Benjamin W. Starnes

A new classification scheme for treating blunt aortic injury

BACKGROUND There are numerous questions about the treatment of blunt aortic injury (BAI), including the management of small intimal tears, what injury characteristics are predictive of death from rupture, and which patients actually need intervention. We used our experience in treating BAI during the past decade to create a classification scheme based on radiographic and clinical data and to provide clear treatment guidelines. METHODS The records of patients admitted with BAI from 1999 to 2008 were retrospectively reviewed. Patients with a radiographically or operatively confirmed diagnosis (echocardiogram, computed tomography, or angiography) of BAI were included. We created a classification system based on the presence or absence of an aortic external contour abnormality, defined as an alteration in the symmetric, round shape of the aorta: (1) intimal tear (IT)-absence of aortic external contour abnormality and intimal defect and/or thrombus of <10 mm in length or width; (2) large intimal flap (LIF)-absence of aortic external contour abnormality and intimal defect and/or thrombus of ≥10 mm in length or width; (3) pseudoaneurysm-presence of aortic external contour abnormality and contained rupture; (4) rupture-presence of aortic external contour abnormality and free contrast extravasation or hemothorax at thoracotomy. RESULTS We identified 140 patients with BAI. Most injuries were pseudoaneurysm (71%) at the isthmus (70%), 16.4% had an IT, 5.7% had a LIF, and 6.4% had a rupture. Survival rates by classification were IT, 87%; LIF, 100%; pseudoaneurysm, 76%; and rupture, 11% (one patient). Of the ITs, LIFs, and pseudoaneurysms treated nonoperatively, none worsened, and 65% completely healed. No patient with an IT or LIF died. Most patients with ruptures lost vital signs before presentation or in the emergency department and did not survive. Hypotension before or at hospital presentation and size of the periaortic hematoma at the level of the aortic arch predicted likelihood of death from BAI. CONCLUSIONS As a result of this new classification scheme, no patient without an external aortic contour abnormality died of their BAI. ITs can be managed nonoperatively. BAI patients with rupture will die, and resources could be prioritized elsewhere. Those with LIFs do well, and currently, most at our institution are treated with a stent graft. If a pseudoaneurysm is going to rupture, it does so early. Hematoma at the arch on computed tomography scan and hypotension before or at arrival help to predict which pseudoaneurysms need urgent repair.

Endovascular Treatment of Massive Thoracic Aortic Thrombus and Associated Ruptured Atheroma

Atheroembolic disease typically presents with isolated lower extremity digital ischemia. Treatment traditionally includes optimization of medical management, with open surgery reserved for complicated or recurrent embolic events. We present a novel endovascular approach for treatment of complicated thoracic aortic atherosclerotic disease incidentally discovered in a 63-year-old female. The patient demonstrated visceral artery embolization from a mobile 2.6 cm atherosclerotic plaque despite maximal medical therapy. Thoracic aortic stent graft placement successfully excluded the atheroma and prevented further embolization. This case demonstrates a unique treatment option for complicated thoracic aortic atheroembolic disease utilizing a minimally invasive endovascular approach.

Successful Emergent Endovascular Repair of a Ruptured Mycotic Thoracic Aortic Aneurysm

BACKGROUND Mycotic thoracic aortic aneurysms are a life-threatening diagnosis and carry a high risk of morbidity and mortality in the perioperative setting. Traditional open repair consists of debridement, drainage, and either in situ or extra-anatomic bypass. Acute rupture portends a dismal prognosis; however, emergent endovascular repair of ruptured mycotic aneurysms has been described in the literature and we present a case of successful endovascular treatment of a ruptured mycotic descending thoracic aortic aneurysm. CASE REPORT We report the case of a 42-year-old male with hypertension and active intravenous drug use who presented with 3 weeks of chest pain, dyspnea, and hemoptysis, and on computed tomography scan was found to have a contained 4.1-cm ruptured mycotic thoracic aortic aneurysm. Blood cultures were positive for methicillin-resistant Staphylococcus aureus. Emergent repair was recommended because of likelihood of further rupture and death. Thoracic endovascular aortic repair (TEVAR) was performed using a rifampin-soaked stent graft without complication. At 2-year follow-up, the patient was asymptomatic and imaging demonstrated the stent graft in excellent position, without endoleak, and complete resolution of the aneurysm sac. CONCLUSIONS TEVAR can be safely employed to treat a ruptured mycotic thoracic aneurysm when open repair is not possible because of patients comorbidity or complex rupture, as these patients face imminent death. Long-term follow-up is necessary for detection of endoleak, recurrence, or propagation of the aneurysm, and persistent bacterial infections.