Endovascular treatment of traumatic ruptures of the thoracic aorta

Rupture of the thoracic aorta after a blunt traumatic accident is a life-threatening event. This injury is instantly fatal in about 80% of the victims, and half of those who initially survive the incident will die during the first day, if left untreated. Before 1997, patients were treated with an open repair, but the conventional surgical approach carries a high mortality and morbidity rate. Graft interposition and cross-clamping of the aorta are responsible for a high paraplegia rate. Despite the fact that active distal perfusion of the aorta lowers the incidence of neurological deficit, the timing of these extensive procedures in the severely injured multi-trauma patient is difficult. The endovascular repair of a traumatic thoracic aortic rupture has gained rapid acceptance as a better alternative. This minimally invasive procedure has a median operating time of <1 h, and it can be done during the same session in which other life-threatening injuries are repaired. There is no need for a thoracotomy or single lung ventilation, blood loss is minimal and systemic heparinization is not required. So far, no spinal cord ischemia has been described for the endovascular repair. Besides numerous advantages, a few problems can be expected. The narrow aortic diameter of these young trauma-victims, combined with a steep aortic arch, makes the adaptation of the endograft along the inner curvature sometimes difficult. Because the smallest endograft usually exceeds the narrow aortic diameter, only excessively oversized devices can be used, which explains the high type I endoleak encountered in the published series. No randomized studies are yet available comparing the open with the endovascular technique, but the initial results of the endovascular repair seem promising and lower mortality and morbidity rates are documented. Long-term outcome are lacking so far, but are needed to address the durability of the procedure. Further research and development should concentrate on the problems we have seen with steep and narrow aortic arches, and devices with more flexible curves and smaller diameters should become available in the near future.