Advances in Treatment of Traumatic Aortic Transection
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1 Advances in Treatment of Traumatic Aortic Transection Himanshu J. Patel MD University of Michigan Medical Center
2 Author Disclosures Consulting fees from WL Gore Inc.
3 There is no disease more conducive to clinical humility than aneurysm of the aorta Sir William Osler
4 Natural History Pioneering work described natural history of untreated blunt thoracic aortic injury Initial mortality rate at 24 hours was 34% Classic teaching of early aortic repair
5 Prospective AAST-1 Study (1997) Immediate repair in 207 of 274 patients 31% mortality rate with 63% of deaths attributable to aortic rupture Paraplegia rate of 9%
6 Contemporary Natural History Akins et. al. (1981) challenged dogma of immediate repair Recent autopsy study (242 patients) suggests 57% dead at scene 37% died in 1 st 4 hours 6% died thereafter
7 Emerging Paradigm Shifts Prospective study: CT for early diagnosis Prompt BP control eliminates rupture risk Treat other life threatening injuries e.g. closed head injury Validated the concept of selective delayed repair
8 Are All Injuries Lethal? Sensitivity of CT scans Classification schema of Azzizadeh et. al.
9 Extent of Injury Determines Therapy Grade 1 Intimal injury usually heals Grade 2 Intramural hematoma usually heals Grade 3 Pseudoaneurysm needs repair
10 Therapeutic Options Open descending aortic repair Thoracotomy Single lung ventilation Extracorporeal support with heparin use Thoracic endovascular repair
11 Prospective AAST-2 Study (2007) Increased utilization of selective delayed management in 198 patients Improved survival No impact of associated injury
12 Prospective AAST Trial-2 (2007) Increased utilization of TEVAR in patients Improved early survival No difference in LOS, ICU stay, ventilator days or systemic complications Reduction in transfusion requirements Type of Repair N % Open Clamp and Sew 11 6 Bypass Endovascular Total 193
13 Prospective AAST Trial-2 (2007) Device related complications seen in 20% (n=25): 9 of 25 required 2 nd TEVAR procedure 6 of 25 required open repair Endograft collapse, branch vessel coverage, access vessel rupture
14 Late Results of Repair of BTAI 109 patients treated from Selective delayed management in 72% treated since 1997 TEVAR in 42% treated since 2002 Anatomical features considered high risk for rupture AND not open surgery candidate - Complete disruption - Lateral pseudoaneurysm Age over 60 years
15 Early Outcomes Early mortality (either in-hospital or 30-day) 5 patients (4.6%) all who had open repair Stroke 2.8% Spinal cord ischemia 1.8% Permanent dialysis 1.8%
16 Early Morbidity Composite outcome of early mortality, stroke, paraplegia or dialysis dependent renal failure Independent Predictors OR p Value Age > 60 years Creatinine Postoperative sepsis Repair type not predictive (p = 0.4)
17 Survival Analysis---Entire Cohort 15 year Survival 81.3%
18 Late Mortality Independent Predictors HR p Value Age > 60 years Creatinine 9.1 <0.001 Postoperative SCI 20.6 <0.001 Repair type not predictive (p = 0.7)
19 Late Aortic Reoperation Entire Cohort 15 Year Freedom 99.1%
20 Late Aortic Reoperation 4 Year Freedom DTAR: 100% TEVAR: 94% p=0.03
21 Early Pitfalls in TEVAR for BTAI Beware the gothic arch and bird-beak in the young trauma patient Vs. 21 yr old 71 yr old
22 Early Pitfalls in TEVAR for BTAI Volume resuscitation increases aortic diameter by at least 10% Oversizing of endografts may predispose to endograft collapse Remember circle of Willis Pre-TEVAR left carotid to left subclavian arterial bypass should be considered
23 Late Pitfalls in TEVAR for BTAI Aortic diameter grows by up to 1 cm from years of age Many young patients will not return for follow-up imaging required for TEVAR Imaging follow-up in our study was 50 months vs. 104 months obtained for primary endpoint of vital status from SSDI
24 Summary 1. Repair for BTAI can be performed with excellent early and late results gold standard remains open repair. 2. With careful selection of candidates for TEVAR, factors other than treatment strategy may impact late survival. 3. Risk for re-intervention remains higher in the TEVAR subset thus providing strong motivation to develop devices tailored to this pathology.
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