Monzer Chehab, MD

William Beaumont HospitalRoyal Oak, Michigan

• Chief Complaint:– Left shoulder and chest pain

• History of Present Illness:– 44 year old female– Restrained passenger in motor vehicle collision (MVC)– Contrast enhanced chest CT showed extensive aortic

injury – Patient remained hemodynamically stable and was

transferred to level 1 trauma center with multiple injuries

• Past Medical History:– Hypertension

• Past Surgical History:– None

• Medications:– None on admission

• Allergies– None

• Social– Nonsmoker– Social drinker– No illicit drugs

• Injuries noted on admission:– Multiple rib fractures– Small left pneumothorax – Left clavicle fracture– Splenic laceration– Right renal infarct– Left eye chemosis – Extensive subcutaneous

emphysema overlying chest – Pneumomediastinum

Noninvasive Imaging

40 year old female status post MVC- Mutidetector contrast enhanced CT images obtained during arterial phase prior to transfer. Axial (A), Coronal (B) and Sagittal (C) planes demonstrate aortic transection at level of aortic isthmus with intimal flap projecting into aortic lumen (red arrow), pseudoaneurysm (arrowhead) and periaortic hematoma (H). Note extensive subcutaneous emphysema (E).

A B C

∧ ∧H

E

Noninvasive ImagingA B C

Complex traumatic injury of Aorta in 44 year old female status post MVC. Repeat contrast enhanced multidetector CT obtained at our institution. Axial (A), Coronal (B) and Sagittal (C) images obtained during arterial phase demonstrates interval enlargement of pseudoaneurysm (arrow)

Diagnosis and Panel Discussion• Diagnosis: Acute Traumatic Aortic Injury

– Intimal flap (transection)– traumatic pseudoaneurysm– contained rupture– intraluminal mural thrombus– abnormal aortic contour– sudden change in aortic caliber (aortic “pseudocoarctation”)

• Treatment Options:– 1. Open Thoracotomy

• Resection of injured segment and reconstruction with Dacron graft

– 2. Endovascular Stent Graft • Fixed graft deployed via femoral access

– 3. Conservative management • Blood pressure control

Potential Complications of Treatment• Open Thoracotomy

– Requires large posterolateral thoracotomy, aortic cross clamp, – Difficult in unstable patients– Results in long hospitalization times and postoperative pain– Risk of spinal ischemia and paraplegia especially in the absence of distal perfusion adjunct

i.e. hepranized cardiopulmonary bypass

• Endovascular stent graft– Stroke, puncture-site complications, device collapse/ endoleak, recurrent laryngeal nerve

damage– Limited devices for small caliber aortas– Long term outcomes and complication data lacking

• Conservative Management– Blood pressure control– High long term aortic complications with up to 40% requiring surgical or endovascular

treatment – Typically reserved for the most minimal intimal injuries

Intervention

Nondeployed stent graft positioned in the

descending thoracic aorta over a Lunderquist wire

placed through a 20F sheath

Bovine Arch

Pseudoaneursym

Intervention• Gore graft placed

intentionally covering left subclavian artery ostium

• Balloon angioplasty avoided

• Retrograde flow (steal phenomenon) into left subclavian artery predisposes to Type 2 endoleak

Intervention • To treat steal phenomenon:

– 8 mm Amplatzer plug placed though 5F brachial artery sheath occlude origin of subclavian artery at its take off

Summary • 44 year old female, status post

endovascular stent graft of Acute Traumatic Aortic Injury– Covering of left subclavian artery– Bovine arch provided good

landing zone– Balloon angioplasty avoided in

traumatic scenario• Subclavian Steal recognized post

deployment – Treated with amplatz plug of left

subclavian take• No acute complication

– No evidence of upper extremity ischemia

• Patient discharged to rehabilitation facility post procedure day 20

Sagittal CT Angiogram 3 months post stent graft repair demonstrates interval resolution of intimal flap and pseudoaneurysm