Thoracic Aortic Emergencies: Presenting Pathologies and Treatment Strategies

Abstract

Thoracic aortic emergencies reflect a wide range of etiologies, pathologic processes, and clinical presentations. Accurate identification with an appropriate treatment algorithm is best accomplished in a multidisciplinary setting with interventional radiologists, vascular surgeons, and cardiothoracic surgeons. While knowledge of thoracic stent graft equipment and technique is essential in the treatment of thoracic aortic emergencies, many clinical settings may employ alternative treatment techniques. This article will review the most common thoracic aortic emergencies and treatment strategies.

Keywords

TEVAR - fenestration - aortic dissection - traumatic aortic injury - interventional radiology

Disclosures

D.M.W.—Consultant, W.L. Gore & Associates; scientific advisory board, Boston Scientific.

M.S.K.—Consultant and received speaker honoraria from Penumbra, Inc.

Remaining authors have no disclosures.

• References

• 1 Cardarelli MG, McLaughlin JS, Downing SW, Brown JM, Attar S, Griffith BP. Management of traumatic aortic rupture: a 30-year experience. Ann Surg 2002; 236 (04) 465-469 , discussion 469–470
• 2 Xenos ES, Minion DJ, Davenport DL. , et al. Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis. Eur J Cardiothorac Surg 2009; 35 (02) 282-286
• 3 Eid-Lidt G, Gaspar Hernández J, González-Pacheco H. , et al. Complicated acute aortic syndromes affecting the descending thoracic aorta: endovascular treatment compared with open repair. Clin Cardiol 2015; 38 (10) 585-589
• 4 Hahn LD, Prabhakar AM, Zucker EJ. Cross-sectional imaging of thoracic traumatic aortic injury. Vasa 2019; 48 (01) 6-16
• 5 Erbel R, Aboyans V, Boileau C. , et al; ESC Committee for Practice Guidelines; The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J 2014; 35 (41) 2873-2926
• 6 Grigorian A, Spencer D, Donayre C. , et al. National trends of thoracic endovascular aortic repair versus open repair in blunt thoracic aortic injury. Ann Vasc Surg 2018; 52 (52) 72-78
• 7 Siegel JH, Yang KH, Smith JA. , et al. Computer simulation and validation of the Archimedes Lever hypothesis as a mechanism for aortic isthmus disruption in a case of lateral impact motor vehicle crash: a Crash Injury Research Engineering Network (CIREN) study. J Trauma 2006; 60 (05) 1072-1082
• 8 Parmley LF, Mattingly TW, Manion WC, Jahnke Jr EJ. Nonpenetrating traumatic injury of the aorta. Circulation 1958; 17 (06) 1086-1101
• 9 Teixeira PG, Inaba K, Barmparas G. , et al. Blunt thoracic aortic injuries: an autopsy study. J Trauma 2011; 70 (01) 197-202
• 10 Kaewlai R, Avery LL, Asrani AV, Novelline RA. Multidetector CT of blunt thoracic trauma. Radiographics 2008; 28 (06) 1555-1570
• 11 Lee WA, Matsumura JS, Mitchell RS. , et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011; 53 (01) 187-192
• 12 Gandhi SS, Blas JV, Lee S, Eidt JF, Carsten III CG. Nonoperative management of grade III blunt thoracic aortic injuries. J Vasc Surg 2016; 64 (06) 1580-1586
• 13 Marcaccio CL, Dumas RP, Huang Y, Yang W, Wang GJ, Holena DN. Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury. J Vasc Surg 2018; 68 (01) 64-73
• 14 Lee WA, Brown MP, Nelson PR, Huber TS. Total percutaneous access for endovascular aortic aneurysm repair (“Preclose” technique). J Vasc Surg 2007; 45 (06) 1095-1101
• 15 McGraw CJ, Gandhi RT, Vatakencherry G, Baumann F, Benenati JF. Percutaneous large arterial access closure techniques. Tech Vasc Interv Radiol 2015; 18 (02) 122-126
• 16 Cline M, Cooper KJ, Khaja MS, Gandhi R, Bryce YC, Williams DM. Endovascular management of acute traumatic aortic injury. Tech Vasc Interv Radiol 2018; 21 (03) 131-136
• 17 Karmy-Jones R, Namias N, Coimbra R. , et al. Western Trauma Association critical decisions in trauma: penetrating chest trauma. J Trauma Acute Care Surg 2014; 77 (06) 994-1002
