Blunt aortic injury in a patient with prior coronary artery bypass surgery.

Traumatic aortic rupture is a significant challenge, further complicated by prior coronary artery bypass graft surgery with a left internal mammary artery anastomosis. We present a patient with prior coronary artery bypass graft and valve replacement who sustained multiple injuries, including an aortic rupture, after a motor vehicle crash. This report describes successful treatment of a patient with a thoracic endograft and carotid subclavian bypass to preserve the left internal mammary artery inflow.

Endovascular repair of traumatic aortic injuries.

Endograft repair has clearly revolutionized the treatment of traumatic aortic injury. Numerous studies, both retrospective and prospective, have documented the advantages with respect to lower mortality and lower paraplegia rates as compared with traditional open repair. Additionally, 2 recent meta-analyses of the published literature both reported significantly lower mortality and paraplegia rates with endovascular repair. These clear improvements, however, come at an increased rate of device-related complications. Currently, newer devices designed to adapt to more acute bends in the proximal thoracic aorta are in the multicenter trial phase. These devices are also expected to be available in a wider range of diameters and lengths, including smaller diameter devices required to treat younger patients. A conformable Gore TAG design is undergoing trials in the United States. Trials of the Talent thoracic device for the treatment of blunt aortic injury are also ongoing. We await the results of the ongoing multicenter trials and expect that with improvements in technology, the vast majority of patients with traumatic aortic injury can be treated without open thoracic aortic surgery. The long-term durability and natural history of thoracic endograft devices, however, are unknown. Continued regular follow-up is recommended, although this can be difficult in this young population of patients. Because follow-up may be ongoing for decades, the need to identify a potential problem has to be weighed against the oncologic risks of repeated radiation exposure.

Traumatic arteriovenous fistula 52 years after injury.

Untreated traumatic arteriovenous fistulae (AVF) have been associated with aneurysmal dilatation of the involved artery and vein, congestive heart failure, and limb ischemia. Open surgical repair of these lesions can be challenging due to the elevated venous pressure and surrounding inflammation. This case report describes a hybrid open and endovascular approach to treatment of a traumatic AVF in the right groin, presenting with aneurysmal ileo-femoral arteries and veins and pulmonary hypertension. It provides a rare look at the natural history of a traumatic AVF over 50 years following the initial injury.

Vascular injuries after blunt chest trauma: diagnosis and management.

BACKGROUND: Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma. METHODS: A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise. DISCUSSION: Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

Endograft repair of traumatic aortic injury-a technique in evolution: a single institution's experience.

OBJECTIVE: We evaluated a large single center experience of endograft repair of blunt traumatic injury of the thoracic aorta. SUMMARY BACKGROUND DATA: Traumatic aortic transection is a devastating injury with high morbidity and mortality. Endograft repair of these injuries has reduced the rates of death and paraplegia seen with open surgical treatment in the past. However, endograft repair has been associated with a higher incidence of device related failure. METHODS: The records of 43 consecutive cases of endograft treatment of traumatic aortic injury from December 2004 to November 2008 were reviewed. Patient demographics, procedure details, and outcomes were recorded. Aortic morphology was analyzed for predictors of device failure. RESULTS: Forty-three patients (32 men) with a mean age of 44 years (range: 17-88) were treated. Primary technical success was 86%. Six proximal endoleaks (14.3%) occurred. Two were repaired with a more proximal cuff, but 3 required explantation and open repair (7%). Mortality in this series was 11.6%, but no death was aorta related. No patient having endograft treatment suffered postoperative paraplegia. Early device failure is associated with sharp angulation of the aorta and shortened distance between the left subclavian artery and the site of injury. Follow-up ranged from 1 to 38 months (mean: 7.4 months). There were no late device failures or complications. CONCLUSIONS: Endovascular repair of blunt traumatic aortic injury can be performed with a low morbidity and mortality. Anatomic patterns in the aortic arch appear to be predictive of early device failure. Midterm durability is excellent, but reliable follow-up remains challenging in this group of patients.

Endovascular embolization of a giant renal artery aneurysm with preservation of renal parenchyma.

