Download Monzer Chehab, MD - SIR

Monzer Chehab, MD
William Beaumont Hospital
Royal 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:
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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
B
A
C
E
H
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).
Noninvasive Imaging
A
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
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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
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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
Bovine Arch
Nondeployed stent graft
positioned in the
descending thoracic aorta
over a Lunderquist wire
placed through a 20F sheath
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