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Endovascular treatment of post-traumatic thoracic aorta lesions

Department of Thoracic and Cardiovascular Surgery, Policlinico G. Martino, Messina 98100 Italy

Endovascular treatment of pseudoaneurysm of the thoracic aorta from a firearm injury

We read with interest the article of Petrucci and colleagues, and we congratulate the authors for precise diagnostics and successful correction of this type of pathology [1].

Trauma of the thoracic aorta, both for blunt trauma, or as in the reported case for penetrating wound, show a very high incidence of mortality. Hospital mortality rate after aortic open surgery is between 15 and 30% [2–3]. Endovascular management can be an alternative [4]. The authors successfully treated this thoracic aorta pseudo-aneurysm by the insertion of an endovascular prosthesis.

Between May 2005 and February 2007, we treated three patients with injury of the thoracic descending aorta, and concomitant haemothorax. All three patients had endovascular treatment. Size of the stent-graft was determined by contrast-enhanced CT and by angiographic images. At the end of the procedure, Digital Subtraction Angiography was performed in all patients to check stent-graft position, confirming complete pseudo-aneurysm exclusion and absence of endoleak. We used COOK ^® thoracic endoprosthesis in two patients, and in the third one, we used two ‘iliac’ stent grafts (COOK iliac extension endograft) due to the small diameter (18-16 mm) of the descending aorta. Technical success rate of stent graft placement was 100%. There was no operative or postoperative mortality nor postoperative paraplegia. All are regularly seen in the out-patient clinic. The follow-up ranges from 10 to 19 months.

The inclusion criteria to treat aortic injury with endovascular repair is dependent upon morphology of lesion, presence of concomitant injuries complicating open repair and availability of stent-grafts. The authors focused on the choice of an endovascular procedure, because the patient had already had a recent previous bilateral thoracotomy. We agree with this decision, and even more we think that in any case, even without previous thoracotomy, we would have treated the patient with an endovascular approach. In the patients we treated, in all of the three, there was associated haemothorax. We treated the patients anyway with endovascular approach, and we associated a video-assisted thoracoscopy to remove clotted residual blood from inside the chest. We think that treatment can be the same, both for blunt trauma and for penetrating thoracic aortic lesion, decreasing mortality and morbidity in comparison to open surgery. The second point, as reported by Petrucci, is the difficulty in some cases to find a stent graft of small dimension, because most medical centers have large sheaths since they treat aneurysmatic aortic lesions. In the case of a small size aorta, it is possible, as we did in one case, to adapt other smaller size grafts like the ones for the iliac artery. In conclusion, we agree, endovascular treatment of thoracic aortic lesions shows a very interesting alternative to open surgery both in blunt traumatic and penetrating lesions. Further studies with larger number of patients and longer follow-up are required to better evaluate the efficacy and the reproducibility of this approach in the treatment of this pathology.

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1. Petrucci O, de Oliveira PPM, Martins AS, Vieira RW. Endovascular treatment of pseudoaneurysm of the thoracic aorta from a firearm injury. Interact CardioVasc Thorac Surg 2008;7:529–531.[Abstract/Free Full Text]
2. Jamieson WR, Janusz MT, Gudas VM, Burr LH, Fradet GJ, Henderson C. Traumatic rupture of the thoracic aorta: third decade of experience. Am J Surg 2002;183:571–575.[CrossRef][Medline]
3. Von Oppell VD, Dunne TT, De Groot MK, Zilla P. Traumatic aortic rupture: twenty year metanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994;58:585–593.[Abstract]
4. Bent CL, Matson MB, Sobeh M, Renfrew I, Uppal R, Walsh M, Brohi K, Kyriakides C. Endovascular management of acute blunt traumatic thoracic aortic injury: a single center experience. J Vasc Surg 2007;46:920–927.[CrossRef][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Salvatore Lentini Roberto Gaeta Permission Requests Google Scholar Articles by Lentini, S. Articles by Spinelli, F. PubMed Articles by Lentini, S. Articles by Spinelli, F. Related Collections Related Article