OBJECTIVE:The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS:A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS:In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS:In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

Évaluer la faisabilité et la fiabilité de la mise en place d'endoprothèses pour traiter les ruptures aiguës post-traumatiques de l'isthme aortique : présentation de notre expérience de 16 patients. Entre janvier 1996 et décembre 2001, 16 patients, âgés en moyenne de 36 ans, ont été traités par cette technique. Tous présentaient des lésions associées et 9 d'entre eux, une instabilité hémodynamique non liée à la rupture isthmique. Après un délai variant de 9 à 245 jours (moyenne 78 jours), une endoprothèse aortique était mise en place par une équipe pluridisciplinaire. Un suivi régulier était réalisé par scanner et échographie transoesophagienne. L'endoprothèse a permis l'exclusion du faux anévrisme dans 100 % des cas. La procédure durait en moyenne 120 minutes et 80 % des patients ont pu être extubés sur table. Le séjour moyen aux soins intensifs était de 24 heures. La seule complication était une compression de la bronche souche gauche par le faux anévrisme, traitée avec succès par une endoprothèse bronchique. Le recul maximal était de 7 ans. La mise en place d'endoprothèse pour rupture aiguë de l'isthme aortique est une technique fiable et peut être proposée comme alternative à la chirurgie pour les polytraumatisés dont les lésions associées augmentent le risque chirurgical. The aim of this study was to evaluate the feasibilityand safety of endovascular repair in acute traumatic aortic rupture on thebasis of our experience with 16 patients. From January 1996 to December 2001,16 patients, with a mean age 36 years, underwent repair of traumatic rupture of the aorta with the use of stent-grafts. Allpatients presented with coexisting injuries and 9 of 16 patients were hemodynamically unstable because of other injury. After a delay rangingfrom 9 to 245 days (mean 78 days), aortic stent-grafting was performed by a multidisciplinary team. Allpatients had regular follow-up with spiral CT and transesophagealechocardiogram. Stent-graftplacement was successful in all patients with exclusion of falseaneurysm. The duration of the procedure was about 120 min andmechanical respiratory assistance could be removed immediately in 80% ofpatients. Mean stay in the intensive care unit was 24 hours. One complication was noted: compression of the left main stem bronchussuccessfully treated with endoprosthesis. Maximum follow-up was7 years. Endovascularstent-graft repair is a valuable technique and is emerging as analternative technique for treating thoracic aortic injury in patients in whomcoexisting injury increases the surgical risk.

PURPOSE:The aim of this study was to evaluate the feasibility and safety of endovascular repair in acute traumatic aortic rupture on the basis of our experience with 16 patients. MATERIALS AND METHODS:From January 1996 to December 2001,16 patients, with a mean age 36 years, underwent repair of traumatic rupture of the aorta with the use of stent-grafts. All patients presented with coexisting injuries and 9 of 16 patients were hemodynamically unstable because of other injury. After a delay ranging from 9 to 245 days (mean 78 days), aortic stent-grafting was performed by a multidisciplinary team. All patients had regular follow-up with spiral CT and transesophageal echocardiogram. RESULTS:Stent-graft placement was successful in all patients with exclusion of false aneurysm. The duration of the procedure was about 120 min and mechanical respiratory assistance could be removed immediately in 80% of patients. Mean stay in the intensive care unit was 24 hours. One complication was noted: compression of the left main stem bronchus successfully treated with endoprosthesis. Maximum follow-up was 7 years. CONCLUSION:Endovascular stent-graft repair is a valuable technique and is emerging as an alternative technique for treating thoracic aortic injury in patients in whom coexisting injury increases the surgical risk.

Objective. - The usual treatment of traumatic aortic rupture (TAR) is surgical. This invasive technique necessitating, thoracotomy and ECC is associated with a mortality rate of more than 20% and a paraplegia risk of about 10%. New minimally-invasive techniques (aortic stent-grafting) are emerging as less risky alternatives to surgery. We report our experience in the percutaneous treatment of TAR with stent-graft via a surgical femoral cut-down.Patients and methods. - Between 1996 and 2002, 23 patients (16-65-year-old, mean 36 years) were treated by thoracic stent-grafting. An informed consent was obtained for every patients. Thirteen patients had an acute or sub-acute TAR (1-8 months, mean 5 months) and five patients had chronic TAR (13-24 years, mean 17 years). The technique was done under general anaesthesia and each patient received a preoperative blood-pressure reduction treatment. During the procedure, anticoagulation (heparin) was given and hypotension was induced when the stent-graft was deployed. Direct positioning control was obtained by means of TEE.Results. - Eighty percent of patients were extubed immediately after the procedure. Bleeding was <150 ml. The primary success rate was 100% with one minor type 2 endoleak that was spontaneously resolved after 2 months. There was no case of mortality or paraplegia. There were three minor complications (17%), two haematomas at the arteriotomy site and one inflammatory syndrome characterised by slight fever, raised biological markers but with negative blood culture.Conclusion. - Percutaneous aortic stent-grafting for TAR is a minimally-invasive technique, which constitute an interesting alternative to surgery. It only necessitates a femoral surgical cut-down compared to the thoracotomy and ECC associated with surgery. The complication rate is low and no mortality or major complication was encountered in our patients. Eventually, the long-term follow-up will allow a widening of indications. (C) 2004 Elsevier SAS. Tons droits reserves.