Renal artery aneurysm is a rare condition that has an unclear etiology. Although some patients present with symptoms of hypertension, pain, hematuria, or rupture, the majority are asymptomatic. Traditional surgical repair of renal artery aneurysms is often complex and may require ex vivo repair and reimplantation of the kidney if branch vessels are involved. Very large aneurysms made require nephrectomy. More recently, reports have described endovascular approaches to renal artery aneurysms, including coil embolization and stent graft coverage. This report describes successful endovascular treatment of a 10-cm renal artery aneurysm with preservation of renal mass.

Endovascular stenting for traumatic aortic injury: an emerging new standard of care.

BACKGROUND: Thoracic aortic injury remains a leading cause of death after blunt trauma. Thoracic aortic stents have the potential to treat aortic tears using a less invasive approach. We have accumulated the largest series of patients treated with blunt thoracic aortic injury over a 2-year period. METHODS: From July 2005 to present, 26 patients presenting with blunt aortic injury were treated with thoracic aortic endografting; these patients were retrospectively compared with the prior 26 patients presenting with similar aortic injury who were treated by open surgical repair. A Severity Characterization of Trauma score calculated for each patient predicts mortality based on severity of injury and degree of physiologic derangement on presentation. RESULTS: Patients treated with endografting had a significantly shorter length of stay, less intraoperative blood loss, decreased 24-hour blood transfusion, and lower incidence of postoperative tracheostomy compared with patients undergoing open repair. Survival in both groups was similar despite a trend toward higher injury severity among patients treated with endografting. CONCLUSIONS: This early experience suggests that aortic endografting may provide a safe and efficient treatment of aortic tears that cardiac surgeons can be successful in employing.

Intraoperative coil embolization reduces transplant nephrectomy transfusion requirement.

Transplant nephrectomy for failed renal transplants can be challenging. Patients often have numerous comorbidities, and the procedure may be associated with considerable blood loss. This study was performed to determine if intraoperative coil embolization of the transplant renal artery reduces blood loss associated with transplant nephrectomy. Data were collected retrospectively on 13 consecutive transplant nephrectomies performed immediately following coil embolization and compared with the 13 most recently performed consecutive transplant nephrectomies without coil embolization. The groups were compared for operative time, estimated blood loss, and transfusion requirements. Mean age was 45 in both groups. There were no major complications in either group. Operative times were not significantly different, although open operative time was reduced in the embolization group (113 vs 96 minutes). Estimated blood loss was 465 mL versus 198 mL (P = .035); packed red blood cell requirements during the operation and subsequent 48 hours were 1.85 units versus 0.31 units (P = .008) and during the operation and subsequent hospital stay were 2.3 units versus 0.69 units (P = .027) in the nonembolized group and embolized group, respectively. Intraoperative embolization of the transplant renal artery immediately prior to surgery facilitates transplant nephrectomy by significantly reducing intraoperative blood loss and transfusion requirements while slightly reducing open operative time.

Twenty consecutive cases of endograft repair of traumatic aortic disruption: lessons learned.

OBJECTIVES: Endograft repair holds considerable promise in the treatment of traumatic disruption of the thoracic aorta because patients often have multiple coexisting injuries further complicating traditional open repair. In addition, patients are often young, with an aortic anatomy dissimilar to those with atherosclerotic aneurysms. As a result, techniques for endograft repair have to be refined accordingly. METHODS: The records of 20 consecutive cases of traumatic aortic disruption treated by endograft repair at a single institution were reviewed. RESULTS: Mean patient age was 40 years (range, 17 to 88 years), and 17 (85%) of 20 patients were men. All cases were completed. There were no procedure related deaths, but four (20%) patients died of their co-injuries. Only two (10%) of 20 required a graft >28 mm in diameter, and nine (45%) aortas were small enough to require use of 23-mm abdominal cuffs. Six (30%) of 20 cases required complete or partial coverage of the left subclavian artery. Placement of a proximal extension was required in one patient for a type I endoleak. A graft collapse occurred in one patient that required surgical removal and aortic repair. CONCLUSIONS: Endovascular repair of traumatic aortic disruption can be accomplished in most cases. Compared with atherosclerotic aneurysms, the proximal thoracic aorta tends to be smaller and the arch angle tighter in an aorta 19mm in diameter. This frequently necessitates the use of smaller devices and less stiff wires. Surgeons should be prepared to cover the left subclavian artery if needed, have a wide range of device sizes in stock to avoid over-sizing, and show restraint if the anatomy appears unsuitable.

