Chapter
Classification
and Decision Algorithm
of Posttraumatic Chronic Lesions
of the Isthmus
and the Descending Thoracic Aorta
35
Jean-Philippe Verhoye, Bertrand De Latour,
Cyryl Kakon, Jean-Franœois Heautot
Contents
. . . . . . . . . . . . . . . . . . . . . . 345
35.1
Introduction
35.2
Classification of Patients with Posttraumatic
Injuries of the Aortic Isthmus or the
Descending Aorta . . . . . . . . . . . . . . . . . . . 346
35.3
Decision Algorithm . . . . . . . . . . . . . . . . . . 347
35.4
Results of a Multicenter Retrospective Study . . . . 347
35.5
Results from the Literature . . . . . . . . . . . . . . 348
35.6
Discussion . . . . . . . . . . . . . . . . . . . . . . . . 348
35.7
Conclusion . . . . . . . . . . . . . . . . . . . . . . . 349
a
35.1 Introduction
The natural history of chronic isthmus and descending
aorta posttraumatic false aneurysms has been directly
related to the limitations of diagnostic imaging. The
considerable progress made in noninvasive angiography
during the last 10 years (mainly through the easy access
to multislice computed tomography, CT, scanners) will
probably contribute to the disappearance of chronic lesions discovered fortuitously by revealing the injuries at
the acute stage.
The lesion is often an intimal tear, more or less circumferential, misdiagnosed at the initial stage, which
evolves towards a saccular pseudoaneurysm, incidentally demonstrated by a thoracic imaging study performed for another reason (Fig. 35.1). Some become
symptomatic by a mechanism of compression (either
b
Fig. 35.1. a Angiography during endovascular treatment of a chronic posttraumatic pseudoaneurysm, showing the stent-graft in its
sheath. b After deployment, angiographic control shows the complete exclusion of the aneurysm
346
VII. Aortic Injury
tracheo-bronchial or recurrent nerve) and are discovered by a targeted imaging study.
Today the progress in intensive care and the wide accessibility to efficient vascular imaging studies in emergency situations have allowed better management of
polytrauma patients. The advances in intensive care
have induced an evolution of therapeutic strategy of
acute ruptures of the aortic isthmus towards delayed
surgery [1], the imaging advances have contributed to a
drastic decrease, nearly disappear of misdiagnosed
chronic false aneurysms.
According to the criteria defined by Langanay et al.
(Chap. 32), the only remaining surgical indication in an
emergency is isolated lesions of less than 24 h, hemodynamically unstable, without associated lesion contraindicating a cardiopulmonary bypass.
It is easy to figure out now, in the precarious context
of a polytrauma patient, that an isthmus lesion can be
medically controlled and treated after a delay, to limit
the inherent morbidity/mortality of the surgical procedure under cardiopulmonary bypass in an emergency.
It is now a consciously ªdelayed acuteº surgical management, where the lesion is voluntarily ªchronicized.º
In spite of intensive care and careful follow-up, patients have suffered ruptures during these periods of
ªcontrolled chronicization.º
Stent-grafts will probably help to prevent these sudden early ruptures while allowing a quick initial treatment of the lesion. This technique does not command
systemic anticoagulation during or after the procedure,
thus limiting the hemorrhagic complications in polytrauma patients. Encouraging results are currently
being published [1, 2]. The challenge of this new management is linked to the midterm and long-term exclusion of the lesion in a definitive way like conventional
surgery does.
a
The nonendothelialization of the stent-graft and the
increasing aortic diameter with the patient's age carries
a risk of late type I endoleaks which could potentially
activate a degeneration of the initial lesion into a
chronic false aneurysm. In this case, the nonendothelialization would be an advantage by facilitating the surgical explantation of the stent-graft and conventional repair of the aorta, even a long time after the endovascular procedure (Fig. 35.2).
The endovascular therapy is a major step in the history of therapeutic management of traumatic injuries of
the isthmus and the descending aorta. Because of this
trend, it has appeared necessary to us to propose a new
classification of these lesions, to better define the management, whichever therapeutic solution is used. The
classification must allow us to define stages for the purpose of comparing therapeutic results among homogeneous groups of patients. It must also propose a decision algorithm to better select the most appropriate
therapeutic choice with respect to the priorities in patient management.
