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Endovascular Treatment of Blunt Thoracic Aortic Injury by Fractured Rib
Endovascular Treatment of Blunt Thoracic Aortic Injury by Fractured Rib Gabriele Pagliariccio,1 Michele Salati,2 Alberto Roncon,2 Giulia Gironi,1 and Luciano Carbonari,1 Ancona, Italy
We treated an 89-year-old patient affected by a descending thoracic aorta lesion due to a rib fracture with a penetrating costal stump. An urgent combined thoracic and endovascular surgical approach was performed, removing the rib fragment and positioning an aortic endoprosthesis simultaneously. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage.
CASE REPORT An 89-year-old woman suffered a severe blunt thoracic trauma and was admitted to our emergency department. The angio-computed tomography (CT) scan revealed a descending thoracic aorta lesion due to a costal penetrating fragment detached from the left-fractured ninth rib (Fig. 1). An urgent combined thoracic and endovascular surgical procedure was performed, once the patient was intubated through a double lumen tube for selective ventilation. Initially, the left femoral artery was exposed to place a guidewire (Back-up Meier; Boston Scientific, Marlborough, Massachusetts, USA) in the ascending thoracic aorta. Then, the patient was placed in lateral decubitus position, and a videothoracic single-port surgical procedure was performed to identify the injured rib and exclude active major bleedings. The diameter of the thoracic aorta at the level of the trauma was 30 mm, so we selected a 34 34 100 mm endoprosthesis with about 15% of oversize. Once the aortic endoprosthesis (Valiant Captivia, Medtronic, Dublin, Ireland) had been placed correctly across the aortic lesion, the penetrating fragment of the rib
1
Department of Vascular Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy. 2 Department of Thoracic Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy.
Correspondence to: Gabriele Pagliariccio, MD, Department of Vascular Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Via Conca, 71, 60126, Ancona, Italy; E-mail: gabriele. [email protected] Ann Vasc Surg 2019; 57: 272.e15–272.e17 https://doi.org/10.1016/j.avsg.2018.10.021 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: July 3, 2018; manuscript accepted: October 10, 2018; published online: 24 January 2019
(Fig. 2) was removed through an auxiliary paravertebral incision, and the endoprosthesis promptly opened. A final angiography was performed showing the exact positioning of the endoprosthesis without any active bleeding from the thoracic aorta. The postoperative angio-CT scan (Fig. 3) also demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage. The postoperative course was uneventful. Owing to the concomitant multiple pulmonary contusions, the patient underwent a tracheotomy for optimizing the ventilatory support.
DISCUSSION The isthmus is the most common site of aortic rupture after blunt thoracic aortic injuries (BTAIs).1 Only 15% of patients with aortic injury survive the journey to hospital.2 The aortic lesion is usually caused by an indirect shearing force due to rapid deceleration and much more rarely as a consequence of direct trauma.3 The endovascular treatment (thoracic endovascular aortic repair [TEVAR]) was considered for many years the treatment of choice for BTAI,4,5 because the risks of death and spinal cord ischemia were significantly lower after endovascular repair compared with open surgery.6 Taking into account this evidence, the guidelines of the European Society of Vascular Surgery6 as well as the ones of the Society of Vascular Surgery7 recommend that endovascular repair of traumatic thoracic aortic injuries should be preferred to open surgical repair or to conservative management strategies. 272.e15
272.e16 Case reports
Annals of Vascular Surgery
Fig. 1. The angio-CT scan shows the aortic lesion due to a rib fracture (red arrow).
Fig. 2. The penetrating fragment of the rib.
Fig. 3. The postoperative angio-CT scan demonstrates the correct position of the endoprosthesis.
Following the Azizzadeh recommendations,5 the treatment of BTAI with TEVAR should be tailored for every specific case.8e10 More recently, some papers11,12 reported that a delayed or conservative treatment is still a viable solution, associated with significantly reduced mortality rate. So the most effective treatment and the timing for BTAI remain controversial in case of intramural hematoma (such as with our patient) or pseudoaneurysm.6,13 In our patient, the aortic lesion was immediately evident during the initial angio-CT scan. It was due to a rib fracture with a penetrating costal stump, fixed in the aortic wall, inducing a subadventitial
hematoma without any sign of hemothorax or active bleeding. Some authors reported delayed aortic injuries caused by a fractured rib fragment that occurred a few days after the chest trauma.14,15 They suggested that the laceration of the aortic wall could be the result of patient mobilization. A combined vascular and thoracic surgical team treated our patient, as the removal of the bone fragment from the aorta could not be safely performed without the simultaneous closure of the hole of the aortic wall. The presence of subadventitial hematoma of the thoracic aorta prevented sudden death and gave us
Volume 57, May 2019
the time to plan the treatment strategy with a delayed TEVAR. As described previously, a delayed treatment of BTAI is feasible especially in particular situations where there are other concurrent injuries that need to be concomitantly treated.8 Taking into account that the rib resection and removal needed the left lateral decubitus with consequent difficult exposure of femoral arteries, we decided to place preliminarily a guidewire into the thoracic aorta through the left femoral vessel while the patient was still supine. Then, the extraction of the rib fragment and the release of the endoprosthesis were performed simultaneously. In conclusion, we believe that the keys for the success of the procedure were the combined approach and the use of the endovascular technique for treating the vascular lesion. REFERENCES 1. Richens D, Field M, Neale M, et al. The mechanism of injury in blunt traumatic rupture of the aorta. Eur J Cardiothorac Surg 2002;21:288e93. 2. O’Conor CE. Diagnosing traumatic rupture of the thoracic aorta in the emergency department. Emerg Med J 2004;21:414e9. 3. Yalcin M, Aytekin I. An unusual complication: aortic graft perforation by a fractured rib after type B aortic dissection. Interact Cardiovasc Thorac Surg 2016;23:338e9. 4. Daenen G, Maleux G, Daenens K, et al. Thoracic aorta endoprosthesis: the final countdown for open surgery after traumatic aortic rupture? Ann Vasc Surg 2003;17:185e91.