OBJECTIVE:The usual treatment of traumatic aortic rupture (TAR) is surgical. This invasive technique necessitating thoracotomy and ECC is associated with a mortality rate of more than 20% and a paraplegia risk of about 10%. New minimally-invasive techniques (aortic stent-grafting) are emerging as less risky alternatives to surgery. We report our experience in the percutaneous treatment of TAR with stent-graft via a surgical femoral cut-down.PATIENTS AND METHODS:Between 1996 and 2002, 23 patients (16-65-year-old, mean 36 years) were treated by thoracic stent-grafting. An informed consent was obtained for every patients. Thirteen patients had an acute or sub-acute TAR (1-8 months, mean 5 months) and five patients had chronic TAR (13-24 years, mean 17 years). The technique was done under general anaesthesia and each patient received a preoperative blood-pressure reduction treatment. During the procedure, anticoagulation (heparin) was given and hypotension was induced when the stent-graft was deployed. Direct positioning control was obtained by means of TEE.RESULTS:Eighty percent of patients were extubed immediately after the procedure. Bleeding was <150 ml. The primary success rate was 100% with one minor type 2 endoleak that was spontaneously resolved after 2 months. There was no case of mortality or paraplegia. There were three minor complications (17%), two haematomas at the arteriotomy site and one inflammatory syndrome characterised by slight fever, raised biological markers but with negative blood culture.CONCLUSION:Percutaneous aortic stent-grafting for TAR is a minimally-invasive technique, which constitute an interesting alternative to surgery. It only necessitates a femoral surgical cut-down compared to the thoracotomy and ECC associated with surgery. The complication rate is low and no mortality or major complication was encountered in our patients. Eventually, the long-term follow-up will allow a widening of indications.

Purpose: To evaluate the midterm outcomes of thoracic aortic stent-grafting and the performance of computed tomographic angiography (CTA), radiography, and magnetic resonance angiography (MRA) in endograft surveillance.Methods: Forty-seven patients with traumatic thoracic aortic ruptures (n=16), aneurysms (n=14), false aneurysms (n=3), penetrating ulcers (n=3), and dissections (n=11) treated with stent-grafts were monitored in follow-up using chest radiography and CTA in all patients and MRA in 23 patients. Two perpendicular maximal aortic diameters, the sum of these diameters, and the elliptical cross-sectional area were determined and compared to baseline for the entire group and in subgroup analyses according to lesion type. CTA, MRA, and radiography were compared for their ability to detect endoleak, monitor stent-graft configuration, and measure aortic diameters.Results: The mortality rate was 8.5%. Severe complications were observed in 14.8% (6% neurological complications); 12 (25.5%) patients had primary endoleaks. Over a mean 11-month follow-up (range 0.25-46 months), the aortic diameters decreased for all patients without endoleak (P<0.001). In the diameter/area subgroup analyses, only the traumatic rupture cohort demonstrated significant decreases in all 4 measurements. CTA and MRA measurements correlated well, but chest radiography was superior to both for visualizing stent-graft shape. In terms of endoleak detection, MRA missed only 1 (12.5%) endoleak (type II) seen on CTA; there were no false positive results with MRA.Conclusions: Morbidity and mortality observed after thoracic stent-grafting are acceptable. Radiography is better for monitoring stent-graft conformation, while CTA provides the best overall morphological information. The performance of MRA in endoleak detection is encouraging.

Purpose: To evaluate the efficacy of stent-graft placement for the treatment of penetrating thoracic aortic ulcers.Methods: Ten patients (7 men; mean age 73.8 years, range 69-79) were treated for penetrating thoracic aortic ulcers using Talent or Excluder stent-grafts. Preoperative examinations included computed tomographic angiography (CTA), transesophageal echography, and digital subtraction angiography (DSA). Follow-up included predischarge multimodal imaging and periodic CTA scans after discharge. Endoleaks, aortic diameter changes, and clinical complications were tracked.Results: Technical success was achieved in 100%, but 1 major neurological complication led to death 3 months after the procedure. Radiological follow-up detected 4 early endoleaks (3 type I and a type II), all of which spontaneously regressed, and 1 secondary type II endoleak. The mean aortic diameter decreased by 22% over a mean 9-month follow-up.Conclusions: Aortic ulcers are potentially lethal lesions. Considering its low morbidity and mortality, endovascular repair could widen the treatment options for these lesions.

HomeCirculationVol. 101, No. 10Limitations to the Therapeutic Potential of Endoluminal Stent Placement in the Thoracic Aorta Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessOtherPDF/EPUBLimitations to the Therapeutic Potential of Endoluminal Stent Placement in the Thoracic Aorta Torsten Doenst, Christian Schlensak and Friedhelm Beyersdorf Torsten DoenstTorsten Doenst Department of Cardiovascular Surgery, University of Freiburg, Freiburg, Germany , Christian SchlensakChristian Schlensak Department of Cardiovascular Surgery, University of Freiburg, Freiburg, Germany and Friedhelm BeyersdorfFriedhelm Beyersdorf Department of Cardiovascular Surgery, University of Freiburg, Freiburg, Germany Originally published14 Mar 2000https://doi.org/10.1161/01.CIR.101.10.e96Circulation. 2000;101:e96To the Editor:In their recent study, Rousseau et al1 report the successful delayed treatment of traumatic rupture of the thoracic aorta by endoluminal stent placement. The results of this technique in the authors' hands were excellent. The authors suggest that this alternative treatment to conventional surgery is feasible and safe but that its use may be restricted by limited durability of the stent graft material.We wish to raise a point that may further limit the therapeutic potential of stent placement in the thoracic aorta. It is our experience from implanting >150 endoluminal stents into the abdominal aorta in order to exclude aneurysms that despite excellent immediate success rates, >10% of the stents had to be surgically removed within the first 4 years after stent implantation (References 2 and 3 and unpublished observations). Others have made similar observations.4 Surgical explantation of the stents in our patients became necessary not only because of problems with the stent durability but mainly because of dislocation of the stents and reexposure of the old aneurysms to systemic