35.2 Classification of Patients
with Posttraumatic Injuries
of the Aortic Isthmus
or the Descending Aorta
Class I: acute (< 48 h)
A: Isolated lesion
1: Stable
B: Polytrauma
2: Unstable
Class I corresponds to a post-raumatic lesion of the
isthmus or the descending aorta, with two subclasses:
b
Fig. 35.2. a CT angiography. Control 6 months after stent-graft
treatment of a chronic posttraumatic pseudoaneurysm, showing a type I endoleak. The endoleak was monitored and spontaneously resolved, but at 3 years the patient suffered bronchial
compression due to endotension. Surgical conversion had to be
performed (graft interposition and aneurysm thrombus resection). b CT angiography, 3D reconstruction, volume rendering.
Control after surgical conversion
J.-P. Verhoye et al. Chapter 35 Classification and Decision Algorithm of Posttraumatic Chronic Lesions of the Isthmus and the Descending Thoracic Aorta
the lesion is either isolated (A) or associated with
others injuries (polytrauma, B), and the patient is hemodynamically stable (1) or unstable (2).
Class II: delayed acute (> 48 h)
A: Isolated lesion
1: Stable
B: Polytrauma
2: Unstable
Class II corresponds to a lesion initially not treated because of misdiagnosis or surgical contraindication. The
lesion is either isolated (A) or associated with other injuries (polytrauma, B), and the patient is hemodynamically stable (1) or unstable (2).
Class III: incidental chronic
A: Stable diameters/unknown
evolutivity
1: Asymptomatic
B: Increasing
2: Symptomatic
Class III corresponds to an incidental posttraumatic
chronic pseudoaneurysm of the isthmus or the descending aorta. This lesion can be stable, or its evolutivity unknown (A), or increasing (more than 1 cm/year)
or a contained ruptured (B). It can also be asymptomatic (1) or symptomatic (dysphonia, cough, bronchitis, chest pain, pleural effusion) (2).
patient status, it can be performed in an acute emergency, a delayed emergency, or after a period of controlled chronicization.
A careful CT scan follow-up is mandatory, at 1 and
6 months, and yearly thereafter, for the current generations of stent-grafts. The patients must be informed of
this requisite and that late disorders can occur, which
can then lead to elective surgery.
The other field of endovascular treatment is the
management of patients older than 70, in which surgery
carries a significantly higher risk. The lesions are often
incidentally diagnosed, asymptomatic, and often large
(maximum diameter frequently more than 60 mm),
after trauma occurred several decades before. The risk
of rupture of these lesions is not known, and endovascular solution seems a better first choice for these patients.
So, a therapeutic decision algorithm is proposed is
as follows:
Class I, II
Class III
A1 < 70 years old
A1 > 70 years old,
A2 and B
A1
A2 < 70 years old
A2 > 70 years, B
Surgery except
contra-indication
Stent-graft
CT follow-up
Surgery, except
contra-indication
Stent-graft
35.3 Decision Algorithm
35.4 Results
of a Multicenter Retrospective Study
Starting from this classification, it is possible to define
a decision algorithm taking into account the surgical
and endovascular results of the last 10 years. Surgery
assisted by cardiopulmonary bypass has proven its
long-term efficacy at the cost of reduced postoperative
morbidity/mortality in patients younger than 70, with
no major risk factor.
The follow-up for patients treated by a stent-graft is
hardly 8 years in the most expert teams, but the best indications are already being defined. To deploy a stentgraft is not to cure because we know now that stentgrafts do not get endothelialized, which can cause midterm and long-term endoleaks and endotension, which
reactivate the aneurysmal process and the risk of sudden rupture.
Regarding this technique, the current strategy is
rather based on getting over the acute phase to avoid
rupture in the critical context of a polytrauma patient.
The surgical access is limited to the groin (depending
on the quality of the iliac arteries) even if it is preferable to perform the operation in an operating room
with cardiopulmonary bypass at hand. According to the
In order to validate the appropriateness of this classification and algorithm, a retrospective study was conducted in six French university centers. We report the
midterm results for 47 class II and III patients. The aortic injuries were diagnosed at the time of the trauma
(63.8%, n=30), or incidentally (36.2%, n=17). Between
January 1996 and June 2004, endovascular repair of the
descending thoracic aorta with commercially available
stent-grafts was performed in 47 patients (mean age,
43 Ô 19 years) at an average of 6 Ô 11 years after the injury. Because of comorbidities, eight patients (17%)
were judged not to be reasonable surgical candidates
for a conventional surgical approach. Follow-up was
100% complete and averaged 18 Ô 13 months.
Stent-graft deployment was successful in all patients.