Case reports 272.e17
5. Azizzadeh A, Keyhani K, Miller CC 3rd, et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009;49:1403e8. 6. Riambau V, B€ ockler D, Brunkwall J, et al. Management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2017;53:4e52. 7. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society of Vascular Surgery. J Vasc Surg 2011;53:187e92. 8. Estrera AL, Gochnour DC, Azizzadeh A, et al. Progress in the treatment of blunt thoracic aortic injury: 12-year singleinstitution experience. Ann Thorac Surg 2010;90:64e71. 9. Seo YJ, Rudasill SE, Sanaiha Y, et al. A nationwide study of treatment modalities for thoracic aortic injury. Surgery 2018;164:300e5. 10. Fortuna GR Jr, Perlick A, DuBose JJ, et al. Injury grade is a predictor of aortic death among patients with blunt thoracic aortic injury. J Vasc Surg 2016;63:1225e31. 11. Marcaccio CL, Dumas RP, Huang Y, et al. Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury. J Vasc Surg 2018;68:64e73. 12. Di Eusanio M, Folesani G, Berretta P, et al. Delayed management of blunt traumatic aortic injury: open surgical versus endovascular repair. Ann Thorac Surg 2013;95: 1591e7. 13. Bottet B, Bouchard F, Peillon C, et al. When and how should we manage thoracic aortic injuries in the modern era? Interact Cardiovasc Thorac Surg 2016;23:970e5. 14. Ryu DW, Lee MK. Cardiac tamponade associated with delayed ascending aortic perforation after blunt chest trauma: a case report. BMC Surg 2017;17:70. 15. Park HS, Ryu SM, Cho SJ, et al. A treatment case of delayed aortic injury: the patient with posterior rib fracture. Korean J Thorac Cardiovasc Surg 2014;47:406e8.
We treated an 89-year-old patient affected by a descending thoracic aorta lesion due to a rib fracture with a penetrating costal stump. An urgent combined thoracic and endovascular surgical approach was performed, removing the rib fragment and positioning an aortic endoprosthesis simultaneously. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage.
CASE REPORT An 89-year-old woman suffered a severe blunt thoracic trauma and was admitted to our emergency department. The angio-computed tomography (CT) scan revealed a descending thoracic aorta lesion due to a costal penetrating fragment detached from the left-fractured ninth rib (Fig. 1). An urgent combined thoracic and endovascular surgical procedure was performed, once the patient was intubated through a double lumen tube for selective ventilation. Initially, the left femoral artery was exposed to place a guidewire (Back-up Meier; Boston Scientific, Marlborough, Massachusetts, USA) in the ascending thoracic aorta. Then, the patient was placed in lateral decubitus position, and a videothoracic single-port surgical procedure was performed to identify the injured rib and exclude active major bleedings. The diameter of the thoracic aorta at the level of the trauma was 30 mm, so we selected a 34 34 100 mm endoprosthesis with about 15% of oversize. Once the aortic endoprosthesis (Valiant Captivia, Medtronic, Dublin, Ireland) had been placed correctly across the aortic lesion, the penetrating fragment of the rib
1
Department of Vascular Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy. 2 Department of Thoracic Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Ancona, Italy.
Correspondence to: Gabriele Pagliariccio, MD, Department of Vascular Surgery, Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona, Via Conca, 71, 60126, Ancona, Italy; E-mail: gabriele. [email protected] Ann Vasc Surg 2019; 57: 272.e15–272.e17 https://doi.org/10.1016/j.avsg.2018.10.021 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: July 3, 2018; manuscript accepted: October 10, 2018; published online: 24 January 2019
(Fig. 2) was removed through an auxiliary paravertebral incision, and the endoprosthesis promptly opened. A final angiography was performed showing the exact positioning of the endoprosthesis without any active bleeding from the thoracic aorta. The postoperative angio-CT scan (Fig. 3) also demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage. The postoperative course was uneventful. Owing to the concomitant multiple pulmonary contusions, the patient underwent a tracheotomy for optimizing the ventilatory support.
