Title: Endovascular Stent Graft Repair of a Penetrating Aortic Injury
Abstract: We report the endovascular stent graft repair of a penetrating aortic injury with active hemorrhage. A 72-year-old man was admitted after getting stabbed in his back. He had a history of coronary heart disease and cardiac infarction. Computed tomography revealed thoracoabdominal aortic rupture. Endovascular repair was performed successfully. The patient recovered uneventfully, and did not complain of discomfort after a 1-year follow-up. Endovascular treatment may be a valuable and lifesaving option for patients sustaining penetrating aortic injury with contraindications to surgery. We report the endovascular stent graft repair of a penetrating aortic injury with active hemorrhage. A 72-year-old man was admitted after getting stabbed in his back. He had a history of coronary heart disease and cardiac infarction. Computed tomography revealed thoracoabdominal aortic rupture. Endovascular repair was performed successfully. The patient recovered uneventfully, and did not complain of discomfort after a 1-year follow-up. Endovascular treatment may be a valuable and lifesaving option for patients sustaining penetrating aortic injury with contraindications to surgery. Endovascular stent graft repair is emerging as a safe, minimally invasive, and attractive alternative to open surgery in the treatment of many aortic diseases. However, surgical graft replacement is still considered the standard treatment of traumatic aortic injury [1Fang T.D. Peterson D.A. Kirilcuk N.N. Dicker R.A. Spain D.A. Brundage S.I. Endovascular management of a gunshot wound to the thoracic aorta.J Trauma. 2006; 60: 204-208Crossref PubMed Scopus (9) Google Scholar], and endovascular treatment is only recommended for patients with contraindications to open surgical repair. At present, endovascular stent graft repair of blunt traumatic aortic injury is well described [2Ehrlich M.P. Rousseau H. Heijman R. et al.Early outcome of endovascular treatment of acute traumatic aortic injuries: the talent thoracic retrospective registry.Ann Thorac Surg. 2009; 88: 1258-1263Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 3Moainie S.L. Neschis D.G. Gammie J.S. et al.Endovascular stenting for traumatic aortic injury: an emerging new standard of care.Ann Thorac Surg. 2008; 85 (discussion 1629–30): 1625-1629Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar], but there is limited literature on the endovascular treatment of penetrating aortic injury [1Fang T.D. Peterson D.A. Kirilcuk N.N. Dicker R.A. Spain D.A. Brundage S.I. Endovascular management of a gunshot wound to the thoracic aorta.J Trauma. 2006; 60: 204-208Crossref PubMed Scopus (9) Google Scholar, 4Yeh M.W. Horn J.K. Schecter W.P. Chuter T.A. Lane J.S. Endovascular repair of an actively hemorrhaging gunshot injury to the abdominal aorta.J Vasc Surg. 2005; 42: 1007-1009Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 5Baldwin Z.K. Phillips L.J. Bullard M.K. Schneider D.B. Endovascular stent graft repair of a thoracic aortic gunshot injury.Ann Vasc Surg. 2008; 22: 692-696Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar]. In this case report, we describe the successful endovascular repair of a penetrating thoracoabdominal aortic injury. A 72-year-old man was admitted 1 hour after having been stabbed by a sharp-pointed fruit knife. The patient complained of abdominal and back pain. He had a 15-year history of coronary heart disease and diabetes mellitus. A cardiac infarction occurred 2 years earlier. Blood pressure on admission was 95/51 mm Hg. His heart rate was 110 beats/min. There was a 3-cm linear wound, with active bleeding on his left back at the T10 vertebral level. The patient's hemoglobin level was 85 g/L, and he received fluid resuscitation and blood products. There was no evidence of new cardiac events. A computed tomography scan revealed thoracicoabdominal aortic rupture and surrounding hematoma. There were two lacerations separated by 18 mm. One was located on the anterior right aspect of the aorta, and the other was located on the posterior median aspect (Fig 1A and B). The distance between the lower laceration and the celiac trunk was almost 10 mm. The proximal and distal aorta at the rupture sites was almost 18 mm in diameter. Given his advanced age and his comorbidities, endovascular treatment was considered and informed consent was signed. Two hours after admission, emergency endovascular stent graft repair was performed under local anesthesia. After the intravenous administration of heparin (100 U/Kg), a right femoral arteriotomy was performed. Aortography revealed contrast extravasation from the anterior and posterior aspects of the aorta (Fig 2A). The effective endograft length for excluding the 2 lacerations was at least 43 mm. Because of limited choices of stent grafts in an emergency, two 22 mm × 30 mm (oversizing, 22%) Talent AAA Aortic Extension grafts (Medtronic Inc, Minneapolis, MN) were selected. The device comprised 2 stents. There was a large nonstented area between 2 stents. The stents were introduced over a superstiff guidewire through the Xcelerant Delivery System (Medtronic). When the top end of the first cuff was 15 mm higher than the higher laceration, the stent was deployed by pulling back a 20F sheath. Then the first cuff was partly overlapped by the second one. Completion angiography showed total exclusion of lacerations with a smooth aorta (Fig 2B), no endoleak was observed, and perfusion of the celiac trunk was