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Endovaskuläre Versorgung der traumatischen Aortenruptur im Akutstadium

Spezielle Problematik und Langzeitergebnisse

Acute-stage TEVAR for traumatic aortic rupture

Special problems and long-term results

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Zusammenfassung

Seit März 1999 wurden bei 48 Patienten 52 Stentgraftsysteme unmittelbar posttraumatisch im Akutstadium der thorakalen Aortenruptur innerhalb der Polytraumaprimärversorgung appliziert. Bei Aortendurchmessern von 12–30 mm kamen jeweils die kleinsten Systeme der Fa. Gore, Medtronic und Cook zum Einsatz. Die primäre Erfolgsrate (Abdichtung der Blutung) betrug 100%. 3 Patienten verstarben aortenunabhängig an ihren schwersten Begleitverletzungen. Von 3 gesehenen akuten Stentkompressionssyndromen verlief eines letztendlich letal. Die spezielle Problematik des jugendlichen Aortenbogens gestattet mit den zurzeit erhältlichen Stentgraftsystemen keine ideale Anpassung an die Aortenbogenkrümmung, sodass Abhebungswinkel an der inneren Kurvatur entstanden, die endsystolisch bis 63° betrugen. Dennoch lag im lückenlos erfassten Langzeitverlauf aller Patienten die Konversionsrate bis zu 10 Jahren bei 0%. Zweiteingriffe nach 30 Tagen waren ebenfalls nicht erforderlich. Zwei weitere Patienten verstarben im Langzeitverlauf nach 3 bzw. 5 Jahren nicht aortenbedingt. Alle anderen Patienten sind in einem MRT-Überwachungsprogramm. Die Mehrzahl der Patienten ist inzwischen wieder arbeitsfähig. Alle Patienten sind wohlauf und werden regelmäßig bei Nachuntersuchungsterminen gesehen. Erst der weitere Langzeitverlauf jenseits von 10 Jahren wird den endgültigen Stellenwert der gezeigten Methode bestimmen.

Abstract

Since March 1999, 52 thoracic endovascular aortic repair (TEVAR) procedures have been done acutely as part of primary polytrauma repair in 48 patients after thoracic aortic rupture. In the presence of aortic diameters of 12–30 mm, only the smallest thoracic stent graft systems available from Gore, Medtronic, and Cook—in one instance, an iliac extension limb—were used. The primary success rate (sealing of the aorta) was 100%. Three patients died from serious concomitant injuries unrelated to the aorta. Of three cases of acute stent compression syndrome, one proved to be lethal. Contemporary stent graft systems show conformability deficits at the narrow curvature of the juvenile aortic arch, with consequent disattachment phenomena and disattachment angles at the inner aortic curvature of up to 63° end-systolic. Nevertheless, the conversion rate up to 10 years was 0%, and no stent corrections were necessary after 30 days. Two additional patients died during the long-term observation period (after 3 and 5 years, respectively) after non-aorta-related trauma. All other patients are under supervision in a special magnetic resonance imaging assessment program; the majority are back to their normal activities and are seen regularly once a year. Ten years of follow-up is a long time, but not long enough in these young patients. Therefore, the definite role of TEVAR can be determined only after another 20 years.

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Literatur

  1. Avery JE, Hall DP, Adams JE et al (1979) Traumatic rupture of the thoracic aorta. South Med J 72(10):1238–1240

    PubMed  CAS  Google Scholar 

  2. Buth J, Harris PL, Hobo R et al (2007) Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 46(6):1103–1110; discussion 1110–1111

    Article  PubMed  Google Scholar 

  3. Buz S, Zipfel B, Mulahasanovic S et al (2008) Conventional surgical repair and endovascular treatment of acute traumatic aortic rupture. Eur J Cardiothorac Surg 33(2):143–149

    Article  PubMed  Google Scholar 

  4. Canaud L, Alric P, Branchereau P et al (2008) Lessons learned from midterm follow-up of endovascular repair for traumatic rupture of the aortic isthmus. J Vasc Surg 47(4):733–738

