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Ann Thorac Surg 2003;76:1465-1470
© 2003 The Society of Thoracic Surgeons
a Departments of DEPARTMENT OF Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Frankfurt/Main, Frankfurt/Main, Germany
b DEPARTMENT OF Diagnostic and Interventional Radiology, Johann Wolfgang Goethe- University Frankfurt/Main, Frankfurt/Main, Germany
* Address reprint requests to Dr Doss, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany.
e-mail: mirkodoss{at}aol.com
Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
Abstract
BACKGROUND: Surgical management of acute thoracic aortic ruptures is controversial, especially in patients with preexisting comorbidities; associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome.
METHODS: From November 1999 to February 2002 a total of 54 patients, age 28 to 83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated type B dissections, 16 traumatic ruptures). Twenty-eight patients were managed surgically using cardiopulmonary bypass (group 1), and 26 patients were treated acutely with an endovascular stent graft (group 2). The resuscitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes.
RESULTS: There were 5 of 28 deaths (17.8%) in the surgical group and 1 of 26 deaths (3.8%) in the endovascular group. In the surgical group 1 of 28 patients (3.6%) exhibited paraplegia; there were no cases of paraplegia in the endovascular group. There were 4 of 28 cases (14.3%) of renal failure in group 1 and 1 of 26 (3.8%) in group 2. In group 1, 8 patients (28.6%) required mechanical ventilation for more than 48 hours; there were 2 of 26 patients (7.7%) in group 2 with this ventilatory requirement. Three patients required a repeat thoracotomy for hemorrhage in the surgical group. There were two access failures in the endovascular group.
CONCLUSIONS: In the treatment of acute ruptures of the thoracic aorta, the immediate outcome of patients treated with endovascular stent grafts appears to be better than with management by conventional surgical repair.
After the first successful repair of a thoracic aortic aneurysm, by Lam and Aram in 1951 [1], great changes have occurred in the techniques used to surgically reconstruct the thoracic aorta. Patients' outcomes have improved considerably, from a perioperative mortality of 26% in 1965 to as low as 2% in specialized centers now [2]. However, increasingly surgeons are encountering older patients with severe comorbidities, which significantly increase operative morbidity and mortality rates for aortic surgery. Especially in the emergency setting, mortality rates of up to 67% are associated with the conventional surgical approach [3]. During the last decade, endovascular stent grafting has been established as an alternative form of treatment. Contrary to open surgery it is significantly less invasive and is accepted within the current environment of cost reduction in the health-care system. More important than costs are the improved clinical outcomes, with regard to mortality and morbidity rates, in patients treated with this procedure [4]. Although these benefits have been described in the literature, few data are available comparing endovascular stent grafting to the conventional surgical approach in the treatment of acute thoracic aortic disease.
The objective of this study was to describe our experiences of the last 4 years in the management of ruptured aortic aneurysms, perforated type B dissections, and traumatic aortic ruptures with these two different treatment options.
Material and methods
Fifty-four consecutive patients underwent repair of an acute perforation of the descending thoracic aorta from November 1999 to February 2002. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes. Twenty-eight patients (12 traumatic aortic ruptures, 11 ruptured thoracic aortic aneurysms, 5 type B dissections) were managed surgically and 26 patients (4 traumatic aortic ruptures, 13 ruptured thoracic aortic aneurysms, 9 type B dissections) were accurately treated with an endovascular stent graft. Overall the presenting pathologic disease process included 24 contained ruptures of descending thoracic aneurysms (Figs 1–3), 14 perforated type B dissections, and 16 contained traumatic ruptures of the descending thoracic aorta. We define an acute thoracic aortic rupture or perforation as follows: there is evidence of leakage from the aorta, there is periaortic hematoma and the presence of left-sided hemothorax; and there is a recent onset of thoracic pain. The diagnosis of acute aortic rupture was established by multidetector computed tomography angiography. In selected cases transesophageal echocardiography was also used.
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Concomitant diseases, rendering patients not suitable surgical candidates, were chronic obstructive pulmonary disease, recent stroke, cardiac disease, renal failure, and hepatic disease (Table 1).
