. To

gain enough proximal landing zone for the stent-

graft so as to obtain a good seal, the left subclavian

artery had to be sacrificed and covered with the

stent-graft for the first five patients (83.3%). In

patient #6, the selective vertebral angiogram

showed a hypoplastic-attenuated right vertebral

artery, suggesting that the left vertebral artery may

be supplying most of the blood to the basilar artery,

and a decision was made to preserve the left subcla-

vian artery, which was done successfully because

the proximal landing zone was 20 mm in length.

None of the patients needed the left common carotid

artery or innominate artery to be covered by the

stent-graft to gain adequate landing zone. Of the

patients who had the left subclavian artery covered,

all did not have a radial or brachial pulse after the

procedure, but none of the patients complained of

ischemic rest pain or claudication in the left upper

limb. None of the patients required carotidesubclavian bypass surgery to revascularize the left

Table I. Procedural information

PatientsAge/gender

Average sizeof thoracicaorta (mm) Device

Devicesize (mm)

Elapsed timefrom injury torepair (hours)

Operatingtime(minutes)

Landingzone (mm)

Left subclavianartery covered

Follow-up(months)

1 40/M 25 Talent 30 � 30 � 100 37.5 125 5 Yes 42

2 38/M 21 Talent 24 � 24 � 100 25 180 16 Yes 12

3 24/F 20 Talent 24 � 24 � 100 48 110 17 Yes 1.5

4 42/M 23 Valiant 28 � 28 � 150 6 105 18 Yes 36

5 72/F 28 Valiant 32 � 32 � 150 7 120 12 Yes 18

6 54/M 21 Valiant 24 � 24 � 150 7.5 135 20 No 3

Vol. 25, No. 5, July 2011 Management of blunt traumatic thoracic aorta injuries 609

subclavian artery or chimney stent to preserve the

left subclavian artery. None of the patients had

a stroke after the procedure. Only one stent-graft

was required for each patient. All the patients had

primary technical success of the stent-graft deploy-

ment (100%).

None of the patients had adverse characteristics

to endovascular stenting such as calcium plaques,

mural thrombus, small iliofemoral access arteries,

or tortuosity of the aorta. Blood loss was minimal

(<100 mLs) for all patients, except for patient #4

(300 mLs). Only patient #1 received 5,000 units of

intravenous unfractionated heparin during deploy-

ment of stent-graft, but this did not result in any

adverse hemorrhagic events. The remaining

patients were not given heparin because they had

suffered multiple other injuries and the surgeon

did not want to induce coagulopathy in these

patients.

There were no early endograft-related morbid-

ities such as graft migration, collapse, infection, or

thrombosis. None of the patients had any postoper-

ative cardiovascular, respiratory, renal, or cerebro-

vascular events. None of the patients suffered from

paraplegia. There were no access site problems

such as groin wound infections, bleeding, hema-

toma, or pseudoaneurysm formation. No para-

plegia, bowel ischemia, or limb ischemia was

observed. No intraoperative, in-hospital, or 30-day

mortalities were observed. None of the patients

required any further procedures for the thoracic

aorta pseudoaneurysm.

Mean follow-upwas 18.8months. Compliance to

follow-up was reduced in two patients. Patient #2

had underlying psychiatric disorder and was non-

compliant to his hospital appointments and was

lost to follow-up after 12 months. Patient #3 was

a domestic worker from Indonesia and chose to

return home for further treatment, explaining the

follow-up of only 1.5 months. In the remaining

four patients, there were no documented late

complications (Fig. 5).

DISCUSSION

Since the introduction of endovascular stenting of

the thoracic aorta, there has been a paradigm shift

toward using this less invasivemethod for treatment

of thoracic aorta pathology such as aneurysmal

disease, dissections, and atherosclerotic ulcers. This

has been fuelled by the benefit gained by the patient

in the form of lower morbidity and mortality rates5

and more economical utilization of hospital

resources resulting from shorter hospital stays and

usage of intensive care facilities associated with

this technique. Trauma patients often have associ-

ated multiple injuries, usually requiring several

operations. The traditional gold standard for trau-

matic thoracic aorta injury is open surgery, with

its high mortality rates in the range of 15-30%.2,3

Avoiding a thoracotomy, cardiopulmonary bypass

and aortic cross-clamping together with its morbid

complications of prolonged ventilatory support,

pulmonary complications, risk of renal failure, and

paraplegia is certainly advantageous to the already

critically ill patient.

With multiple injuries and operations often

required in trauma patients, the need for massive

blood transfusion coupled with hypothermia

common in this set of patients, concomitant coagul-

opathy remains a major concern. Systemic heparin-

ization usually given before stent deployment can

further worsen the coagulopathy. The role of

heparin is to prevent thrombus formation in the

aorta and iliac vessels around the endovascular

deployment device and also in the important

arteries arising from the aorta such as the visceral

vessels. In our study, only one patient (16.7%)

received intraoperative heparin, but there were no

thromboembolic complications noted despite

omission of heparin in most of our patients.

Because most injuries occur at the aortic isthmus

with limited landing zone for the stent-graft, left

subclavian artery coverage may be inevitable.

Several studies have shown the safety of left

Fig. 5. Post-stenting with left subclavian artery preserved.