• 18 Schulz C, Südkamp NP, Khodadadayan C, Haas NP, Neuhaus P. [Penetrating thoracic injuries--a 10 year analysis of 179 patients]. Aktuelle Traumatol 1994; 24 (03) 75-78
• 19 Demetriades D. Penetrating injuries to the thoracic great vessels. J Card Surg 1997; 12 (2, Suppl): 173-179 , discussion 179–180
• 20 Brown J, Grover FL. Trauma to the heart. Chest Surg Clin N Am 1997; 7 (02) 325-341
• 21 Kolbeck KJ, Kaufman JA. Endovascular stent grafts in urgent blunt and penetrating thoracic aortic trauma. Semin Intervent Radiol 2011; 28 (01) 98-106
• 22 Stanson AW, Kazmier FJ, Hollier LH. , et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986; 1 (01) 15-23
• 23 Corvera JS. Acute aortic syndrome. Ann Cardiothorac Surg 2016; 5 (03) 188-193
• 24 Nathan DP, Boonn W, Lai E. , et al. Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg 2012; 55 (01) 10-15
• 25 Maddu KK, Shuaib W, Telleria J, Johnson JO, Khosa F. Nontraumatic acute aortic emergencies: Part 1, Acute aortic syndrome. AJR Am J Roentgenol 2014; 202 (03) 656-665
• 26 Pape LA, Awais M, Woznicki EM. , et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol 2015; 66 (04) 350-358
• 27 Hagan PG, Nienaber CA, Isselbacher EM. , et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283 (07) 897-903
• 28 Chiu P, Miller DC. Evolution of surgical therapy for Stanford acute type A aortic dissection. Ann Cardiothorac Surg 2016; 5 (04) 275-295
• 29 Ehrlich MP, Ergin MA, McCullough JN. , et al. Results of immediate surgical treatment of all acute type A dissections. Circulation 2000; 102 (19) (Suppl. 03) III248-III252
• 30 Di Eusanio M, Trimarchi S, Patel HJ. , et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg 2013; 145 (02) 385-390.e1
• 31 Grimm JC, Magruder JT, Crawford TC. , et al. Differential outcomes of type A dissection with malperfusion according to affected organ system. Ann Cardiothorac Surg 2016; 5 (03) 202-208
• 32 Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg 1983; 31 (01) 37-40
• 33 Roselli EE, Bakaeen FG, Johnston DR, Soltesz EG, Tong MZ. Role of the frozen elephant trunk procedure for chronic aortic dissection. Eur J Cardiothorac Surg 2017; 51 (51) (Suppl. 01) i35-i39
• 34 van Bakel TM, de Beaufort HW, Trimarchi S. , et al. Status of branched endovascular aortic arch repair. Ann Cardiothorac Surg 2018; 7 (03) 406-413
• 35 Ghoreishi M, Shah A, Jeudy J. , et al. Endovascular repair of ascending aortic disease in high-risk patients yields favorable outcome. Ann Thorac Surg 2019 Doi: 10.1016/j.athoracsur.2019.07.015 [Epub ahead of print]
• 36 Piffaretti G, Grassi V, Lomazzi C. , et al; GREAT participants. Thoracic endovascular stent graft repair for ascending aortic diseases. J Vasc Surg 2019; 70 (05) 1384-1389.e1
• 37 Dake MD. Endovascular stent-graft management of thoracic aortic diseases. Eur J Radiol 2001; 39 (01) 42-49
• 38 Fattori R, Cao P, De Rango P. , et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013; 61 (16) 1661-1678
• 39 Lombardi JV, Cambria RP, Nienaber CA. , et al; STABLE I Investigators. Five-year results from the Study of Thoracic Aortic Type B Dissection Using Endoluminal Repair (STABLE I) study of endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg 2019; 70 (04) 1072-1081.e2
• 40 Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation 2005; 112 (24) 3802-3813
• 41 Nienaber CA, Kische S, Rousseau H. , et al; INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv 2013; 6 (04) 407-416
• 42 Iannuzzi JC, Stapleton SM, Bababekov YJ. , et al. Favorable impact of thoracic endovascular aortic repair on survival of patients with acute uncomplicated type B aortic dissection. J Vasc Surg 2018; 68 (06) 1649-1655
• 43 Yang B, Norton EL, Rosati CM. , et al. Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: a 20-year experience. J Thorac Cardiovasc Surg 2019; 158 (03) 675-687.e4