blood pressure. These dislocations were due to dilatation of the aorta at the anchoring site of the stent. Dilatation of the aorta may also occur in the thoracic aorta. Because of the elastic nature of the vessel walls, dislocation of stents may even be facilitated. Although our experience with the placement of thoracic stents is limited, we would expect a similar condition in these cases. Thus, we propose that stent graft placement into the thoracic aorta should only be considered a palliative treatment option. The possible requirement for surgical explantation of the stent at a later time point should be taken into account at the time the decision for stent placement is made. References 1 Rousseau H, Soula P, Perreault P, Bui B, Janne d'Othée B, Massabuau P, Meites G, Concina P, Mazerolles M, Joffre F, Otal P. Delayed treatment of traumatic rupture of the thoracic aorta with endoluminal covered stent. Circulation.1999; 99:498–504.CrossrefMedlineGoogle Scholar2 Blum U, Voshage G, Lammer J, Beyersdorf F, Tollner D, Kretschmer G, Spillner G, Polterauer P, Nagel G, Holzenbein T, Thurnher S, Langer M. Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J Med.1997; 336:13–20.CrossrefMedlineGoogle Scholar3 Schlensak C, Blum U, Munzar T, Spillner G, Beyersdorf F. Three-year follow-up after endoluminal treatment for abdominal aortic aneurysm. Thorac Cardiovasc Surg. 1998;45(suppl I):177. Abstract.Google Scholar4 May J, White GH, Waugh R, Stephen MS, Chaufour X, Yu W, Harris JP. Adverse events after endoluminal repair of abdominal aneurysms: a comparison during two successive periods of time. J Vasc Surg.1999; 29:32–39.CrossrefMedlineGoogle ScholarcirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinsResponseRousseau H., MD, Janne d'Othée B., MD, Perreault P., MD, Meites G., MD, Joffre F., MD, Otal P., MD, Soula P., MD, Concina P., MD, Massabuau P., MD, Mazerolles M., MD, and Bui B., MD14032000Doenst et al, from the team who played a major role in the widespread diffusion of stent grafting for abdominal aortic aneurysms (AAA) by their major publication in the New England Journal of Medicine,R1 raise an essential point concerning long-term benefits of aortic endoprostheses.All prospective studies and registers do indeed show that stent grafting gives good immediate results for treatment of AAA, with a 30-day morbidity and mortality rate less than that of classic surgery. On middle-term follow-up studies, the complication rate, however, is not negligible and mostly consists of secondary leaks.R2 Whereas size increase of the proximal aneurysmal neck may account for some of these endoleaks, most are related to changes in aneurysmal volume after successful exclusion, which results in device distortions, kinkings, or modular disconnections. Most of these complications can be treated via an endovascular approach. This demonstrates the importance of close follow-up to detect and treat them. Lastly, these somewhat deceiving results were observed with first-generation devices. New models, as used in our study, seem to confer substantial advantages.In addition, thoracic aortic aneurysms differ considerably from AAAs in several ways. First, only 1 tubular device is needed for endovascular treatment in most patients, thereby eliminating the risk for leaks between adjacent stent grafts. Second, in our article, the only accepted indication concerned isthmic lesions that occurred on otherwise healthy aortas and in patients in whom surgery was contraindicated in many cases. Third, oversizing by at least 10% the diameter of the device (compared with the normal aortic diameter) reduces the risk of migration, even if aortic size increases with time.The Stanford teamR3 has reported similar results as we did, with a mean follow-up of 15 months for traumatic thoracic aortic lesions, and they did not observe any aneurysm expansion or rupture. Their overall experience of stent grafting in a relatively large population also encompasses other aortic diseases. So far, the main concerns about thoracic stent grafting involve potential complications, such as mortality and paraplegia rates.R4R5 But on the basis of nonrandomized studies, it appears that these complications probably occur less frequently than with surgery. To the best of our knowledge, stent-graft explantation has not yet been necessary or considered at the level of the thoracic aorta.In conclusion, our current experience (20 patients, mean follow-up of 20 months, range 1 to 42 months) is still preliminary but has led to encouraging results. The benefits of aortic endoprostheses in terms of morbidity and mortality by far outweigh those of classic surgery by thoracotomy. In our opinion, this enforces justifications for their use, although this area is still in the prospective study stage. Previous Back to top Next FiguresReferencesRelatedDetails March 14, 2000Vol 101, Issue 10Article InformationMetrics Copyright © 2000 by American Heart Associationhttps://doi.org/10.1161/01.CIR.101.10.e96 Originally publishedMarch 14, 2000 PDF download Advertisement

Although diabetes is a classical risk factor for macroangiopathy, the prevalence of renal artery stenosis (RAS) in this type of pathology has not been clearly determined. More than 50% of RAS occur in diabetic patients (almost exclusively Type 2), whereas autopsy findings and the few clinical surveys reported indicate that the percentage of RAS within the diabetic population is close to 30%. RAS occur especially in elderly subjects with Type 2 diabetes and multiple vascular involvement, and bilateral stenoses are frequent. Diagnostic imaging of RAS can cause adverse effects in the diabetic patient if iodinated contrast media are used, especially in cases of renal insufficiency. The presence of this risk factor requires that iodinated radiological explorations be performed with due caution, or that another product be substituted as a contrast agent (CO(2) or gadolinium), or that an imaging technique without iodine be used (colour Doppler ultrasound, magnetic resonance angiography). The therapeutic management of RAS in the diabetic patient differs little from that employed for other atheromatous stenoses of the renal artery. Endovascular treatment of RAS is the technique of choice for most patients, whether diabetic or not. The existence of diabetes has little effect on therapeutic strategy, except in cases of renal insufficiency when the risk of iodine overload should limit the doses of contrast medium or require the partial or even total substitution of another agent (CO(2), gadolinium). As in the case of other RAS, the indications depend on the lesion and the clinical presentation. Similarly, the results are both clinical and anatomical, and the existence of diabetes has a limited impact on these different parameters.