DISCUSSION The isthmus is the most common site of aortic rupture after blunt thoracic aortic injuries (BTAIs).1 Only 15% of patients with aortic injury survive the journey to hospital.2 The aortic lesion is usually caused by an indirect shearing force due to rapid deceleration and much more rarely as a consequence of direct trauma.3 The endovascular treatment (thoracic endovascular aortic repair [TEVAR]) was considered for many years the treatment of choice for BTAI,4,5 because the risks of death and spinal cord ischemia were significantly lower after endovascular repair compared with open surgery.6 Taking into account this evidence, the guidelines of the European Society of Vascular Surgery6 as well as the ones of the Society of Vascular Surgery7 recommend that endovascular repair of traumatic thoracic aortic injuries should be preferred to open surgical repair or to conservative management strategies. 272.e15
272.e16 Case reports
Annals of Vascular Surgery
Fig. 1. The angio-CT scan shows the aortic lesion due to a rib fracture (red arrow).
Fig. 2. The penetrating fragment of the rib.
Fig. 3. The postoperative angio-CT scan demonstrates the correct position of the endoprosthesis.
Following the Azizzadeh recommendations,5 the treatment of BTAI with TEVAR should be tailored for every specific case.8e10 More recently, some papers11,12 reported that a delayed or conservative treatment is still a viable solution, associated with significantly reduced mortality rate. So the most effective treatment and the timing for BTAI remain controversial in case of intramural hematoma (such as with our patient) or pseudoaneurysm.6,13 In our patient, the aortic lesion was immediately evident during the initial angio-CT scan. It was due to a rib fracture with a penetrating costal stump, fixed in the aortic wall, inducing a subadventitial
hematoma without any sign of hemothorax or active bleeding. Some authors reported delayed aortic injuries caused by a fractured rib fragment that occurred a few days after the chest trauma.14,15 They suggested that the laceration of the aortic wall could be the result of patient mobilization. A combined vascular and thoracic surgical team treated our patient, as the removal of the bone fragment from the aorta could not be safely performed without the simultaneous closure of the hole of the aortic wall. The presence of subadventitial hematoma of the thoracic aorta prevented sudden death and gave us
Volume 57, May 2019
the time to plan the treatment strategy with a delayed TEVAR. As described previously, a delayed treatment of BTAI is feasible especially in particular situations where there are other concurrent injuries that need to be concomitantly treated.8 Taking into account that the rib resection and removal needed the left lateral decubitus with consequent difficult exposure of femoral arteries, we decided to place preliminarily a guidewire into the thoracic aorta through the left femoral vessel while the patient was still supine. Then, the extraction of the rib fragment and the release of the endoprosthesis were performed simultaneously. In conclusion, we believe that the keys for the success of the procedure were the combined approach and the use of the endovascular technique for treating the vascular lesion. REFERENCES 1. Richens D, Field M, Neale M, et al. The mechanism of injury in blunt traumatic rupture of the aorta. Eur J Cardiothorac Surg 2002;21:288e93. 2. O’Conor CE. Diagnosing traumatic rupture of the thoracic aorta in the emergency department. Emerg Med J 2004;21:414e9. 3. Yalcin M, Aytekin I. An unusual complication: aortic graft perforation by a fractured rib after type B aortic dissection. Interact Cardiovasc Thorac Surg 2016;23:338e9. 4. Daenen G, Maleux G, Daenens K, et al. Thoracic aorta endoprosthesis: the final countdown for open surgery after traumatic aortic rupture? Ann Vasc Surg 2003;17:185e91.
Case reports 272.e17
5. Azizzadeh A, Keyhani K, Miller CC 3rd, et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009;49:1403e8. 6. Riambau V, B€ ockler D, Brunkwall J, et al. Management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2017;53:4e52. 7. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society of Vascular Surgery. J Vasc Surg 2011;53:187e92. 8. Estrera AL, Gochnour DC, Azizzadeh A, et al. Progress in the treatment of blunt thoracic aortic injury: 12-year singleinstitution experience. Ann Thorac Surg 2010;90:64e71. 9. Seo YJ, Rudasill SE, Sanaiha Y, et al. A nationwide study of treatment modalities for thoracic aortic injury. Surgery 2018;164:300e5. 10. Fortuna GR Jr, Perlick A, DuBose JJ, et al. Injury grade is a predictor of aortic death among patients with blunt thoracic aortic injury. J Vasc Surg 2016;63:1225e31. 11. Marcaccio CL, Dumas RP, Huang Y, et al. Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury. J Vasc Surg 2018;68:64e73. 12. Di Eusanio M, Folesani G, Berretta P, et al. Delayed management of blunt traumatic aortic injury: open surgical versus endovascular repair. Ann Thorac Surg 2013;95: 1591e7. 13. Bottet B, Bouchard F, Peillon C, et al. When and how should we manage thoracic aortic injuries in the modern era? Interact Cardiovasc Thorac Surg 2016;23:970e5. 14. Ryu DW, Lee MK. Cardiac tamponade associated with delayed ascending aortic perforation after blunt chest trauma: a case report. BMC Surg 2017;17:70. 15. Park HS, Ryu SM, Cho SJ, et al. A treatment case of delayed aortic injury: the patient with posterior rib fracture. Korean J Thorac Cardiovasc Surg 2014;47:406e8.