Özlem BALCIOĞLU, Sedat KARACA, Mustafa PARILDAR, Ümit KAHRAMAN, Hakan POSACIOĞLU

Akut aort transeksiyonlarının endovasküler tedavisinde başarıyı etkileyen faktörler

Amaç: Bu çalışmada Akut Aort Transeksiyonu tanısıyla 2002 – 2018 yılları arasında endovasküler tedavi ile tedavi edilmiş hastaların sonuçları ve başarıyı etkileyebilecek faktörleri sunmak amaçlanmıştır. Gereç ve Yöntem: Çalışmaya toplam 17 hasta dahil edilmiş olup retrospektif olarak planlanmıştır. Hastaların tüm verilerine dosyaları taranarak ulaşılmış ve tüm hastaların demografik verileri kaydedilmiştir. Çalışmaya dahil edilen tüm hastalardan yazılı onam belgesi alınmıştır. Hastaların travma şekilleri ve cinsiyet oranları yüzdelik olarak hesaplanmıştır. Kesin tanı için kontrastlı torakoabdominal bilgisayarlı tomografi çekilerek endovasküler tedavi açısından değerlendirme yapılmıştır. Endovasküler tedaviye uygun görülen tüm hastalara ilk 24 saat içinde müdahale edilmiştir. Bulgular: Çalışmamıza dahil edilen hasta grubunun evrelemesinde büyük çoğunluğu evre 4 hastalar oluşturmakta olup etiyolojide en büyük sebebin araç içi trafik kazaları olduğu göze çarpmaktadır. Çalışmaya dahil edilen 17 hastanın 2’si erken dönemde 1’i takip sürecinde kaybedilmiştir. Endovasküler tedavinin komplikasyonları olarak bilinen greftte migrasyon, psödoanevrizma ve greftte kıvrılma gibi komplikasyonlar ile karşılaşılmamıştır. On yedi hastanın 12’sinde sol subklaviyen arter kapatılmış olmasına rağmen sadece ikisine karotis – subklaviyen baypas uygulama ihtiyacı oluşmuştur. Sonuç: Konvansiyonel cerrahiye oranla endovasküler tedavinin düşük mortalite ile uygulanabiliyor olması akut aort transeksiyonlarında mortaliteyi azaltmaktadır. Müdahalenin ilk 24 saatte, bu konuda deneyimli merkezlerde yapılması ve greft seçiminde aort çapının %10’unun aşılmaması, balon dilatasyonundan kaçınılması tedavi başarısını etkileyen en önemli faktörlerdendir.

Factors affecting success in endovascular treatment of acute aortic transections

Aim: In this study, it was aimed to present the results of patients treated with endovascular treatment between 2002 and 2018 with the diagnosis of Acute Aortic Transection and the factors that may affect the success. Materials and Methods: A total of 17 patients were included in the study and it was planned as retrospectively. All data of the patients were collected by file searching method and demographic features of the patients were recorded. Written informed consent was obtained from all patients prior to study. Trauma types and gender ratios of the patients were calculated as percentages.. Contrast-enhanced thoraco-abdominal computed tomography was performed for definitive diagnosis, and endovascular treatment was evaluated. All patients deemed suitable for endovascular treatment were intervened within the first 24 hours. Results: The most majority of our patient group was in stage 4 and the most common etiology was recorded as in - vehicle traffic accidents. Of the 17 patients included in the study, 2 died in the early period and 1 died in the follow-up period. Complications such as graft migration, pseudo aneurysm and graft kinking, which are known as complications of endovascular treatment, were not encountered. Although the left subclavian artery was closed in 12 of 17 patients, only two of them required carotid- subclavian bypass. Conclusion: The fact that endovascular treatment can be applied with low mortality compared to conventional surgery reduces mortality in acute aortic transections. The most important factors affecting the success of the treatment are that the intervention is performed in the 24 hours, in experienced centers, and that 10% of the aortic diameter is not exceeded in the graft selection, and balloon dilatation is avoided.