BACKGROUND:Stent grafting is emerging as a new treatment for several pathological conditions involving the thoracic aorta. We studied the feasibility and safety of this technique for delayed treatment of ruptures of the aortic isthmus.METHODS AND RESULTS:Nine patients (14 to 76 years old; mean, 37 years; male/female ratio, 8/1) underwent stent grafting of the aortic isthmus in subacute (n=5) or chronic (n=4) aortic traumatic rupture after a motor accident. In subacute ruptures, this treatment was delayed (1 to 8 months; mean, 5.4 months) because of the severity of other associated injuries. Stent grafting was technically successful (defined as complete exclusion of the pseudoaneurysmal sac) in all patients. Short-term fever and biological inflammatory syndrome occurred in 3 patients. Two major complications occurred: in 1 patient, an early occlusion of the left subclavian artery was treated by placement of 2 Palmaz stents. In another patient, an atelectasis related to an increase of preexisting compression of the left main bronchus by the pseudoaneurysmal sac was successfully treated by temporary placement of an endobronchial silicone stent. Mean follow-up was 11.6 months (range, 3 to 21 months). Thrombosis of the pseudoaneurysmal sac was found in all patients.CONCLUSIONS:In the absence of available extended follow-up about the safety and effectiveness of endovascular grafting, this approach seems to be a viable therapeutic option for traumatic rupture of the aortic isthmus, but appropriately controlled prospective studies are needed before we can recommend its widespread use.

Acute rupture of the thoracic aorta caused by blunt chest trauma is a life-threatening injury accounting for up to 18% of deaths in motor vehicle accidents.1Greendyke RM Traumatic rupture of the aorta: special reference to automobile accidents.JAMA. 1966; 195: 527-530Crossref PubMed Scopus (208) Google Scholar The site of aortic rupture is the isthmus in 84% to 90% of cases.2Duhaylongsod FG Glower DD Wolfe WG Acute traumatic aortic aneurysm: the Duke experience from 1970 to 1990.J Vasc Surg. 1992; 15: 331-343Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 3Kodali S Jamieson WRE Leia-Stephens M Myagishima RT Janusz MT Tyers GFO Traumatic rupture of the thoracic aorta: a 20-year review: 1969-1989.Circulation. 1991; 84: 40-46PubMed Google Scholar The natural history of the patient with aortic transection is self-selective. Death follows a bimodal distribution, with most patients dying at the scene, whereas approximately 15% to 20% of the victims reach the hospital alive because of the preserved continuity of adventitia and mediastinal structures surrounding the injured aorta.4Merrill WA Lee RB Hamman JW Frist WH Stewart JR Bender HW Surgical treatment of acute traumatic tear of the thoracic aorta.Ann Surg. 1988; 207: 699-706Crossref PubMed Scopus (63) Google Scholar Of those potentially curable patients the overall mortality rate is estimated to be 32%, with one third dying before surgical repair is attempted.5VonOppell UO Dune TT DeGroot MK Zilla P Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia.Ann Thorac Surg. 1994; 58: 585-593Abstract Full Text PDF PubMed Scopus (383) Google Scholar Since Parmley et al.'s6Parmley LF Mattingly TW Manion WC Jahnke EJ Nonpenetrating traumatic injury of the aorta.Circulation. 1958; 17: 1086-1100Crossref PubMed Scopus (971) Google Scholar report in 1958 on the natural history of the injury, many aspects of aortic transection have changed, from the design of motor vehicles, which alters survival rates, through the creation of heparinless partial bypass techniques, and, more recently, to the tremendous development of endovascular intervention. This report relates our experience with two patients in whom treatment was deliberately delayed for periods of 1 and 6 months, respectively, and who subsequently underwent transluminal placement of endovascular covered stents for the management of traumatic rupture of the descending aorta. Case 1. A 15-year-old boy was transferred to our center from a peripheral hospital 8 hours after having been struck by a car while riding a moped. Before the transfer a splenectomy had been performed because of hemodynamic instability attributed to a ruptured spleen with hemoperitoneum. On arrival the patient was comatose (initial Glasgow coma scale 3), hemodynamically stable but severely hypoxemic (PaO2: 60), and anuric. Clinical and radiologic evaluation revealed a closed head injury with subarachnoid and intraventricular hemorrhage associated with a right hemorrhagic frontal contusion and an open fracture of the right tibia. The chest roentgenogram showed a widened mediastinum with blurred aortic knob and depressed left mainstem bronchus. Spiral computed tomography (CT) of the chest with three-dimensional vascular reconstruction revealed a traumatic rupture of the descending aorta with mediastinal hematoma confirmed by transesophageal echocardiography. Bilateral pulmonary contusions were also present. Because of the precarious condition of the patient, the aortic lesion was not treated initially. Moreover, the risk of intrathoracic exsanguination was thought to be rather low in the absence of active ongoing hemorrhage and elevated blood pressure. After 6 months of convalescence with close monitoring and blood pressure control, the patient showed marked neurologic and respiratory improvement, and plans could be made for elective treatment of the now stable and well-concealed pseudoaneurysm that had developed at the site of the previous aortic rupture (Fig. 1). Chronic pulmonary infection with multiresistant Staphylococcus aureus precluded an open thoracotomy because of the risk of graft infection in the event that primary closure proved impossible. Thoracic spiral CT and digital subtraction angiography of the thoracic aorta with a calibrated catheter were performed for sizing and localizing purposes (Figs. 1 and 2). Selective intercostal arteries catheterization revealed that the Adamkiewitcz artery originated from the ninth intercostal artery on the right side. Consent was obtained, and a team of vascular surgeons and interventional radiologists performed the endovascular procedure with the patient under general anesthesia with endobronchial