• 44 Yang B, Rosati CM, Norton EL. , et al. Endovascular fenestration/stenting first followed by delayed open aortic repair for acute type A aortic dissection with malperfusion syndrome. Circulation 2018; 138 (19) 2091-2103
• 45 Thakkar D, Dake MD. Management of Type B aortic dissections: treatment of acute dissections and acute complications from chronic dissections. Tech Vasc Interv Radiol 2018; 21 (03) 124-130
• 46 Norton EL, Williams DM, Kim KM. , et al. Management of malperfusion syndrome in acute type A aortic intramural hematoma. Ann Cardiothorac Surg 2019; 8 (05) 540-550
• 47 Williams DM, Lee DY, Hamilton BH. , et al. The dissected aorta: percutaneous treatment of ischemic complications--principles and results. J Vasc Interv Radiol 1997; 8 (04) 605-625
• 48 Williams DM, Lee DY, Hamilton BH. , et al. The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology 1997; 203 (01) 37-44
• 49 Khayat M, Cooper KJ, Khaja MS, Gandhi R, Bryce YC, Williams DM. Endovascular management of acute aortic dissection. Cardiovasc Diagn Ther 2018; 8 (08) (Suppl. 01) S97-S107
• 50 Kim JB, Kim K, Lindsay ME. , et al. Risk of rupture or dissection in descending thoracic aortic aneurysm. Circulation 2015; 132 (17) 1620-1629
• 51 Rath A, Wakap S. Prevalence of rare diseases: bibliographic data. Orphanet Report Series, Rare Diseases collection; 2017: 1
• 52 Germain DP. Ehlers-Danlos syndrome type IV. Orphanet J Rare Dis 2007; 2: 32
• 53 Williams JA, Loeys BL, Nwakanma LU. , et al. Early surgical experience with Loeys-Dietz: a new syndrome of aggressive thoracic aortic aneurysm disease. Ann Thorac Surg 2007; 83 (02) S757-S763 , discussion S785–S790
• 54 Bergqvist D, Björck M, Wanhainen A. Treatment of vascular Ehlers-Danlos syndrome: a systematic review. Ann Surg 2013; 258 (02) 257-261
• 55 Cooper DG, Walsh SR, Sadat U, Hayes PD, Boyle JR. Treating the thoracic aorta in Marfan syndrome: surgery or TEVAR?. J Endovasc Ther 2009; 16 (01) 60-70
• 56 Riesenman PJ, Brooks JD, Farber MA. Thoracic endovascular aortic repair of aortobronchial fistulas. J Vasc Surg 2009; 50 (05) 992-998
• 57 Jonker FH, Schlösser FJ, Moll FL. , et al. Outcomes of thoracic endovascular aortic repair for aortobronchial and aortoesophageal fistulas. J Endovasc Ther 2009; 16 (04) 428-440
• 58 Jonker FH, Heijmen R, Trimarchi S, Verhagen HJ, Moll FL, Muhs BE. Acute management of aortobronchial and aortoesophageal fistulas using thoracic endovascular aortic repair. J Vasc Surg 2009; 50 (05) 999-1004
• 59 Thomas BK, Elmore JR, Garvin RP, Ryer EJ. Endovascular retrieval of an irrigation cannula from the thoracic aorta following cardiac surgery: a case report. Int J Surg Case Rep 2015; 16 (16) 195-197
• 60 Canaud L, Gandet T, Sfeir J, Ozdemir BA, Solovei L, Alric P. Risk factors for distal stent graft-induced new entry tear after endovascular repair of thoracic aortic dissection. J Vasc Surg 2019; 69 (05) 1610-1614
• 61 Pantaleo A, Jafrancesco G, Buia F. , et al. Distal stent graft-induced new entry: an emerging complication of endovascular treatment in aortic dissection. Ann Thorac Surg 2016; 102 (02) 527-532
• 62 Weng SH, Weng CF, Chen WY. , et al. Reintervention for distal stent graft-induced new entry after endovascular repair with a stainless steel-based device in aortic dissection. J Vasc Surg 2013; 57 (01) 64-71
• 63 Lam CH, Vatakencherry G. Spinal cord protection with a cerebrospinal fluid drain in a patient undergoing thoracic endovascular aortic repair. J Vasc Interv Radiol 2010; 21 (09) 1343-1346
• 64 Matsumura JS, Lee WA, Mitchell RS. , et al; Society for Vascular Surgery. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg 2009; 50 (05) 1155-1158
• 65 Contrella BN, Sabri SS, Tracci MC. , et al. Outcomes of coverage of the left subclavian artery during endovascular repair of the thoracic aorta. J Vasc Interv Radiol 2015; 26 (11) 1609-1614