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Interact CardioVasc Thorac Surg 2007;6:823-824. doi:10.1510/icvts.2007.159145 © 2007 European Association of Cardio-Thoracic Surgery
Endovascular management of a thoracic aortic disruption following failure of deployment of a parachuteDepartment of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, 2632 N.20th Street, Phoenix, AZ 85006, USA Received 6 May 2007; received in revised form 21 August 2007; accepted 22 August 2007
*Corresponding author. Fax: +1-602-604-5020.
Traumatic thoracic aortic disruption is a life-threatening lesion associated with a high surgical mortality. Endovascular stent graft repair is a minimal invasive approach that does not require a thoracotomy, aortic cross clamping and cardiopulmonary bypass. We report the use of an endoluminal graft to treat a 58-year-old male, who sustained multiple injuries including thoracic aortic disruption in a sky-diving accident due to failure of deployment of his parachute.
Key Words: Parachute; Thoracic aortic disruption; Endoluminal graft
Traumatic aortic disruption of the thoracic aorta (TDTA) arises as a result of a lesion involving the aortic wall from the intima to the adventitia from blunt thoracic aortic trauma. Most patients with TDTA are victims of motor vehicle accidents with 80–90% dying at the scene of the accident from free rupture and exsanguinations into the chest. We report the endovascular management of a 58-year-old police officer who sustained significant injuries following failed deployment of a parachute during a sky-diving excursion. A 58-year-old police officer sustained multiple life threatening injuries including thoracic aortic disruption when his parachute failed to deploy. He was admitted to a trauma unit where he was initially evaluated. Due to loss of vitals in the emergency department, he was resuscitated and immediately taken to surgery where he underwent an exploratory laparotomy which revealed splenic rupture, liver contusion and retroperitoneal hematoma and exploratory clam-shell thoracotomy for pericardial tamponade, which revealed laceration to the atrium and hematoma around the aorta. A CT-scan performed post-surgery showed a thoracic aortic disruption (Fig. 1a,b). Due to his life threatening injuries, he was not deemed a candidate for open surgical repair, he was, therefore, transported to our institution 6 h after the injury for consideration for an endovascular repair under a Food and Drug Administration sponsored Investigational Devices Exemption Protocol.
Open retrograde access of the right common femoral artery was performed with a 9 French sheath with retrograde percutaneous access of the left common femoral artery with a 5F sheath. An aortogram performed demonstrated the area of thoracic aortic disruption. Sizing of the thoracic aorta was performed with an intravascular ultrasound and a 34-mm Gore TAG device (Flagstaff, AZ) was felt to be the adequate sized graft. Right groin 9F sheath was exchanged for a 22F sheath and the Gore 34 mmx15 cm device was advanced through the Gore sheath and subsequently deployed over an extra stiff wire to exclude the area of aortic disruption after marking the exact proximal and distal landing zones on our road map. A completion angiogram demonstrated exclusion of the area of aortic disruption with no endoleak. All wires and sheaths were removed and the right common femoral artery was closed in a transverse fashion with restoration of flow. He was transferred back to the trauma hospital for further management of his other injuries. Postoperative CT-scan (Fig. 2) performed one month post-repair demonstrated no endoleak with exclusion of area of transection.
The aortic isthmus is the principal area ruptured in 80% of cases in pathological series and 90–95% of cases in clinical series [1, 2] followed by the ascending aorta, or aortic arch, 18%, and the distal aorta, 14%. Making the diagnosis requires a high index of suspicion and most patients have other more obvious injuries. Operative intervention requiring delayed open surgical repair has been advocated by some authors [3, 4]. For patients that survive and are stable delaying repair and treatment of co-morbidities decreases overall morbidity without increasing mortality. Endovascular endografts have recently been approved to treat thoracic aortic aneurysms with decreased morbidity and mortality compared to open surgical repair [5]. Endovascular management of traumatic aortic transection confers an advantage over open surgical repair by avoiding thoracotomy, cross clamping, single lung ventilation, reduced blood loss, heparinization and reduced ischemic events relating to spinal chord, viscera and kidneys [6, 7]. The endoluminal graft can be deployed with minimal operative intervention via the common femoral artery. Potential short-comings include endoleaks, endograft migration, device infection caused by fistula formation, and not all patients have adequate aortic morphology to undergo repair. Younger patients are particularly challenging because they have a tapering luminal aortic diameter as well as a higher aortic pulsatile compliance than elderly patients. The smallest commercially available endoluminal graft, 26 mm, in a thoracic aorta <22 mm may result in gross over sizing, which may result in suboptimal conformability along the inner curve of the aortic arch and thus can lead to device fracture, endoleaks, migration and device collapse, which have been estimated to be approximately 3% in the traumatic aortic disruptions. In conclusion, endoluminal graft for the management of disruption of the thoracic aorta provides a minimal invasive way to treat such lethal injuries with acceptable morbidity and mortality. Device refinements, such as a more flexible shaft to accommodate the aortic curvature, may be needed in young patients who have a sharp aortic angulation juxta distal to the subclavian artery reducing the need for coverage of the left subclavian artery. Occasionally, off-the-shelf abdominal endoluminal graft cuffs or iliac limbs may need to be custom assembled to accommodate the small aortic diameter.
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Abstract
1. Introduction