intubation and mechanical ventilation. The procedure was conducted in a sterile radiologic vascular interventional suite (in accordance to the World Health Organization's recommendation on air handling of surgical suites). The operative field was prepared and draped for thoracotomy in the event the endovascular device could not be deployed or a major complication occurred. The endovascular device used was a straight covered stent7Blum U Voshage G Lammer J Beyerdorf F Follner D Kretschmer G et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (558) Google Scholar (Mintec, Freeport, Bahamas) 22 mm in diameter and 8 cm long with 1.2 cm bare at the proximal end. Measurements were based on the digital subtraction angiography and the spiral CT data. The graft diameter was oversized by 10% to achieve a tight friction seal. The right common femoral artery was isolated, and a transverse arteriotomy was performed after intravenous administration of 5000 IU heparin. A right brachial artery puncture allowed a 2.60 m long 0.035-inch stiff guide wire (Amplatz, Meditech, Watertown, Mass.) to be tethered between the two vascular accesses, ensuring a rigid axis and smooth tracking of the device. Under fluoroscopic and transesophageal echocardiographic guidance the delivery system was advanced until the sheath was correctly positioned with the first leading platinum marker on the compressed stent-graft at the preestablished level. The outer sheath was then slowly withdrawn approximately 3.5 cm. The latex balloon was positioned in the first leading lumen of the stent-graft and was inflated to fully anchor the barbs on the neck of the stent into the nonaneurysmal wall of the aorta. The outer sheath was then withdrawn completely to fully deploy the implant. Thereafter the prosthesis was modeled with a 20 mm angioplasty balloon (Medi-tech, Watertown, Mass.). Finally the introducer delivery system was removed, and after repeat angiography and transesophageal echocardiography were performed, the arteriotomy was repaired. With this technique the covered stent was deployed with the proximal end just distal to the left subclavian artery ostium and the distal end 2.5 cm under the aortic rupture. Angiography (Fig. 3) and perioperative transesophageal sonography revealed complete thrombosis of the pseudoaneurysm with exclusion of the neck. However, a sudden rise in pressure inside the pseudoaneurysmal sac with fresh thrombosis resulted in complete left lung atelectasis caused by acute compression of the left mainstem bronchus. An endobronchial silicone stent was then installed with good clinical and bronchoscopic results. The clinical outcome was favorable, and the patient had no sensory or motor deficit. Follow-up cranial CT revealed a postcontusionnal hypodensity in the right frontal lobe responsible for posttraumatic seizures well controlled by medication. The bronchial stent was removed 3 months later. Spiral CT and transesophageal echocardiography at 15 days, 3 months (Fig. 4), and 6 months showed complete exclusion and significant involution of the pseudoaneurysm. The lung parenchyma was normal. At 15 months after treatment (21 months after trauma) spiral CT revealed complete involution of the pseudoaneurysm with the prosthesis intact and stable (Fig. 5). Fig. 5Thoracic spiral CT 15 months after treatment showing complete involution of pseudoaneurysm, good apposition of prothesis to aortic wall, and patent left bronchus.View Large Image Figure ViewerDownload (PPT) Case 2. A 19-year-old man involved in a violent head-on collision (restrained) was admitted with multiple traumatic injuries. Examination revealed a severe brain injury (initial Glasgow coma scale 6) with left parietal and left ischiopubic fractures and scrotal hematoma. No motor deficit was present. He was hemodynamically stable, had undergone intubation, and had fair oxygen saturation. The initial chest x-ray evaluation showed a widened mediastinum, left pleural cap, blurred aortic knob, and a right pulmonary contusion. Thoracic spiral CT revealed a significant hemomediastinum, a right hemopneumothorax, and a right pulmonary contusion. Contrast injection with three-dimensional vascular reconstruction demonstrated a contained rupture of the aortic isthmus with pseudoaneurysm confirmed at transesophageal echocardiography. Head CT showed a left frontoparietal epidural hematoma (1.8 × 1.6 cm) with moderate mass effect. Because of the patient's neurologic condition the aortic surgery was postponed, and his blood pressure and hemodynamic status were closely monitored in an intensive care setting. After 1 month of convalescence with neurologic and respiratory improvement, endovascular treatment of the now stable aortic pseudoaneurysm was proposed. The epidural hematoma showed some regression (1.5 cm thick). With a similar technique and under the same conditions, a 26 mm diameter, 9 cm long covered stent was installed. The first 12 mm of the prosthesis was not covered with Dacron and overlapped the ostium of the left subclavian artery because of the close proximity of the pseudoaneurysmal sac. Angiography and transesophageal echocardiography showed complete exclusion of the pseudoaneurysm with good apposition of the stent-graft to the aortic wall. The left subclavian artery remained patent with good opacification. After an uneventful procedure and recovery, the patient was discharged in good condition on the eighth postoperative day. Transesophageal echocardiography 2 months after the intervention revealed normal patency of the stent-graft with a small inner deformity caused by the more compliant Dacron membrane compared with the inner metal frame, slightly protruding within the neck of the pseudoaneurysm. No color or duplex signal was recorded within the totally excluded false aneurysm. Spiral CT at 2 and 4 months demonstrated stability of the thrombosed pseudoaneurysm with no evidence of perigraft leak. Spiral CT at 9 months after intervention showed complete involution of the pseudoaneurysm with patency of the stent, the thoracic aorta, and the brachiocephalic arteries including the left subclavian artery. Figs. 6 and 7 demonstrate angiographic and CT documents before and after intervention. Fig. 7Spiral CT evidence of pseudoaneurysm (arrow) exclusion by patent covered stent.View Large Image Figure ViewerDownload (PPT) For many decades standard surgical practice has dictated that traumatic rupture of the thoracic aorta must be diagnosed quickly and managed aggressively by immediate surgical repair. Behind that well-anchored dogma is the natural history of the injury, as reported by Parmley et al.6Parmley LF Mattingly TW Manion WC Jahnke EJ Nonpenetrating traumatic injury of the aorta.Circulation. 