Initial presentation
A 59-year old man with history of a sports-associated polytrauma was admitted to our hospital. The initial whole-body computer tomography (CT)-scan showed an aortic lesion at the level of TH8 in addition to multiple rib fractures and a TH6-vertebral fracture. The aortic injury presented with the typical features of intramural hematoma with contained blood collection between the sub-intimal layer and the muscular and adventitial layers. The aortic tear also caused a pseudoaneurysm in the ostium of the TH8-intercostal artery with the following characteristics: a size of 11 × 7 × 16 mm and a small intimal defect of 1.4 × 1.8 mm (Figs. 2 and 3).
Because we were concerned regarding a potential endoleak type 2 through the intercostal artery into the defect after endograft placement and the risk of medullary ischaemia, we decided to treat the lesion through coil embolization.
Interventional procedure
After written informed consent by the patient, an elective intervention was performed under local anesthesia using a 4Fr right common femoral artery access.
A directed thoraco-lumbar (TH4-L2) aortogram was performed using a 4Fr straight graduated catheter (Angiodynamics Accu-Vu, Queensbury, NY, USA) (Fig. 3). Selective catheterization of the aortic tear at TH8 level was performed using a 4Fr SIM-1 catheter (Cordis, Miami Lakes, Florida, USA). Selective angiography confirmed communication of the cavity with the intercostal artery at the level of TH8. The spinal artery or anastomoses were not present between the TH8 intercostal artery and other vessels. We changed to a 4Fr C2 Cobra catheter (Cordis, Miami Lakes, Florida, USA) and using a 2,7Fr coaxial microcatheter system (Terumo Progreat, Tokyo, Japan) we selectively catheterized the corresponding intercostal artery TH8 via the aortic tear. First, a 10x320mm Hydrogel coated coil (Azur Microvention, Tustin, California, USA) was deployed in the intercostal artery to avoid future retrograde re-perfusion of the aortic lesion (back door embolization). Then, the pseudoaneurysm was filled with four 6x100mm IDC coils (Boston Scientific, Cork, Ireland). The coiling was challenging due to instability of the microcatheter, especially during the last phase of coil deployment, nevertheless, sufficient coil packing was achieved. The final angiogram showed complete occlusion of the pseudoaneurysm and no evidence of retrograde perfusion through the intercostal artery previously occluded (Fig. 2). No early complications were observed. The 4Fr sheath was removed, followed by manual compression. The total intervention time was 48 min from initial arterial access to last angiogram with a total radiation dose of 143,836 mGy/cm2.
Follow-up
During and after the procedure, vital signs and neurological signs were clinically monitored (paresthesia, temperature, power and sensation in the lower limbs). There was no clinical evidence of acute spinal ischaemia. The patient was sent to an observation unit for 24 h and was discharged from the hospital afterwards. After 3, 6, 12 and 21 months, the patient was followed with CT-Angiograms that showed no extension of the aortic tear (Fig. 3). The implanted coils remained in place and the aortic wall was completely normal without signs of aortic lesion reperfusion or complications (i.e. aortitis, aneurysm, dissection). During all this time the patient remained asymptomatic.