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1. 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 (1): 187-192. doi:10.1016/j.jvs.2010.08.027
2. Akhmerov A, DuBose J, Azizzadeh A. Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges. Ann Vasc Dis. 2019; 12 (1): 1-5. doi:10.3400/avd.ra.18-00139
3. Agee CK, Metzler MH, Churchill RJ, Mitchell FL. Computed tomographic evaluation to exclude traumatic aortic disruption. J Trauma. 1992; 33 (6): 876-881. doi:10.1097/00005373-199212000-00014
4. Azizzadeh A, Keyhani K, Miller CC 3rd, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg. 2009; 49 (6): 1403-1408. doi:10.1016/j.jvs.2009.02.234
5. Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury - concepts and management. J Cardiothorac Surg. 2020; 15 (1): 62. Published 2020 Apr 19. doi:10.1186/s13019-020-01101-6
6. Hoornweg LL, Dinkelman MK, Goslings JC, et al. Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multicenter analysis of 28 cases in The Netherlands. J Vasc Surg. 2006; 43 (6): 1096-1102. doi:10.1016/j.jvs.2006.01.034
7. Demetriades D, Velmahos GC, Scalea TM, et al. Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study. J Trauma. 2009; 66 (4): 967-973. doi:10.1097/TA.0b013e31817dc483
8. Sandhu HK, Leonard SD, Perlick A, et al. Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries. J Vasc Surg. 2018; 67 (2): 389-398. doi:10.1016/j.jvs.2017.07.111
9. Demetriades D, Velmahos GC, Scalea TM, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma. 2008; 64 (3): 561-571. doi:10.1097/TA.0b013e3181641bb3
10. DuBose JJ, Leake SS, Brenner M, et al. Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study [published correction appears in J Trauma Acute Care Surg. 2015 Mar; 78 (3): 656]. J Trauma Acute Care Surg. 2015; 78 (2): 360-369. doi:10.1097/TA.0000000000000521
11. Chalvatzoulis E, Megalopoulos A, Trellopoulos G, et al. Endovascular repair of traumatic aortic transection. Interact Cardiovasc Thorac Surg. 2010; 11 (3): 238-242. doi:10.1510/icvts.2010.235473
12. Buket S, Yağdı T, Çıkrıkçıoğlu M, Durmaz İ. Aortanın Travmatik Lezyonları. In: Buket S, Yağdı T (Editors). Aort Cerrahisi. 2003 Edition. Tavaslı Matbaası 2003: 407-438.
13. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991 Nov; 5 (6): 491-9. doi: 10.1007/BF02015271. PMID: 1837729.
14. Azizzadeh A, Keyhani K, Miller CC 3rd, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg. 2009; 49 (6): 1403-1408. doi:10.1016/j.jvs.2009.02.234
15. von Oppell UO, Dunne TT, De Groot MK, Zilla P. Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg. 1994; 58 (2): 585-593. doi:10.1016/0003-4975 (94) 92270-5
16. Azizzadeh A, Charlton-Ouw KM, Chen Z, et al. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. J Vasc Surg. 2013; 57 (1): 108-115. doi:10.1016/j.jvs.2012.05.110
17. McBride CL, Dubose JJ, Miller CC 3rd, et al. Intentional left subclavian artery coverage during thoracic endovascular aortic repair for traumatic aortic injury. J Vasc Surg. 2015; 61 (1): 73-79. doi:10.1016/j.jvs.2014.05.099
18. Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury - concepts and management. J Cardiothorac Surg. 2020; 15 (1): 62. Published 2020 Apr 19. doi:10.1186/s13019-020-01101-6
19. Ergun O, Canyiğit M, Hıdıroğlu M, et al. Endovascular treatment for acute traumatic thoracic aortic transection. Ulus Travma Acil Cerrahi Derg. 2015; 21 (4): 285-290. doi:10.5505/tjtes.2015.21556
20. Sanioğlu S, Sahin S, Aydoğan H, Barutça H, Eren E. Akut travmatik aort transeksiyonunda endovasküler onarim: olgu sunumu [Endovascular repair for an acute traumatic aortic transection: a case report]. Ulus Travma Acil Cerrahi Derg. 2012; 18 (2): 178-180. doi:10.5505/tjtes.2012.45389