1958; 17: 1086-1100Crossref PubMed Scopus (971) Google Scholar in 1958, who from an autopsy series postulated that mortality increased significantly with delayed recognition and repair. This statement of outcome has previously been challenged by other investigators in light of today's practice with its full range of diagnostic tools and therapeutic modalities.8Pate JW Fabian TC Walker W Traumatic rupture of the aortic isthmus: an emergency?.World J Surg. 1995; 19: 119-126Crossref PubMed Scopus (173) Google Scholar Moreover, controversy remains regarding the best method of intraoperative management. A meta analysis of articles concerning the surgical management of acute traumatic rupture of the descending thoracic aorta has been reported recently.5VonOppell UO Dune TT DeGroot MK Zilla P Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia.Ann Thorac Surg. 1994; 58: 585-593Abstract Full Text PDF PubMed Scopus (383) Google Scholar It showed that the risk of paraplegia complicating surgery on hemodynamically stable patients with acute rupture of the thoracic aorta is at least 2.3%, even if active distal perfusion is provided. With either passive shunting or simple aortic cross-clamping the risk of paraplegia is 11.1% and 19.2%, respectively. However, the risk of full systemic heparinization in patients with acute traumatic rupture of the aorta, because of the high incidence of associated cerebral and visceral injuries in these patients, has been highlighted previously.9Kirsh MM Behrendt DM Orringer MB Gago O Gray LA Mills LJ et al.The treatment of acute traumatic rupture of the aorta: a 10 -year experience.Ann Surg. 1976; 184: 308-315Crossref PubMed Scopus (176) Google Scholar Heparinization has been suggested to contribute to morbidity by aggravating neurologic injuries,10Mattox KL Holzman M Pickard LR Beall Jr, AC DeBakey ME Clamp/repair: a safe technique for treatment of blunt injury to the descending thoracic aorta.Ann Thorac Surg. 1985; 40: 456-463Abstract Full Text PDF PubMed Scopus (117) Google Scholar by causing intrapulmonary hemorrhage, and by increasing surgical mortality.10Mattox KL Holzman M Pickard LR Beall Jr, AC DeBakey ME Clamp/repair: a safe technique for treatment of blunt injury to the descending thoracic aorta.Ann Thorac Surg. 1985; 40: 456-463Abstract Full Text PDF PubMed Scopus (117) Google Scholar, 11Vasko JS Raess DH Williams TE Kakos GS Kilmen JW Meckstroth V et al.Nonpenetrating trauma to the thoracic aorta.Surgery. 1977; 82: 400-406PubMed Google Scholar, 12Stavens B Hashim SW Hammond GL Stansel HC Gatehouse J Kopf GS et al.Optimal methods of repair of descending thoracic aortic transections and aneurysms.Am J Surg. 1983; 145: 508-513Abstract Full Text PDF PubMed Scopus (22) Google Scholar Data from the 20-year meta analysis did document a higher mortality rate in patients treated with systemic heparinization (18.2%) as opposed to heparinless modalities (11.9%). It must be kept in mind that severe associated head, pulmonary, orthopedic, vascular, and abdominal injuries are present in more than 75% of patients with blunt trauma to the thoracic aorta.13Mattox LK Invited commentary.in: Williams TE Vasko JS Kakos JS Treatment of acute and chronic traumatic rupture of the descending thoracic aorta. World J Surg. 4. 1980: 452-454Google Scholar Thus patients with multisystem lesions must be carefully evaluated to establish a plan of therapy for each injury. Recently the concept of deliberate delayed repair has been reported in the literature,14Akins CW Buckley MJ Dagget W McIlduff JB Austen WG et al.Acute traumatic disruption of the thoracic aorta: a ten year experience.Ann Thorac Surg. 1981; 31: 305-309Abstract Full Text PDF PubMed Scopus (185) Google Scholar, 15Stiles QR Cohlmia GS Smith JH Dunn JT Yellin AE Management of injuries of the thoracic and abdominal aorta.Am J Surg. 1985; 150: 132-140Abstract Full Text PDF PubMed Scopus (27) Google Scholar and many recent publications report the possibility of delaying the surgery.8Pate JW Fabian TC Walker W Traumatic rupture of the aortic isthmus: an emergency?.World J Surg. 1995; 19: 119-126Crossref PubMed Scopus (173) Google Scholar, 16Fisher RG Oria RA Mattox KL Whigham CJ Pickard LR Conservative management of aortic lacerations due to blunt trauma.J Trauma. 1990; 30: 1562-1566Crossref PubMed Scopus (61) Google Scholar, 17Stulz P Reymond MA Bertschmann W Graedel E Decision-making aspects in the timing of surgical intervention in aortic rupture.Eur J Cardiothorac Surg. 1991; 5: 623-627Crossref PubMed Scopus (26) Google Scholar, 18Maggisano R Nathens A Alexandrova NA Cina C Boulanger B McKenzie R et al.Traumatic rupture of the thoracic aorta: should one always operate immediately?.Ann Vasc Surg. 1995; 9: 44-52Abstract Full Text PDF PubMed Scopus (185) Google Scholar, 19Kipfer B Leupi F Schuepbach P Friedli D Althaus U Acute traumatic rupture of the thoracic aorta: immediate or delayed surgical repair?.Eur J Cardiothorac Surg. 1994; 8: 30-33Crossref PubMed Scopus (71) Google Scholar, 20Striffeler H Leupi F Kaiser G Althaus U Traumatic rupture of the thoracic aorta in childhood with special reference to the therapeutic strategy.Eur J Pediatr Surg. 1993; 3: 50-53Crossref PubMed Scopus (18) Google Scholar It stands to reason that immediate surgical repair of aortic injury is mandatory if a significant hemothorax or a pseudocoarctation syndrome indicates impending free rupture. However, in most patients reaching the hospital alive, the adventitia and surrounding mediastinal structures remain more or less intact, thus partially preserving the integrity of the disrupted aorta and preventing acute exsanguination into the thorax.21Dart CH Braitman HE Traumatic rupture of the thoracic aorta: diagnosis and management.Arch Surg. 1976; 111: 697-702Crossref PubMed Scopus (19) Google Scholar In