Lemierre's syndrome: a potentially fatal complication that may require vascular surgical intervention.

Septic phlebitis of the internal jugular vein, Lemierre's syndrome, is extremely rare. However, Lemierre's syndrome may cause septic pulmonary emboli or result in fatal systemic sepsis, or both, if a timely diagnosis and appropriate treatment are not provided. We present a case of Lemierre's syndrome that occurred in an otherwise healthy young man. In this case, progression to a moribund state was rapid, and surgical intervention proved lifesaving.

Exteriorization and control of a retained embolization coil in the carotid artery--a case report.

Advances in endovascular technology have enabled the development of complex techniques for the treatment of vascular conditions. Not surprisingly, the modern vascular surgeon will likely encounter unusual complications and will need to formulate plans for their management. In the current case report, the vascular surgery service was consulted to assist in the management of a retained embolization coil in the carotid artery. Relevant aspects of detachable coils are discussed and the successful management of this potentially hazardous complication is described.

Combined endovascular and surgical repair of a large traumatic pseudoaneurysm of the thigh-a case report.

Thigh pseudoaneurysms are rare compared to pseudoaneurysms of the groin, and usually result from direct injury to an arterial branch. Direct open repair can be associated with a large volume blood loss. The authors describe a combined endovascular and surgical approach to a large, traumatic, pseudoaneurysm of the thigh. The patient was a 49-year-old man with a history of left femur fracture treated by open reduction and internal fixation, who presented with a painfully swollen left thigh. Duplex ultrasound and computed tomography (CT) scan suggested a large (7.7 x 5.0 x 6.3 cm) pseudoaneurysm that appeared to be associated with a branch of the deep femoral artery. In the operating room, angiography was used to identify and selectively access the feeding artery. This artery was then successfully coil embolized, allowing surgical decompression of the thigh with minimal effort and blood loss. Endovascular and surgical therapy were complementary in successfully treating a large traumatic pseudoaneurysm of the thigh.

Surgical thrombectomy and transluminal balloon angioplasty for failed above-knee femoropopliteal polytetrafluoroethylene bypass grafts.

Endovascular therapy offers an alternative to redo bypass or surgical graft revision for failed above-knee femoropopliteal PTFE bypass grafts. We evaluated the outcome of surgical thrombectomy and balloon angioplasty for the treatment of thrombosed bypass grafts. Thirty selected patients with thrombosed above-knee femoropopliteal PTFE bypass grafts were treated. Under local anesthesia, a surgical thrombectomy followed by bypass graft angiography and balloon angioplasty of perianastomotic stenoses was performed. Stents were used selectively for suboptimal angioplasty results. Patients underwent duplex scanning of the bypass graft postoperatively and at 6-month intervals. Life-table analysis and log-rank (Mantel-Cox) comparisons were performed. Patients were categorized into two groups on the basis of time elapsed from initial bypass graft construction to graft failure. Group 1 included 21 patients with a mean time to graft failure of 10 months (range, 0-20). Surgical thrombectomy was successful in 20 grafts (95%) and 17 patients had a stent placed after angioplasty. Rethrombosis occurred within 30 days in seven grafts (33%) in group 1 and major amputations were performed in six patients (28%). Group 2 included nine patients with a mean time to initial bypass graft failure of 48 months (range, 29-96). All patients in group 2 had a successful surgical thrombectomy and all received a stent. None of the grafts treated in group 2 reoccluded within 30 days of intervention and one patient (11%) went on to require a major amputation. By life-table analysis, the 6- and 12-month patency for group 1 was 15.3% and 5.1%, compared to 58.3% and 38.9% for group 2 (p = 0.027). Surgical thrombectomy along with balloon angioplasty has an unacceptably high rate of failure and limb loss in patients treated for early (<2 years) femoropopliteal PTFE bypass graft thrombosis. Surgical graft revision or redo bypass is recommended to achieve successful revascularization in these patients. Treatment with surgical thrombectomy and balloon angioplasty achieves significantly greater short-term patency results in patients with late (>2 years) bypass graft failure and may be a reasonable alternative for patients who cannot tolerate reoperation or lack autogenous conduit.

