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Open versus endovascular repair for patients with acute traumatic rupture of the thoracic aorta

Ludovic Canaud, Pierre Alric, Pascal Branchereau, Frédéric Joyeux, Kheira Hireche, Jean-Philippe Berthet, Charles Marty-Ané
Journal of Thoracic and Cardiovascular Surgery 2011, 142 (5): 1032-7
21397264

OBJECTIVE: The study objective was to compare the outcome between open and endovascular repair of acute traumatic rupture of the thoracic aorta.

METHODS: Seventy-five patients (mean age 38.6 ± 10.7 years) with an acute traumatic aortic rupture were referred to the Arnaud de Villeneuve Hospital between January 1990 and January 2010. Between January 1990 and December 2000, 35 patients (33 men, mean age 35.8 ± 11.3 years) underwent surgical repair using cardiopulmonary bypass. From January 2001, an endovascular approach was deliberately chosen; 40 patients (30 male, mean age 41 ± 10.1 years) underwent endovascular repair. The 2 groups were statistically comparable.

RESULTS: The overall mortality rates for the surgical and endovascular groups were 11.4% (intraoperative mortality: 8.5%) and 2.5% (intraoperative mortality: 0%), respectively. The mortality rates related to aortic repair for the surgical and endovascular groups were 11.4% and 0%, respectively. In the surgical group, the morbidity rate was 14.2%: 4 cases of recurrent nerve palsy and 1 case of false anastomotic aneurysm were diagnosed at 52 months. In the endovascular group, the morbidity rate was 20%: 3 cases of intraoperative inadvertent coverage of supra-aortic trunks (requiring a secondary procedure in 2 cases after 1 and 2 years to revascularize the supra-aortic trunks), 1 proximal type I endoleak (requiring deployment of a second stent-graft at day 2), 2 stent-graft collapses in the first postoperative month (treated by open repair and explantation in 1 case and by the deployment of a second stent-graft in 1 case), 1 vertebrobasilar insufficiency after left subclavian artery coverage, and 1 intraoperative iliac rupture (surgically repaired). No cases of paraplegia or stroke were observed. The median follow-up was 7.7 (range, 0.4-15) years.

CONCLUSIONS: Compared with open repair, endovascular repair of traumatic thoracic aortic rupture is associated with a lower death rate but failed to reach statistical significance, most likely because of underpowering. These results prompt us to consider endovascular repair as the first-line therapy for acute traumatic rupture of the thoracic aorta, except in some rare but challenging anatomic situations. New stent-graft designs, sizes, and deployment systems could improve the results of endovascular repair in these indications.

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