fact, exsanguination caused by delayed free rupture of an initially stable aortic tear may be less frequent than previously assumed. Supporting this hypothesis is a retrospective analysis of 5752 autopsies in which 168 subjects had acute disruption of the thoracic aorta.22Kalmar P Otto CD Rodelwald G Selection of proper time for operation of traumatic thoracic aortic aneurysms (abstract).in: Presented at the Eleventh Annual Meeting of the German Society of Cardiovascular Surgeons, Bad Nauhein1982Google Scholar One hundred sixty-six of them died within 2 hours of the accident, precluding surgery; only one patient died of delayed rupture of a periaortic hematoma. In a review of the American literature, Walker and Pate23Walker WA Pate JW Medical management of acute traumatic rupture of the thoracic aorta.Ann Thorac Surg. 1990; 50: 965-967Abstract Full Text PDF PubMed Scopus (45) Google Scholar and Pate24Pate JW Traumatic rupture of the thoracic aorta: emergency operation.Ann Thorac Surg. 1985; 39: 531-537Abstract Full Text PDF PubMed Scopus (57) Google Scholar found 64 patients with thoracic aortic trauma treated initially by conservative therapy; in none of the cases reported did free rupture of the periaortic hematoma occur. Maggisano et al.18Maggisano R Nathens A Alexandrova NA Cina C Boulanger B McKenzie R et al.Traumatic rupture of the thoracic aorta: should one always operate immediately?.Ann Vasc Surg. 1995; 9: 44-52Abstract Full Text PDF PubMed Scopus (185) Google Scholar demonstrated that with a more selective approach consisting of immediate repair for unstable patients and stable patients with no contraindications to early repair and deliberate delayed repair for patients with concomitant injuries or sepsis, the operative mortality rate was 9%. This result compares favorably with the 20-year meta analysis' operative mortality rate of 21.3%.5VonOppell UO Dune TT DeGroot MK Zilla P Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia.Ann Thorac Surg. 1994; 58: 585-593Abstract Full Text PDF PubMed Scopus (383) Google Scholar Furthermore they stated that the very common postoperative complication of respiratory insufficiency (26%) could have been reduced had operative repair been delayed until after the associated pulmonary contusion had completely resolved, a common occurrence in the patient with multiple trauma. Pate et al.8Pate JW Fabian TC Walker W Traumatic rupture of the aortic isthmus: an emergency?.World J Surg. 1995; 19: 119-126Crossref PubMed Scopus (173) Google Scholar found that the risk of free rupture after arrival at the hospital with the periaortic hematoma contained in the mediastinum appeared to be considerably less than the risk involved in emergency aortic repair in patients with serious associated injuries. Moreover, they showed that no patient whose arterial pressure was maintained at less than 140 mm Hg by drug therapy had free rupture. They remind us that one of the major determinants of rupture of the pseudoaneurysm is the left ventricular systolic ejection dynamics, which suggest that the use of β-blockers is even more essential than simple antihypertensive therapy. Both of our patients were closely monitored for any rise in blood pressure. The goal was to maintain a mean arterial pressure less than 80 mm Hg. This goal was achieved with a combination of a β-blockers and vasodilators. Since Parodi et al.25Parodi JC Palmaz JC Barone HD Transfemoral intraluminal graft implantation for abdominal aortic aneuryms.Ann Vasc Surg. 1991; 5: 491-499Abstract Full Text PDF PubMed Scopus (2797) Google Scholar reported in 1991 the feasibility of transfemoral intraluminal graft implantation for the treatment of abdominal aortic aneurysms, many authors have reported the efficacy and low morbidity associated with endoluminal management of arterial aneurysms.7Blum U Voshage G Lammer J Beyerdorf F Follner D Kretschmer G et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (558) Google Scholar, 26Dake MD Miller DC Semba CP Mitchell RS Walker PJ Liddell RP Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms.N Engl J Med. 1994; 331: 1729-1734Crossref PubMed Scopus (1303) Google Scholar, 27Dake MD Semba CP Kee ST Kato N Mitchell RS Miller DC Complications of transluminal endovascular stent-graft treatment of descending thoracic aortic aneurysm (abstract). Radiological Society of North America,, Chicago, Illinois1996Google Scholar, 28Rousseau H Gieskes L Joffre F Dube M Roux D Soula P et al.Percutaneous treatment of peripheral aneurysms with the Cragg Endopro system.J Vasc Interv Radiol. 1996; 7: 35-39Abstract Full Text PDF PubMed Scopus (38) Google Scholar, 29Mitchell RS Dake MD Sembra CP Fogarty TJ Zarms CK Lidell RP et al.Endovascular stent-graft repair of thoracic aortic aneurysms.J Thorac Cardiovasc Surg. 1996; 11: 1054-1062Abstract Full Text Full Text PDF Scopus (270) Google Scholar, 30Marin ML Veith FJ Cynamon J Sanchez LA Lyon RT Levine et al.Initial experience with transluminally placed endovascular grafts for the treatment of complex vascular lesions.Ann Surg. 1995; 222: 449-469Crossref PubMed Scopus (261) Google Scholar Although most investigation is currently focused on abdominal aortic aneurysm, there is sometimes an even greater need for this type of device for the management of thoracic aortic aneurysm. Mitchell et al.29Mitchell RS Dake MD Sembra CP Fogarty TJ Zarms CK Lidell RP et al.Endovascular stent-graft repair of thoracic aortic aneurysms.J Thorac Cardiovasc Surg. 1996; 11: 1054-1062Abstract Full Text Full Text PDF Scopus (270) Google Scholar recently reported a series of 44 patients treated for thoracic aortic aneurysm by transluminal stent graft placement. Their results supported the hypothesis that endovascular stent-graft placement may be a safe and durable treatment for selected patients with aneurysmal disease of the descending thoracic aorta. It offers an alternative approach for elderly patients and those with previous operations, obesity, respiratory insufficiency, or other concomitant illnesses with potentially less morbidity and quicker recovery. From a recently updated series of 82 patients treated by stent-graft for thoracic aneurysms resulting from a variety of causes, Dake et al.26Dake MD Miller DC Semba CP Mitchell RS Walker PJ Liddell