Stenting in Trauma
Grant Christey
Outline
Stenting in Trauma
Injury 2005
Grant Christey
Today
Vascular stenting
Thoracic aorta
Carotids
Subclavian arteries
The rest
Non-vascular stenting
The Future
Progress
First proposed by Dotter in 1969
Reported in humans in 1983
To date..
Most vital vessels have been stented
Covered stents developed
Open arteriotomy or percutaneous routes
Technical skills, stent technology and delivery systems continue to evolve
Aims of Vascular stenting
Occlude injury to walls of vital arteries without compromising flow
Exclude pseudo-aneurysms or fistulas
Prevent backflow of embolic materials into vital arteries after branch embolisation
Advantages
Endovascular approach is from a distant non-injured site
Avoids morbidity from surgical access and difficult surgical dissection and repair in injured tissue
Most beneficial in the critically ill where anaesthesia or vascular reconstruction may be hazardous
Useful for delayed diagnosis or rupture if surgical access is limited (hostile abdomen)
Advances
Reduced patient transport, time to repair, and time to haemostasis.
Effective and minimally invasive.
Commercial stents replace ‘homemade” ones.
Young trauma victims have good vessels
We are getting better at it.
Pic of covered stent
Short term outcomes are promising
Arterial stenting - multiple series axillary/subclavian/aorta/iliac/femoral
[Rich NM et al. Vascular Trauma 2nd ed 2004]
Technical success 94-100%
Complication rate 0-7%
Primary patency 85-100%
Mean follow-up 10-18 months
But….
Operator dependent and resource intensive
Rare complications include rupture, dissection, immediate or late occlusion
Lack of long term follow-up
Still need to operate if unstable, multi-traumatised, or wounds contaminated.
Thoracic aortic rupture
Pre-hospital death rate of 80-90%.
Usually involves injury at the level of the isthmus causing aortic transection with pseudo-aneurysm
Standard treatment is open repair
But, 8-33% mortality and 2-26% paraplegia rates
(Jahromi et al. J Vasc Surg. 2001;34:1029-34)
Stenting is emerging as the primary method to treat blunt aortic injuries
Thoracic aortic stents
Avoid the morbidity of open repair, bypass, heparinisation and one-lung anaesthesia
Good for pseudo-aneurysms and A-V fistulas, and useful in high-risk multi-trauma or co-morbid patients.
Multiple small series have shown impressive results
Commercial stents are now available
Successful stenting requires
Adequate vascular access via iliac artery and aorta
Minimal aortic tortuosity
lesion >15 cm above celiac artery and >5mm from left subclavian artery
Therasse et al. Radiographics 2005;25:157-173
Complications
( 9 stent studies 1996-2003)
Dunham et al. J Trauma 2004;56(6):1173-78
Stent Open
Technical success 98.5% 75-95%
Overall mortality 5.9% 5-28%
Paraplegia 0% 9-26%
Endoleaks 7.4%
Graft-related death rate 1.5%
But….
Graft durability is unknown over a lifetime of dynamic motion in a thoracic aorta.
Grafts can migrate.
5-20% endoleak rate in proximal lesions.
Long term effects of covering subclavian origin and vertebral are unknown.
No large trials have been done validating the technique. (The current AAST Multicentre Trial may solve this.)
Carotid stenting is controversial
Coldwell et al. J Trauma. 2000 Mar;48(3):470-2
27 pts with extracranial ICA injury
0% stroke rate at 2.5 yrs
Clothren et al. Arch Surg. 2005 May;140(5):480-5
46 pts with extracranial ICA injury
23 pts got stents for pseudoaneurysms after 7-10 days of anticoagulation
45% reocclusion rate
10% stroke rate
Joo et al. J Trauma 2005 June; 58(6):1159
6 pts stented for intra- and extra-cranial ICA injuries
no vascular or neurologic complications at 20 months
Cohen et al. Stroke. April 2005;36(4):45-7
10 pts stented ICA injury and high stroke risk (cerebral hypoperfusion or failed anticoagulation)
mean dissection stenosis 69% -> 8%
no neurologic complications at 16 months
ICA Injury
Penetrating
Operate if hard signs present, or injury is accessible
Blunt
Standard treatment is anticoagulation
Other options..
(a) Accessible to surgeon (below C2):
Operative repair or temporary balloon occlusion then repair.
(b) Inaccessible:
Embolisation, stenting or combinations.
Carotid pics
Joo et al Fig2
Carotid Stenting Summary
Indications for carotid stenting in trauma are unclear
Useful in inaccessible lesions, esp at the skull base
Medium term results encouraging but no long term outcome studies to date
Subclavian artery stent
A wave of vascular stents
Axillary artery
Papaconstantinou et al. J Trauma 2004;57:180-83
Axillary vein
Kumar J. Vasc Surg Dec 2004;40(6):1243-4
Subclavian artery
Xenos et al. J Vasc SurgSep 2003 38(3):451-4
Subclavian vein
Jeroukhimov et al. J Trauma 2004;57:1329-30
Renal artery
Inoue et al. J Urol. 2004; 171:347-8
IVC
De Naeyer et al. J Vasc surg 2005 Mar;41(3):552-4
More vascular stents
Cervicothoracic arteriovenous fistulas
DuTiot et al. BJS. Dec 2003 90(12):1516-21
Brachial artery
Maynar et al. J Trauma 2004; 56:1336-41
Iliac Arteries
Shah et al. J Trauma 2003;55:383-5
Bilateral iliac occlusion
Sternbergh et al. J Vasc Surg. Sept 2003;38(3):589-92
Iliac veins
Kataoka et al. J Trauma 2005 Apr; 58(4):704-8
SMA
Appel et al. J Vasc Intervent. Radiol. 2003;14:917-22
Non-vascular stenting
Ureters
Commonly used. Mandatory adjunct to operative and non-operative treatment
Pancreas
Early open surgery is standard.
Stents useful for fistulas. Beware late strictures.
Emerging primary role in children
Canty et al J Trauma 2001;50:1001-7
Biliary
Surgery standard if extrahepatic
Stents useful if intrahepatic
Nathan et al. Surg Laparosc Percut Tech.Oct 2003;13(5):350-2
D’amours et al. J Trauma 2001;51:159-61
Larynx
Soft, sutured stents for comminuted fractures and mucosal damage. Remove 2-3/52
Hwang SY et al. J Laryngol Otol. 2004 May;118(5):325-8.
Bronchus
Early surgery is best. Consider stents for delayed diagnoses.
Sim et al. Sing Med J 1999; 40(6)
The Future
Exciting and expanding field
Improvement in techniques, imaging and stent technology and delivery systems
Success requires combined skills of surgeons and interventionists
New systems and protocols will develop as the data matures
The Last Word
“The long-term consequences of endovascular stents in trauma are not yet defined”
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Ministry of Health