No early death occurred. One late transient paraparesia
occurred. Two patients had a primary endoleak, one
type I and one type II which spontaneously resolved at
1 and 6 months, respectively. Two endotensions were
described after 36 months (currently being monitored)
and 30 months (surgical conversion). The actuarial survival estimates at 1 and 3 years were 97.7 Ô 2.3 and
347
348
VII. Aortic Injury
87.9 Ô 9.5%, respectively. The actuarial freedom from reintervention on the descending thoracic aorta was 100
and 90.9 Ô 8.7% at 1 and 3 years, respectively. The actuarial freedom from treatment failure (a conservative,
all-encompassing performance indicator including endoleak, device mechanical fault, reintervention, late aortic-related death, or sudden, unexplained late death) at
1 and 3 years was 97.7 Ô 2.3 and 74.6 Ô 11.9, respectively.
The mean diameter of the pseudoaneurysm was
44 Ô 18 mm before treatment and decreased significantly
(p<0.001) to 40 Ô 18 mm after treatment.
35.5 Results from the Literature
These results from the literature are summarized in Tables 35.1 and 35.2.
Table 35.1. Surgical results from the literature
FinkelMcCollum
meyer
et al. [4]
et al. [3]
Patients (N)
413
Operative
4.6
mortality (%)
Respiratory
0.7
complications (%)
Paraplegia (%)
1.4
Paraparesia (%)
1.4
Stroke (%)
1.1
Renal failure (%)
1.4
Recurrent
6.7
paralysis (%)
Soyer
Roques
et al. [5] et al.
[6]
50
4
20
0
19
0
2
±
26
±
±
±
2
4
±
15
±
±
±
±
±
±
±
10
35.6 Discussion
Elective surgery of posttraumatic pseudoaneurysms has
proven efficient. Direct suturing with cardiopulmonary
bypass is possible in nearly half of cases. It carries a
low mortality, and a low renal and respiratory morbidity. The rate of paraplegia is close to zero in the best series. So, in these cases, the only advantage of endovascular techniques is the mini-invasivity. Stent-graft treatment has proven its feasibility. As the adjacent aortic
wall is normal, nondegenerative, late endoleaks are
more unlikely than in cases of degenerative aneurysms
[7]. The limits are known. Long proximal necks and
long one-piece stent-grafts are required to achieve good
preliminary results. This will probably make more frequent prior surgical bypass of the left supra-aortic vessels (Fig. 35.3) in order (1) to get a longer proximal
neck and (2) to maintain the patency of the left subclavian artery, essential for spinal cord blood perfusion as
has been shown by surgery studies, because long stentgrafts will increase the risk of paraplegia if the left subclavian artery has to be intentionally occluded [10].
Table 35.2. Endovascular results from the literature
Demers Kato
Rousseau French
et al. [7] et al. [8] et al. [9] multicenter
study
Patients (N)
Operative mortality
Respiratory
complications
Paraplegia
Paraparesia
Stroke
Renal failure
Recurrent paralysis
Vascular access
complication
15
1
±
10
0
1
8
0
1
47
0
±
±
±
±
±
±
±
±
±
±
±
±
1
±
±
±
±
±
1
0
1
±
±
±
2
Fig. 35.3. Computed tomography (CT) angiography, 3D reconstruction, volume rendering. Control of a stent-graft 4 years
after endovascular treatment of a chronic posttraumatic pseudoaneurysm. The left supra-aortic vessels have been bypassed
(arrow), in order to get a longer proximal neck
J.-P. Verhoye et al. Chapter 35 Classification and Decision Algorithm of Posttraumatic Chronic Lesions of the Isthmus and the Descending Thoracic Aorta
35.7 Conclusion
The management of acute and chronic lesions of the
isthmus and the descending aorta has markedly evolved
with advances of imaging and intensive care.
Endovascular techniques, limiting the morbidity of
the treatment at the acute, delayed acute and controlled
chronic phases in unstable and trauma patients, do not
preclude delayed surgical options, currently the gold
standard for definitive lesion exclusion.
The endovascular techniques also seem a good option in incidental lesions, with favourable anatomy, in
elderly patients.
It must be kept in mind that currently to deploy is
not to cure, and that life-long imaging follow-up is necessary.
Acknowledgements. Frdric Thony (University Hospital, Grenoble), Herv Rousseau (University Hospital,
Toulouse), Pascal Leprince (University Hospital, Paris
Salpetri re), Philippe Douek (University Hospital, Lyon)
and Louis Boyer (University Hospital, Clermont-Ferrand) are thanked for their contribution to the French
multicenter retrospective study of endovascular treatment of chronic posttraumatic aortic false aneurysms.
2.
3.
4.
5.
6.
7.
8.
9.
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