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To proceed with an endovascular procedure, patients had to respond to our resuscitation therapy, fulfilling the following criteria: systolic blood pressure of 90 to 120 mm Hg, a heart rate less than 110 beats/min, central venous pressure of 7 to 14 cm H2O, and hemoglobin of more than 10 g/dL. The majority of patients presented in a state of shock and either needed inotropic resuscitation with dopamine or norepinephrine in moderate dosages, or volume resuscitation using colloids and blood products. Overall, 27 patients needed opioids to treat their acute back or chest pain. Five patients were severely hypertensive on admission, with systolic blood pressures of up to 200 mm Hg. To control their hypertension ß-blockers, 
-blockers, and nitrates were used. Resuscitation details are shown in Table 2.
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Endovascular group
Our current technique of endovascular stent graft deployment to the descending thoracic aorta has been described elsewhere [5]. Two different commercially available thoracic stent graft systems were implanted in this study, the Talent LPS (Medtronic World Medical, Sunrise, FL) and the Excluder (W.L. Gore & Associates, Inc, Sunnyvale, CA). After successful surgical exposure of the femoral artery and transverse arteriotomy, a pigtail catheter was positioned in the ascending thoracic aorta over a soft, angled guidewire (Radiofocus standard guidewire M; Terumo, Tokyo, Japan). The guidewire was exchanged for a stiff guidewire (Lunderquist extra stiff; Cook Inc, Bloomington, IN) for stent graft insertion. After an initial, angulated DSA of the thoracic aorta with 30 mL of contrast material (Visipaque 320; Nycomed Amersham, Buchler, Germany) and a flow rate of 15 mL/s, 5000 IU of heparin was administered intraaortically. The stent graft system was then advanced into the desired position, and the correct location was verified by an additional DSA immediately before stent graft deployment. To avoid downstream migration of the device during deployment, systolic arterial blood pressure was lowered to 70 mm Hg using sodium nitroprusside just before release of the device, or short cardiac arrest was achieved by intravenous injection of adenosine (6 to12 mg) to ease device deployment and allow exact device positioning at the orifice of the left subclavian or carotid artery. In all cases, dilation after placement of the stent was performed using an endovascular balloon to obtain optimal shape and sealing of the implanted stent graft.
A final DSA was performed to verify appropriate stent graft localization and to demonstrate free perfusion of the supraaortic vessels as well as the stent graft. All interventional materials were removed, and the arteriotomy was closed with a continuous 5-0 Prolene (Ethicon, Somerville, NJ) suture. All patients were transferred to the intensive care unit for postoperative surveillance for at least 4 hours. All patients had a single-shot broad-spectrum antibiotic prophylaxis (third-generation cephalosporins) just before the initial incision. Follow-up examinations were performed using multidetector-computed tomography angiography scans before discharge, and at 3, 6, and 12 months after implantation.
Results
The overall perioperative mortality was 11.1% (6 of 54 patients). It was 17.8% (5 of 28 patients) for patients who received emergent surgical treatment and 3.8% (1 of 26 patients) for patients in the endovascular group. The causes of death in the surgical group were low output syndrome in 2 patients, sepsis in 1 patient, and intraoperative hypovolemia in 2 patients. After 12 months of follow-up, no further deaths had occurred in either group. The perioperative mortality according to the type of aortic lesion is shown in Table 3.
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Morbidity
In the surgical group 28.6% (8 of 28 patients) of the patients required mechanical ventilation for more than 48 hours, 14.3% (4 of 28 patients) developed renal failure requiring dialysis, and 10.7% (3 of 28 patients) required surgical reexploration for bleeding.
In the endovascular group 7.7% (2 of 26 patients) of the patients required mechanical ventilation for more than 48 hours, and 3.8% (1 of 26 patients) developed renal failure requiring dialysis. None of the patients needed reexploration for bleeding or conversion to conventional surgery. However, there was access failure in 2 patients (7.7%) as a result of small and calcified iliac arteries; there was one case of iliac artery dissection (3.8%). One of these patients died intraoperatively from left ventricular failure. The second patient was stabilized and discharged on medical therapy. Two patients developed distal type 1 endovascular leaks (7.7%) that became apparent at discharge from hospital. After 6 months both endovascular leaks had sealed spontaneously without the need for further intervention.