RP Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms.N Engl J Med. 1994; 331: 1729-1734Crossref PubMed Scopus (1303) Google Scholar, 27Dake MD Semba CP Kee ST Kato N Mitchell RS Miller DC Complications of transluminal endovascular stent-graft treatment of descending thoracic aortic aneurysm (abstract). Radiological Society of North America,, Chicago, Illinois1996Google Scholar reported a stent-related mortality rate of 8.5%. Other complications included paraplegia (3.6%), stroke (4.8%), perigraft leak (4.8%), groin infection (1.4%), and non-Q-wave myocardial infarct (1.2%). Overall, it suggested that the frequency and extent of complications are not significantly different from those reported for traditional surgery. Moreover, that same series of 82 patients included 9 patients who were treated for acute contained ruptures, 3 of them caused by traumatic transection similar to our 2 patients. The theoretical advantages of endovascular treatment of acute rupture of the thoracic aorta are multiple: a simple arteriotomy is performed without thoracotomy or aortic clamping, and the length of covered aorta is limited to the diseased segment, which lessens the risk of medullary ischemia. We can also state that severe head injury and pulmonary contusions pose less of a problem with this approach, because for severe head injuries the absence of aortic cross-clamping prevents an intracranial pressure rise, and for pulmonary contusions there is no need for intraoperative one-lung ventilation. Precise sizing is critical to those endovascular procedures. In our institution we use data from digital subtraction angiography with calibrated catheter and spiral CT with three-dimensional reconstructions. We find that the multiple angles of views provided by three-dimensional reconstructions offer a unique way to thoroughly evaluate neck lengths, topography of aneurysm in relation with branch vessels, and aortic diameters. We believe that in the near future spiral CT might be the only imaging study required before stent-graft therapy. However, because of a lack of strong scientific data confirming this premise, we keep performing preprocedure angiography with calibrated catheter as a complementary investigation. Moreover, digital subtraction angiography provides a better evaluation of iliac arteries, which is mandatory before the large delivery systems of the currently used stent-grafts are introduced. For all of these reasons that new therapeutic strategy seems very appealing. However, a few drawbacks are worth mentioning. 1.The covered stents currently in use can treat only aortas with a diameter less than 40 mm.2.The caliber of the delivery system is quite important (18F to 24F), which can potentially be a problem with small and spastic arteries of young people and tortuous and rigid arteries of older people.3.The durability of stent-graft material and the fixation system, which is crucial to the success of this technique, is a subject of concern.7Blum U Voshage G Lammer J Beyerdorf F Follner D Kretschmer G et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (558) Google Scholar4.We do not yet have any long-term follow-up, so we cannot comment on late complications. Moreover, the effect of endoluminal grafting on paraplegia rates is unknown. This raises the question of whether it is justified to use this new approach to replace standard treatment in patients who have the usual indications for surgery with no major systemic or local factors that increase risk and contraindicate standard therapy. The minimally invasive nature of endovascular prostheses makes them very attractive in accordance to the new trend in surgery to develop less invasive procedures to accomplish treatment goals with reduced operative risk and complications. We might even expect in the future to apply this new endovascular technology in the acute setting of traumatic aortic tear. Because the thoracic aorta is a high-flow area and the stagnation of blood flow has a very short duration limited to the few seconds of balloon inflation, we are able to deploy an aortic stent-graft with a minimal amount of heparin without undue risk of thrombosis. Endovascular treatment in the acute setting might be possible when standard material will be available at hand, which is reasonable to expect in the near future. However, because the devices and techniques for inserting endovascular grafts are still in the early stages of development, we should follow reasonable guidelines that have been created to direct the development of the technique and to prevent unjustified overuse.31Veith FJ Abbott WM Yao JS Goldstone J White RA Abel D Endovascular Graft Committee et al.Guidelines for development and use of transluminally placed endovascular prosthetic grafts in the arterial system.J Vasc Surg. 1995; 21: 670-685Abstract Full Text Full Text PDF PubMed Scopus (82) Google ScholarJ Vasc Interv Radiol. 1995; 6: 477-492Abstract Full Text PDF PubMed Scopus (6) Google Scholar In conclusion, we do not yet have extended follow-up data on the safety and effectiveness of endovascular grafting. This approach may be a viable therapeutic option for acute traumatic rupture of the aorta, but appropriately controlled prospective studies are required before we can recommend its widespread use.

Randomized double-blind placebo controlled trial performed in two parallel groups of patients, aged 43 to 92, suffering from advanced arterial disease of the lower limbs to be treated with angioplasty. The aim was to compare the efficacy of infusions of buflomedil with placebo on peripheral tissue oxygenation following lower limb angioplasties. Treatments consisted of 3 hour infusion of buflomedil or isotonic saline combined with arterial disobstruction. The major outcome measures were transcutaneous oxygen tension (TCpO2) correlated to ankle systolic pressure index (SPI). An increase of TCpO2 values (p < 0.01) as well as the mean individual variations of TCpO2 (p < 0.05) before and after angioplasty were observed in the buflomedil-treated group, whereas SPI values varied similarly in both groups. No adverse event was shown. In conclusion, buflomedil infusions during angioplasties of the lower limbs may improve tissue oxygenation subsequent to arterial disobstruction and are well tolerated.