| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
|
Interact CardioVasc Thorac Surg 2008;7:529-530. doi:10.1510/icvts.2007.172304 © 2008 European Association of Cardio-Thoracic Surgery
Endovascular treatment of pseudoaneurysm of the thoracic aorta from a firearm injury
a Cardiac Surgery Unit, Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Rua Alexander Fleming, 181, Cidade Universitária ‘Zeferino Vaz’, 13083-970, Campinas, São Paulo, Brazil Received 28 November 2007; received in revised form 30 January 2008; accepted 1 February 2008
*Corresponding author. Rua João Baptista Geraldi, 135, Campinas, SP, Brazil, CEP 13085020. Tel./fax: +55-19-32490051.
A 24-year-old male patient was the victim of a firearm wound that penetrated the thorax. He arrived at another hospital hemodynamically unstable and was submitted to exploratory surgery by means of bithoracotomy. A lesion of the left branch of the pulmonary artery was detected and successfully repaired. He was submitted for computer-aided tomography on the fifth postoperative day, and a lesion of the mid-thoracic aorta was detected, which formed a saccular image. Considering that the patient had already been submitted to a bithoracotomy and that a direct approach to repair would involve another thoracotomy within a short period of time, endovascular treatment was chosen in our hospital. The procedure was performed under fluoroscopy. A second computer-aided tomography indicated adequate treatment of the lesion, with no indication of an endoleak. He has undergone ambulatory follow-up for 36 months without any problem related to the procedure. While endovascular treatment of the aorta has developed enormously, multicenter studies are needed to better define the long-term results of this approach.
Key Words: Aorta; Pseudoaneurysm; Gunshot wounds; Penetrating wounds
Lesions caused by firearm injury to the mediastinum are normally fatal; most patients die at the scene or upon admittance to an emergency unit [1]. Formation of an arteriovenous fistula or pseudoaneurysm of the aorta is not uncommon, and the currently accepted treatment is open surgery with exchange of the affected segment in the acute forms [2]. A more recent approach for such lesions is endovascular treatment, but the literature regarding this approach is limited [3]. Here we present a case study of a firearm injury in which the patient was successfully submitted to endovascular treatment for traumatic pseudoaneurysm of the thoracic aorta.
A 24-year-old male patient was the victim of a firearm wound that penetrated the thorax from right to left, crossing the medium mediastinum, and lodging in the left hemithorax. The patient arrived at another hospital hemodynamically unstable and was submitted to exploratory surgery by means of bithoracotomy. A lesion of the left branch of the pulmonary artery was detected and successfully repaired. No other lesion was observed during the intraoperative period. He was submitted for computer-aided tomography on the fifth postoperative day, and a lesion of the mid-thoracic aorta was detected, which formed a saccular image (Fig. 1). The patient was then brought to our tertiary hospital. Considering that the patient had already been submitted to a bithoracotomy and that a direct approach to repair would involve another thoracotomy within a short period of time (one week), endovascular treatment was chosen.
The procedure was performed under fluoroscopy by the right femoral artery and a 26x90-mm self-expanding stent (Braile Biomédica®) was deployed with full coverage of the pseudoaneurysm. The procedure was considered a success. A second computer-aided tomography indicated adequate treatment of the lesion, with no indication of an endoleak (Fig. 2). The patient was discharged from the hospital two days after the procedure. He has undergone ambulatory follow-up for 36 months without any problem related to the procedure.
Penetrating lesions to the aorta are rare, representing <1% of all lesions to the aorta [4, 5]. Several authors have compared endovascular treatment and open surgery of the aorta. In a comparative study, Brandt et al. demonstrated that endovascular surgery is associated with lower complication rates, reduced hospitalization time, and lower mortality [6]. Existing criteria for endovascular treatment of aortic diseases are the same as those used in patients with blunt lesions of the aorta. Open surgery in patients with blunt trauma to the aorta is associated with mortality rates close to 30% and a 20% chance of paraplegia of various degrees [2]. Several authors have demonstrated the efficacy of endovascular treatment of blunt lesions of the aorta [7, 8]. In brief, these authors showed that in the short-term, endovascular surgery presents lower mortality and morbidity rates than does open surgery. In the cases of patients seriously affected by blunt trauma, other lesions are generally treated first, making endovascular treatment very attractive. In contrast, penetrating lesions are usually well delimited, with smaller systemic effects that, in principle, do not favor endovascular treatment. Furthermore, these injuries generally involve a younger population, having fewer comorbidities; we still do not have information related to long-term follow-up of stents in this population with extended life expectancy. Another important consideration when treating penetrating lesions of the aorta is that most medical centers have large sheaths since they treat aneurysmatic lesions to the aorta, which involve normal caliber aortas. The follow-up of patients with stents in the thoracic aorta due to blunt trauma is relatively short. Dake et al. reported results of endovascular treatment for patients with thoracic aortic aneurysms with an average follow-up time of 55 months. The actuarial curve with six years of follow-up free of reoperation was 70±15% [9]. These findings suggest that the treatment is effective in the short-term, but does not provide optimum long-term results. In the case described herein, there were no further complications within the 36-month follow-up. The option for endovascular treatment was decided based on the recent performance of a large bithoracotomy (one week). Penetrating gunshot aortic lesions are rare, especially in the thoracic aorta. Yeh and colleagues reported a successful endovascular repair of an actively hemorrhaging gunshot injury to the abdominal aorta [10]. In summary, while endovascular treatment of the aorta has developed enormously, multicenter studies are needed to better define the long-term results of this approach. This rare case was treated by endovascular approach considering recent bithoracotomy and its implications.
Related Article
This article has been cited by other articles:
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
Top
Abstract
1. Introduction