preserved. The total effective endograft length after overlap was about 45 to 50 mm. There were no symptoms of endovascular stenosis after stent graft placement. The arteriotomy was sutured after the completion of the aortography. Total operative time was 50 minutes. The patient recovered uneventfully. No discomfort has been complained of during regular follow-up. The left ankle-brachial index was 0.97 and the right side was 1.0 at rest. The 12-month follow-up computed tomography scan showed no graft collapse or stenosis (Fig 3). The patient has been undergoing close follow-up. Penetrating aortic injury is a life-threatening condition associated with high mortality. Open surgical repair has been accepted as the gold standard in emergency settings. Endovascular stent graft repair of penetrating aortic injury is only considered in patients with compelling contraindications to open surgical repair, such as significant comorbidities, concomitant injuries, and advanced age [1Fang T.D. Peterson D.A. Kirilcuk N.N. Dicker R.A. Spain D.A. Brundage S.I. Endovascular management of a gunshot wound to the thoracic aorta.J Trauma. 2006; 60: 204-208Crossref PubMed Scopus (9) Google Scholar]. So far, there have been few case reports of endovascular treatment of penetrating aortic injury. In 2005, Yeh and colleagues [4Yeh M.W. Horn J.K. Schecter W.P. Chuter T.A. Lane J.S. Endovascular repair of an actively hemorrhaging gunshot injury to the abdominal aorta.J Vasc Surg. 2005; 42: 1007-1009Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar] described an endovascular repair of an actively hemorrhaging penetrating abdominal aortic injury after intraabdominal sepsis. In 2006, Fang and coworkers [1Fang T.D. Peterson D.A. Kirilcuk N.N. Dicker R.A. Spain D.A. Brundage S.I. Endovascular management of a gunshot wound to the thoracic aorta.J Trauma. 2006; 60: 204-208Crossref PubMed Scopus (9) Google Scholar] performed endovascular stent graft repair in a patient with a traumatic aorta-innominate fistula complicated by a pulmonary embolism. With this report we present another successful endovascular repair of penetrating aortic injury with active hemorrhage. In this case, the advanced-aged patient had a history of coronary heart disease, cardiac infarction, and diabetes mellitus. Although endovascular stent graft repair is a minimally invasive technique for penetrating aortic injury, several unresolved problems remain in the endovascular treatment of penetrating aortic injury. In many hospitals, clinical experience in treatment of penetrating aortic injury is limited. There are usually no appropriate caliber grafts for otherwise normal aortas in the trauma setting. The grafts are not designed for these aortas and are usually too large for many patients, which could lead to stent-related complications. In the report by Fang and colleagues [1Fang T.D. Peterson D.A. Kirilcuk N.N. Dicker R.A. Spain D.A. Brundage S.I. Endovascular management of a gunshot wound to the thoracic aorta.J Trauma. 2006; 60: 204-208Crossref PubMed Scopus (9) Google Scholar], graft infolding was regarded as a consequence of the larger graft size compared with the patient's aorta. In studies of stent graft collapse and infolding [6Lazar H.L. Varma P.K. Shapira O.M. Soto J. Shaw P. Endograft collapse after thoracic stent-graft repair for traumatic rupture.Ann Thorac Surg. 2009; 87: 1582-1583Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 7Idu M.M. Reekers J.A. Balm R. Ponsen K.J. de Mol B.A. Legemate D.A. Collapse of a stent-graft following treatment of a traumatic thoracic aortic rupture.J Endovasc Ther. 2005; 12: 503-507Crossref PubMed Scopus (117) Google Scholar, 8Sze D.Y. Mitchell R.S. Miller D.C. et al.Infolding and collapse of thoracic endoprostheses: manifestations and treatment options.J Thorac Cardiovasc Surg. 2009; 138: 324-333Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar], excessive oversizing was considered a potential reason for incomplete deployment. Oversized stent grafts are especially susceptible to wrinkling [7Idu M.M. Reekers J.A. Balm R. Ponsen K.J. de Mol B.A. Legemate D.A. Collapse of a stent-graft following treatment of a traumatic thoracic aortic rupture.J Endovasc Ther. 2005; 12: 503-507Crossref PubMed Scopus (117) Google Scholar]. Our experience confirms results of other reports: endografts with approximate 10% oversizing may be more appropriate for patients in the endovascular treatment of traumatic aortic injury. A Zenith iliac leg endograft (Cook, Bloomington, IN) would probably have been a better choice for our patient. The long-term outcomes of endovascular treatment of penetrating aortic injury are unknown. Penetrating aortic injury usually occurs in young patients with long life expectancy. The long-term durability of endografts is especially important and needs to be proven by further clinical studies. We agree with Fang and colleagues' [1Fang T.D. Peterson D.A. Kirilcuk N.N. Dicker R.A. Spain D.A. Brundage S.I. Endovascular management of a gunshot wound to the thoracic aorta.J Trauma. 2006; 60: 204-208Crossref PubMed Scopus (9) Google Scholar] viewpoint that at present, endovascular stent graft repair should only be performed in patients with limited life expectancy or at high risk for surgical intervention. In conclusion, endovascular stent graft repair is a feasible and lifesaving approach for patients sustaining penetrating aortic injury with surgical contraindications. Intensive follow-up should be performed after endovascular treatment of penetrating aortic injury.