Trauma patients were successfully treated with a minimally invasive technique without open chest surgery
Surgeons at the University of Maryland Medical Center are using an innovative approach to save the lives of trauma patients who have a torn aorta, a life-threatening injury that can occur after a high-speed car crash. A tear in the aorta, which is the body’s main artery, is a life-threatening situation. The surgeons have successfully repaired this type of injury, called an aortic transection, in more than 20 patients at the R Adams Cowley Shock Trauma Center, without making any chest incision, using a minimally invasive approach called an endovascular repair.
Their experience using this technique is published in the March 2007 issue of the Journal of Vascular Surgery, in which the first 20 cases are described. It is the largest published number of endovascular aortic repairs in trauma patients at a single center in the world.
“This endoscopic repair probably is the most significant advance in the treatment of aortic trauma in the last 50 years, because many trauma patients have other serious injuries that make the traditional open surgery to repair the aorta extremely risky,” says David G. Neschis, M.D., a vascular surgeon at the University of Maryland Medical Center and the lead author of the article. The risks of open surgery in these patients, he says, include paralysis and death.
“The minimally invasive technique to repair traumatic aortic injuries appears to be very safe and effective, giving us a good method to treat patients who are badly injured and too unstable for the traditional surgical repair,” adds Dr. Neschis, who is also an associate professor of surgery at the University of Maryland School of Medicine.
To perform an endovascular repair, surgeons first insert a catheter in the top of the leg. Using X-ray guidance, they feed the catheter up through the blood vessels and into the aorta. The catheter contains a tube-shaped device called an endograft, which is opened inside the injured portion of the aorta. The device creates a new lining for the aorta. It covers the injured area, protecting it, while also allowing blood to flow through it normally.
“Using a minimally invasive approach for cases like these is remarkable and can be a life-saving option for trauma patients,” explains Thomas M. Scalea, M.D., physician-in-chief at the R Adams Cowley Shock Trauma Center and professor of surgery and director of the Program in Trauma at the University of Maryland School of Medicine.
In their Journal of Vascular Surgery article, the physicians report on the first 20 trauma patients who had the minimally invasive repair, beginning in 2005. Four of the patients subsequently died from other injuries not related to a torn aorta, while the other 16 survived. To date, the University of Maryland surgical team has performed endovascular aorta repair on seven more trauma patients, all of whom survived but one needed a conversion to the open operation to repair the aorta.
Prior to using the minimally invasive repair technique for trauma patients, Dr. Neschis and the team of vascular surgeons at the University of Maryland Medical Center had years of experience using the endovascular procedure for elective patients—those who had learned that their aorta was at risk of rupturing due to an aneurysm and needed to have it repaired.
With the older, traditional method to repair aortic transection, surgeons would sew in a graft after making a large incision, cutting open the chest and clamping the aorta. In that procedure, the patient also needed to go on a heart-lung bypass machine.
“We knew from our experience that we could fix the torn aorta with a graft. The difference in these cases was in the delivery. By going through the bloodstream, we had a minimally invasive procedure with virtually no blood loss. We also cut down on operating time and dramatically reduced the risks for these trauma patients. The recovery time is also much quicker,” says Bartley P. Griffith, M.D., chief of cardiac surgery at the University of Maryland Medical Center, and professor and head of the Division of Cardiac Surgery at the University of Maryland School of Medicine.
Each year, approximately 8,000 people have aortic injuries due to vehicle-related trauma. As with anyone who receives an endograft, these patients will need frequent follow up screenings, including CT scans, to be sure the endografts are functioning well.
One of those patients is Sam Einsidler, 18. On September 20, 2006, as he was driving a mile away from his home in West Friendship, Maryland, an animal dashed out in front of his car. He swerved to miss it and ran into a tree. He was flown to the Shock Trauma Center, which is part of the University of Maryland Medical Center, with multiple serious injuries, including a torn aorta.
Sam’s mother, Terri, says, “We were very fortunate because we live near such an excellent trauma center and Dr. Neschis knew how to perform this procedure to repair Sam’s aorta, which helped save his life.” Sam also had a broken femur and a head injury. After three weeks at Shock Trauma and months of rehabilitation, his prognosis is good. He has made significant progress and hopes to return to college in the fall.
Aortic transection can occur after a high-speed car crash because when a person traveling a high rate of speed suddenly stops, part of the aorta stays in place while another part continues to move. That stress tears the artery. In many cases, this rupture can be fatal. For those who initially survive, the damaged aorta almost always needs to be repaired.
“The endovascular approach can be a life-saving option for trauma patients whose other injuries preclude them from having the surgery,” says Dr. Scalea. “Because the procedure does not involve a large incision, recovery is quicker, which can be very beneficial for a trauma patient who has other serious injuries.”
Adds Dr. Neschis, “Our experience with the endograft and our expertise in trauma, cardiac surgery and vascular surgery put the University of Maryland Medical Center in a unique position to use this minimally invasive approach to treat aortic transection. We also have a specially designed operating room with the most modern imaging equipment needed for the endograft procedure.”
“All of us are looking to make things better for our patients,” says Dr. Griffith. “This less invasive approach to fixing aortic transection can be seen as a major leap forward to accomplishing that goal.”
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