Magnetic resonance imaging for planning aortic endograft procedures.

Patients with aortic aneurysms and renal insufficiency are at an increased risk when conventional imaging modalities (contrast enhancing computed tomography and arteriography) are used for aortic endograft design. Magnetic resonance imaging (MRI) provides a nonionizing, noninvasive alternative to standard measurement techniques. Reliable diameter and length measurements can be obtained with MRI at a computer workstation without the use of iodinated radiologic contrast agents. The authors describe their experience with the use of magnetic resonance angiography as the sole imaging modality for aortic endograft design. Although not without limitations, MRI can be an effective measurement tool, particularly in patients who are at high risk of complications related to conventional imaging.

Endovascular repair of a penetrating thoracic aortic ulcer by way of the carotid artery.

INTRODUCTION: Endovascular repair of thoracic aortic lesions offers an attractive alternative to traditional open repair. Access to the thoracic aorta can occasionally be challenging because of large device size and vessel tortuosity. Traditional access by way of the femoroiliac vessels might not be possible in the setting of synchronous iliac occlusive disease. MATERIALS AND METHODS: A 63-year-old woman presented with a 7.1-cm symptomatic, penetrating ulcer of the descending thoracic aorta. The patient's severe pulmonary disease prohibited an open repair. A Talent endoprosthesis was placed under compassionate use with approval of the institutional review board. The graft was placed by way of the left common carotid artery because of severe iliac occlusive disease. RESULTS: The thoracic endograft was successfully placed with exclusion of the pseudoaneurysm. The patient's chest pain resolved immediately. She developed mild left-sided weakness from a postoperative right anterior cerebral artery stroke that quickly resolved. The patient was discharged on postoperative day 5. No aortic endoleak was noted on follow-up computerized tomography scan at 1 month. CONCLUSIONS: Endovascular repair should be considered in patients with thoracic aortic aneurysms, particularly those with severe medical comorbidities. Placement by way of the common carotid artery is technically feasible in the setting of synchronous aortoiliac disease.

Coagulopathy as a result of factor V inhibitor after exposure to bovine topical thrombin.

We describe a case of severe coagulopathy after mesenteric revascularization. Laboratory investigation results revealed the presence of plasma inhibitors of factor V believed to result from exposure to bovine thrombin used for intraoperative hemostasis. Vascular and cardiothoracic surgeons commonly use topical thrombin for surgical hemostasis, and many patients undergo multiple exposure. More patients likely have factor V inhibitors develop than has previously been realized, and this may account for some otherwise unexplained postoperative coagulation disorders. This report may alert surgeons to coagulation disturbances that can result from exposure to bovine thrombin and provide guidelines for diagnosis and management.

Platelets inhibit the lysis of pulmonary microemboli.

Using tracings of (125)I-labeled fibrin(ogen) in rodents, we examined the hypothesis that platelets impede the lysis of pulmonary emboli. (125)I-Microemboli (ME, 3-10 micron diameter) lodged homogeneously throughout the lungs after intravenous injection in both rats and mice (60% of injected dose), caused no lethality, and underwent spontaneous dissolution (50 and 100% within 1 and 5 h, respectively). Although lung homogenates displayed the most intense fibrinolytic activity of all the major organs, dissolution of ME was much slower in isolated perfused lungs (IPL) than was observed in vivo. Addition of rat plasma to the perfusate facilitated ME dissolution in IPL to a greater extent than did addition of tissue-type plasminogen activator alone, suggesting that permeation of the clot by plasminogen is the rate-limited step in lysis. Platelet-containing ME injected in rats lysed much more slowly than did ME formed from fibrin alone. (125)I-Thrombi, formed in the pulmonary vasculature of mice in response to intravascular activation of platelets by injection of collagen and epinephrine, were essentially resistant to spontaneous dissolution. Moreover, injection of the antiplatelet glycoprotein IIb/IIIa antibody 7E3 F(ab')(2) facilitated spontaneous dissolution of pulmonary ME and augmented fibrinolysis by a marginally effective dose of Retavase (10 microg/kg) in rats. These studies show that platelets suppress pulmonary fibrinolysis. The mechanism(s) by which platelets stabilize ME and utility of platelet inhibitors to facilitate their dissolution deserves further study.