Comment
In patients with acute ruptures of the descending thoracic aorta, conventional surgical management currently is still the treatment of choice. However, in an aging population with limiting comorbidities, associated mortality and morbidity rates have been high, especially in an emergency setting. Bui and colleagues [3] reported perioperative mortality rates of 29% to 67%, with an associated paraplegia rate of 20%, for the emergent surgical treatment of ruptured aortic aneurysms. The perioperative mortality of perforated type B dissection as an emergency procedure has been described by Nienaber and colleagues [6] to be 10% to 60%, with a paraplegia rate of 20%. In the surgical treatment of acute traumatic aortic rupture, Miller and Calhoon [7] reported a perioperative mortality rate of 30% to 35% and a paraplegia rate of 25%.
With improvements in surgical techniques, there has been a steady reduction in perioperative mortality during the last decade. Jamieson and colleagues [8] reported an intraoperative mortality of 6.7% for acute traumatic ruptures of the thoracic aorta in their third decade of experience. In the treatment of acute type B dissections records of perioperative mortality vary strongly among centers and range from 0% to 40% [9, 10]. With the widespread use of spinal cord protective measures, such as utilization of cardiopulmonary bypass, left heart bypass, hypothermia, cerebrospinal fluid drainage, and monitoring of evoked potentials during the last decade, paraplegia rates have also decreased. Kwon and colleagues [11] report a 9.5% paraplegia rate for the emergent repair of ruptured descending thoracic aortic aneurysms. In the acute treatment of type B dissections, Lansman and associates [9] describe a paraplegia rate of 2.9% in their patient cohort. Our results in the surgical group also reflect these improved outcomes of patients, with an overall mortality of 17.8% and a paraplegia rate of 3.6%.
Within the last decade, endovascular stent grafting has been established as an alternative to conventional surgery in the treatment of aortic lesions. In an elective setting a significantly lower rate of morbidity and mortality has been achieved, thereby offering treatment to patients who were previously considered not suitable for surgery [12, 13]. With a mortality rate of 3.8% for the endovascular group, our series suggests that this might also be true for the emergent stent grafting of acute lesions of the descending thoracic aorta. Similarly, the incidence of paraplegia was lower in the endovascular group. None of the patients in our series of patients treated with emergent stent grafting showed paraplegia or associated neurologic complications. In the literature, placement of endovascular stent grafts for acute ruptures of the thoracic aorta also did not seem to increase the risk of paraplegia when compared with conventional surgical treatment [14].
Further advantages of the endovascular approach in our series were the lower rate of respiratory insufficiency, renal failure, and need for reexploration because of bleeding. These findings have been described in the literature by other authors as well [15–17].
However, none of the other studies compared a cohort of patients treated within a defined period of time by either endovascular or conventional surgical means, undergoing the same preoperative workup and resuscitation protocol as well as postoperative care by the same team. Comparative single-center experiences or randomized trials are not available for the emergency treatment of thoracic aortic lesions.
In our study it became clear that the interval from diagnosis to treatment was longer in the endovascular group. This was mainly because of the fact that some stent graft sizes were not available within the hospital and had to be ordered from the company. During this period (an additional 4 to 8 hours) the patients were monitored in our intensive care ward. This delay in treatment did not seem to negatively affect clinical outcomes in these patients. In fact, several studies showed that surgical mortality after aortic injury can be significantly reduced when deliberately delayed surgical repair is performed [18, 19].
The emergency endovascular treatment of acute lesions of the thoracic aorta is feasible and an exciting alternative to conventional surgery. Although we achieved very good short-term results with this method, questions regarding long-term complications and durability of stent grafts remain unanswered. Long-term follow-up of these patients will therefore be necessary and allow for a definitive conclusion.
Acknowledgments
We thank Prof Dr Thomas Vogl for his expert advice and Dr Maria Dalmau for her help and inspiration in completing this work.
Discussion
DR SCOTT MITCHELL (Stanford, CA): Doctor Guyton, Doctor Murray, members, and guests. Doctor Doss and his colleagues are to be congratulated for an excellent presentation and certainly very good results in a very challenging group of patients. And although I basically agree with your treatment algorithms, I think we have to look a little bit more closely when one starts to do comparisons, because I think that these are in fact not comparable groups of patients. Although it would appear that the endovascular approach was associated with less morbidity and mortality, this was not a randomized study, and I do not think that these groups are truly comparable.