610 Glenn Tan et al. Annals of Vascular Surgery

subclavian artery sacrifice,7-10 which we have

further emphasized in our study in which 83.3%

of our patients had uneventful sacrifice of the left

subclavian artery. Although some investigators

have reported complications from left subclavian

artery coverage11 and the necessity for prophylactic

carotidesubclavian bypass12 or creating a window

in the stent-graft for the left subclavian artery

ostium,13 we have not experienced the need for

these extra procedures that will lengthen the opera-

tive time and may add further stress to an already

compromised trauma patient.We do advocate selec-

tive vertebral angiogram during the procedure to

assess the posterior circulation to the brain. This

practice helped pick a patient in our cohort with

an attenuated hypoplastic right vertebral artery

and we opted to preserve the left subclavian artery

circulation in this case. In cases when the left subcla-

vian artery has to be sacrificed with potential reduc-

tion of blood flow to the posterior circulation, the

adjunct maneuvers described by Rousseau et al.13

can be used or carotidesubclavian bypass operation

should be performed before stent-graft deployment.

CT angiogram is another option that can be used to

define the anatomy of the vertebral arteries but will

necessitate another journey to the CT scanner

because most CT scans of the thorax do not include

the vertebrobasilar arterial system. We prefer intra-

operative selective vertebral angiogram before stent

placement because it gives amore physiologic repre-

sentation of the dominance of the posterior circula-

tion and Circle of Willis and does not significantly

increase the operative time and can potentially

prevent a catastrophic posterior circulation stroke.

There has been some controversy regarding the

timing of intervention for traumatic thoracic aortic

injuries with some advocating delayed treat-

ment,13,14 whereas others have recommended

immediate repair.15 In patients with traumatic

aortic injury, blood flow ismaintained in the disrup-

ted aorta by the adventitia and surrounding medias-

tinal structures. This is a precarious situation with

a potential for acute exsanguination into the thorax

at any time. Some previous studies have suggested

that repair can be delayed for patients who are stable

with concomitant injuries, presumably owing to the

stress of additional surgery.16,17 In our study, all

patients had endovascular repair as soon as other

more life-threatening injuries were treated and the

patient was stable for transfer to the angiography

suite. We have not experienced any major

morbidity or mortality from early endovascular

stent-grafting in our series despite the fact that all

our patients had associated injuries, with many

requiring multiple operations.

Despite all the advantages of endovascular repair

in thoracic aorta injuries, there remain some chal-

lenges to this technique. The typical trauma patient

is younger than the average patient with degenera-

tive aortic disease for whom the stent-grafts were

initially designed. Furthermore, most injuries occur

at the isthmus, thereby requiring for the stent-grafts

to be placed across a tighter more angulated aortic

arch. Younger subjects also have smaller caliber

aorta and iliac access vessels, which may present

difficulties in inserting the devices, stent-graft

conformity to aortic wall, or obtaining an accurate-

sized stent-graft. These factors may lead to higher

risk of endoleaks, stent collapse,18-20 or iliac artery

avulsions.4,5 Asian patients are of smaller build

and thus are perceived to have smaller aortas and

access vessels, which may be a contraindication to

endovascular approach to the management of

traumatic thoracic aortic injuries. However, we

have not encountered any problems with small ilio-

femoral arteries requiring access conduits or small

aortas where a suitably sized stent-graft was not

available.

In our series, we did not need to use any uncov-

ered bare stents, although we acknowledge their

usefulness in certain situations. It can be deployed

within the stent-grafts in the acute setting to allow

better conformity to the native aortic curvature in

cases when there is poor apposition of the proximal

portion and also in delayed partial or complete

collapse of the stent-grafts. However, there are

concerns that bare stentsmay erode though the graft

fabric over time or result in proximal aortic perfora-

tions and hence our reservations about their use.21

Vol. 25, No. 5, July 2011 Management of blunt traumatic thoracic aorta injuries 611

Endovascular stent-grafts require long-term

surveillance to assess for stent-graft durability and

endoleaks, usually with regular CT scans. This

results in large amounts of radiation exposure, espe-

cially undesirable in young patients. Only long-term

results will demonstrate the robustness of the endo-

vascular stents and provide a clearer direction or

alternatives for follow-up.

CONCLUSION

Endovascular stent-graft for traumatic thoracic

aorta injury has been shown to be a feasible and

safe method of repair. This is particularly advanta-

geous in trauma patients who have multiple

injuries, where avoiding a major thoracotomy can

reduce morbidity for the patient. Left subclavian

artery coverage by endovascular stent-graft to

obtain adequate landing zone is also safe when

intraoperative vertebral angiogram has shown

adequate posterior circulation to the brain from

the right vertebral artery. Omitting systemic hepa-

rinization during stent-graft deployment does not

increase the risk of thromboembolic complications

from the procedure and may be desirable in trauma

patients to reduce the risk of coagulopathy. Our

study demonstrates feasibility of endovascular

management of thoracic aorta injury in Asian

patients and did not encounter any problems with

small access vessel and aorta size that is widely

perceived in Asian patients because of their smaller

build.

The authors thankMs Karen Go andMs Yen Teng Yeo for the use

of information from the Trauma registry and Ms Wenzhao Sun

for help in tracing the medical records. The authors would also

like to thank the library services (Ms Cecilia James and Ms

Norina Hamid) in TTSH for providing reference materials.

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