    Article  PubMed  Google Scholar 

  5. McCarthy MJ (2008) Is endovascular repair now the first line treatment for traumatic transection of the thoracic aorta? Eur J Vasc Endovasc Surg 36:158–159

    Article  PubMed  CAS  Google Scholar 

  6. Fattori R, Buttazzi K, Russo V et al (2007) Evolving concepts in the treatment of traumatic aortic injury. A review article. J Cardiovasc Surg (Torino) 48(5):625–631

    Google Scholar 

  7. Giovannelli A, Alessandri G, Rama A et al (2008) The endovascular treatment of traumatic isthmic aortic rupture: three years follow-up. Eur Rev Med Pharmacol Sci 12(4):271–274

    PubMed  CAS  Google Scholar 

  8. Hinchliffe RJ, Krasznai A, Schultzekool L et al (2007) Observations on the failure of stent-grafts in the aortic arch. Eur J Vasc Endovasc Surg 34(4):451–456

    Article  PubMed  CAS  Google Scholar 

  9. Hoornweg LL, Dinkelman MK, Goslings JC et al (2006) Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multicenter analysis of 28 cases in The Netherlands. J Vasc Surg 43(6):1096–1102 discussion 1102

    Article  PubMed  Google Scholar 

  10. Idu MM, Reekers JA, Balm R et al (2005) Collapse of a stent-graft following treatment of a traumatic thoracic aortic rupture. J Endovasc Ther 212(4):503–507

    Article  Google Scholar 

  11. Inglese L, Mollichelli N, Medda M et al (2008) Endovascular repair of thoracic aortic disease with the EndoFit stent-graft: short and midterm results from a single center. J Endovasc Ther 15(1):54–61

    Article  PubMed  Google Scholar 

  12. Kalmár P, Püschel K, Stubbe HM, Gültekin E (1996) Delayed surgical therapy of acute aortic rupture. Zentralbl Chir 121(9):750–755

    PubMed  Google Scholar 

  13. Iezzi R, Cotroneo AR, Marano R et al (2008) Endovascular treatment of thoracic aortic diseases: Follow-up and complications with multi-detector computed tomography angiography. Eur J Radiol 65(3):365–376

    Article  PubMed  Google Scholar 

  14. Kühne CA, Ruchholtz S, Voggenreiter G et al (2005) AG Polytrauma DGU. Traumatic aortic injuries in severely injured patients. Unfallchirurg 108(4):279–287

    Article  PubMed  Google Scholar 

  15. Lebl DR, Dicker RA, Spain DA, Brundage SI (2006) Dramatic shift in the primary management of traumatic thoracic aortic rupture. Arch Surg 141(2):177–180

    Article  PubMed  Google Scholar 

  16. Marcheix B, Dambrin C, Bolduc JP et al (2006) Endovascular repair of traumatic rupture of the aortic isthmus: midterm results. J Thorac Cardiovasc Surg 132(5):1037–1041

    Article  PubMed  Google Scholar 

  17. Marty B (2008) Management of traumatic aortic rupture: endovascular is the winner. Eur J Cardiothorac Surg 33(2):149–151

    Article  PubMed  Google Scholar 

  18. Mattox KL (1991) Thoracic Vascular Injury. Int Trends Gen Thorac Surg 7:428–442

    Google Scholar 

  19. Moainie SL et al (2008) Endovascular stenting for traumatic aortic injury: an emerging new standard of care. Ann Thorac Surg 85(5):1625–1629

    Article  PubMed  Google Scholar 

  20. Muhs BE, Balm R, White GH, Verhagen HJ (2007) Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture. J Vasc Surg 45(4):655–661

    Article  PubMed  Google Scholar 

  21. von Oppell UO, Dunne TT, de Groot MK et al (1994) Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 58:585–593

    Google Scholar 

  22. Orend KH, Zarbis N, Schelzig H et al (2007) Endovascular treatment (EVT) of acute traumatic lesions of the descending thoracic aorta--7 years‘ experience. Eur J Vasc Endovasc Surg 34(6):666–672

    Article  PubMed  CAS  Google Scholar 

  23. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr (1958) Nonpenetrating Traumatic Injury of the Aorta. Circulation 17:1086