If my understanding is correct, after a few learning-curve patients, then all subsequent patients were considered to be endovascular candidates if there were adequate-sized access vessels, the diameter of the aorta was less than 44 mm, there was a landing zone distal to the carotid and proximal to the celiac access greater than 1.5 cm, there was a lack of extreme tortuosity, either in the abdominal or thoracic aorta, and there was an available stent graft. And I think this preselects a certain group of patients for whom this modality is particularly favorable but for whom the surgical options are perhaps also quite favorable.
As you stated in your presentation, there was frequently a delay of 4 to 8 hours while you awaited the arrival of an appropriately sized graft, and I suggest that this may select a group of patients who are survivors. With this in mind, I have several questions.
For your surgical group, I noticed that hypothermic circulatory arrest at 18°C was used for all patients. Is that your normal protocol or is that just necessary because of the adverse proximal anatomy for this surgical group?
You state that important intercostal arteries were reattached. I wondered which intercostal arteries you thought were important.
There was a single episode of paraplegia in the surgical group, and I wondered whether this patient had a cerebrospinal fluid drain.
In the stent graft group, there were 2 patients in whom there was access failure. I wondered what you did with these patients and how they were treated in the analysis.
I was a little surprised to see that there was 1 patient with Marfan's disease who was treated with a stent graft, and I was curious whether you consider the Marfan aorta to be a suitable substrate for endograft repair.
I noticed also a preponderance of your traumatic patients were treated surgically. We seem to think that this is an ideal candidate for stent grafts, and I wonder why so many patients were treated with the endografts.
And finally, did any of these patients who were awaiting delivery of a stent graft become unstable and require urgent thoracotomy?
I would caution you that perhaps we are comparing apples to oranges.
I very much enjoyed your presentation and I commend you on fine results. I would like to thank the Society for the privilege of discussing this manuscript.
DR JOSEPH BAVARIA (Philadelphia, PA): The two distal endoleaks, were those type B dissection patients or other?
DR ROBERT T. REICHMAN (Escondido, CA): I have two questions for Doctor Doss. Number one is, did you have any patients with preoperative paraplegia and what was their outcome either in the endovascular or the open groups?
The other is, with the endovascular leaks, did you measure volumes in the aorta postoperatively and did the volume change when the endovascular leak sealed?
DR DOSS: Well, there are a whole lot of questions that I have to answer.
First of all, Doctor Mitchell is absolutely correct when he says that it was not a randomized trial and that the patients might not be ideally comparable, and that is true. And, of course, we had to exclude patients who were not suitable for stent graft deployment and treat them surgically, and these patients often had involvement of the subclavian artery and that is why we had to use circulatory arrest in these patients, and perhaps that is why this group was a bit more diseased than the endovascular group.
Concerning intercostals, the intercostal arteries were reattached if on examination they seemed to be large. That is how we considered them to be important.
The patient who exhibited a paraplegia in the surgical group did have a cerebrospinal fluid drain and developed paraplegia after 3 days. He was actually intubated and under anesthesia for 3 days and on awakening had paraplegia with a cerebrospinal fluid drain.
Concerning access failure, one of the patients with access failure was the patient who died intraoperatively. We considered that access failure. And the second patient was an 86-year-old woman with very small iliac arteries and a thoracic aortic aneurysm. We did not treat that patient surgically afterward and just stabilized her. Eventually we discharged her on medical treatment.
Concerning Marfan's disease, the patient who we treated with Marfan's disease was a patient who had a previous aortic arch replacement. So when deploying the stent graft, we actually had a good proximal landing zone, and the distal landing zone is where your criticism is correct, that was still an aorta that was probably diseased with Marfan's disease. Other than that, we did not treat any Marfan patients, and usually we do not treat them actually.
Regarding traumatic patients, we only treated a few patients with endovascular grafts because the cooperation in our department between the traumatic surgeons and us in the first years was not as good as it became later. So initially, patients, before we could actually evaluate them for endograft treatment, would have been already scheduled for surgery by them. That is why we did not treat a lot of these patients in the beginning. Now we try to treat this group, in particular, with endovascular stent grafts.
Talking about conversions, we did not have any conversions after treatment of endovascular stent grafting, so these patients did not become unstable after the graft was placed.
Now, talking about the endovascular leaks, there were two distal endovascular leaks. One of the patients was a type B dissection and one of the patients had an aortic aneurysm. That answers your question. We did not have any patients with preoperative paraplegia. And we did not measure the volume changes of the aorta after stent graft placement.
References
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