    PubMed  CAS  Google Scholar 

  24. Pate JW (1994) Is traumatic rupture of the aorta misunderstood? Ann Thorac Surg 57(3):530–531

    Article  PubMed  CAS  Google Scholar 

  25. Patel HJ, Williams DM, Upchurch GR Jr et al (2008) A comparison of open and endovascular descending thoracic aortic repair in patients older than 75 years of age. Ann Thorac Surg 85(5):1597–1603; discussion 1603–1604

    Article  PubMed  Google Scholar 

  26. Plummer D, Petro K, Akbari C, O’Donnell S (2006) Endovascular repair of traumatic thoracic aortic disruption. Perspect Vasc Surg Endovasc Ther 18(2):132–139

    Article  PubMed  Google Scholar 

  27. van Prehn J, van Herwaarden JA, Muhs BE et al (2008) Difficulties with endograft sizing in a patient with traumatic rupture of the thoracic aorta: the possible influence of hypovolemic shock. J Vasc Surg 47(6):1333–1336

    Article  Google Scholar 

  28. Rasche V, Bornstedt A, Hombach V et al (2009) Comprehensive assessment of of thoracic stent grafts after emergency implantation in multi trauma patients. J Cardiovasc Magn Reson (Suppl 1): 168

    Article  Google Scholar 

  29. Rasche V, Crelier GR, Bornstedt A et al (2009) Reconstruction of aortic blood flow pattern after thoracic stent graft implantation. In: „Procceding Annual Meeting ISMRM, Honolulu“ 3862

  30. Reddy VS (2007) Endovascular approaches for traumatic thoracic aortic injury: immediate versus delayed therapy. J Trauma 62 (6 Suppl): 23

    Article  Google Scholar 

  31. Schmidt CA, Wood MN, Razzouk AJ et al (1992) Primary repair of traumatic aortic rupture: a preferred approach. J Trauma 32(5):588–592

    Article  PubMed  CAS  Google Scholar 

  32. Schumacher H, Böckler D, Allenberg JR (2004) Surgical management of thoracic aortic lesions. Aneurysm, dissection and traumatic rupture. Chirurg 75(9):937–958

    Article  PubMed  CAS  Google Scholar 

  33. Steinbauer MG, Stehr A, Pfister K et al (2006) Endovascular repair of proximal endograft collapse after treatment for thoracic aortic disease. J Vasc Surg 43(3):609–612

    Article  PubMed  Google Scholar 

  34. Townsend RN, Colella JJ, Diamond DL (1990) Traumatic rupture of the aorta – critical decisions for trauma surgeons, J Trauma 30(9):1169–1174

    Google Scholar 

  35. Vrancken Peeters MP, Muhs BE, Van Der Linden E et al (2007) Endovascular treatment of traumatic ruptures of the thoracic aorta. J Cardiovasc Surg (Torino) 48(5):557–565

    Google Scholar 

  36. Yamane BH, Tefera G, Hoch JR et al (2008) Blunt thoracic aortic injury: open or stent graft repair? Surgery 144(4):575–580; discussion 580–582

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Klinik für Thorax- und Gefäßchirurgie, Universitätsklinikum Ulm, Steinhövelstr. 9, 89075, Ulm, Deutschland

    L. Sunder-Plassmann, A. Oberhuber, B. Mühling, G. Lang, H. Schelzig, G. Bischoff, K.-H. Orend & V. Rasche

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  1. L. Sunder-Plassmann
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  2. A. Oberhuber
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  3. B. Mühling
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  4. G. Lang
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  5. H. Schelzig
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  6. G. Bischoff
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  7. K.-H. Orend
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  8. V. Rasche
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Correspondence to L. Sunder-Plassmann.

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Sunder-Plassmann, L., Oberhuber, A., Mühling, B. et al. Endovaskuläre Versorgung der traumatischen Aortenruptur im Akutstadium. Gefässchirurgie 14, 213–218 (2009). https://doi.org/10.1007/s00772-009-0671-7

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  • DOI: https://doi.org/10.1007/s00772-009-0671-7

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