Endovascular Repair of an Asymptomatic Aortic Pseudoaneurysm after Penetrating Injury Donald G. Harris,1 Megan L. Brenner,2,3 Michelle Ho,3 Shahab Toursavadkohi,3 Michael P. Lilly,3 and Robert S. Crawford,3,4 Baltimore, Maryland
Penetrating injuries to the aorta usually result in immediate life-threatening hemorrhage. Because these lesions are typically either fatal or identified and controlled surgically, chronic pseudoaneurysms after penetrating aortic trauma are rare. Most of these patients present with rupture or local complications, and management before the endovascular era has historically been open repair. As such, there are limited data to guide the modern management of an asymptomatic, posttraumatic aortic pseudoaneurysm. Here, we describe a 54-year-old man who was diagnosed with an incidental, supraceliac aortic pseudoaneurysm 14 years after an abdominal stab wound. He underwent successful and uncomplicated endovascular repair.
Penetrating aortic injuries are infrequent but are associated with significant early mortality. Most patients present in shock1 but some have limited hemorrhage, typically due to pseudoaneurysm formation with effective tamponade of the injury.2 Historic autopsy data and contemporary case series suggest the natural history of traumatic aortic pseudoaneurysms is delayed onset of symptoms or rupture.2e8 Here, we describe the diagnosis and endovascular repair of an asymptomatic, traumatic aortic pseudoaneurysm in a patient 14 years after an abdominal stab wound.
1 Division of General Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD. 2 R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, University of Maryland, Baltimore, MD. 3 Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD. 4 Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, MD.
Correspondence to: Donald G. Harris, MD, Division of General Surgery, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1933.e15e1933.e18 http://dx.doi.org/10.1016/j.avsg.2014.06.077 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 22, 2014; manuscript accepted: June 19, 2014; published online: July 11, 2014.
CASE REPORT The patient is a 54-year-old man with chronic hepatitis C infection and hypertension who was stabbed with a knife in the upper abdomen 14 years prior. Per the patient’s history, he underwent exploratory laparotomy and although hemoperitoneum was noted, no definitive injuries were found. The patient recovered uneventfully and without sequelae. Six months before his current presentation, he had a diagnostic abdominal computed tomography (CT) to evaluate for cirrhotic changes secondary to chronic hepatitis. A supraceliac aortic aneurysm was incidentally diagnosed and he was referred for vascular surgery consultation. On physical examination, a well-healed midline laparotomy scar was noted. Otherwise, his abdominal and vascular exams were unremarkable. A current CT angiogram demonstrated a saccular pseudoaneurysm approximately 4 cm in diameter, arising from a mural defect on the anterior aspect of the distal descending thoracic aorta. The calcified wall extended inferiorly to within 1.5 cm of the celiac trunk. These findings were confirmed by contrast aortography (Fig. 1). This was felt to be a posttraumatic pseudoaneurysm based on the patient’s history of trauma. Importantly, the patient had no symptoms or signs such as fever, leukocytosis, positive blood cultures, or findings concerning endocarditis to implicate an infectious etiology. Given the patient’s young age and the risk for progressive enlargement leading to local complications or rupture,
1933.e15
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Annals of Vascular Surgery
Fig. 1. Preoperative imaging. (A) Axial CT demonstrating saccular aneurysm of the supraceliac aorta (arrow), with a calcific rim. (B) Right sagittal image. (C) Preoperative
diagnostic aortogram demonstrating contrast filling of the aneurysm neck (arrow). Note the short distance to the celiac trunk in images (B and C).
elective repair was recommended. Preoperative computerized aortic reconstruction was used to help with planning and device sizing. The patient was admitted for endovascular exclusion of the pseudoaneurysm. Under general anesthesia, the femoral arteries were exposed bilaterally to facilitate aortic and celiac catheterization. After heparinization, the left common femoral artery was punctured and a 0.035 Bentson guidewire (Cook, Bloomington, IN) passed into the descending thoracic aorta followed by exchange for a 5F Pinnacle sheath (Terumo, Somerset NJ). To enable additional access for cannulation of the celiac access, a double-puncture was performed on the left to place a 7F Pinnacle sheath, which was used to position a 5F pigtail catheter into the descending thoracic aorta. The right femoral artery was then punctured and a 0.035 Lunderquist (Cook) wire advanced into the aortic arch via a 5F Pinnacle sheath. An aortogram was performed via the pigtail catheter to define the pseudoaneurysm and the visceral branches. The initial left 5F sheath was exchanged for a 7F Flexor Ansel sheath (Cook), which was used to select and cannulate the celiac trunk. This was used as a marker for the distal endograft landing site and to maintain secure celiac access in case placement of a chimney prosthesis was required for device extension. To ensure wire purchase, the hepatic artery was catheterized with a 5F Cobra (Terumo) catheter and a Rosen wire advanced just distal to its tip (Fig. 2A). The right femoral sheath was removed and an arteriotomy made to pass a 30 58 mm Zenith endograft (Cook) oversized by 15% over the Lunderquist wire into the descending thoracic aorta. The device was deployed, but the proximal end prolapsed into the aneurysm sac, resulting in poor apposition and a type I endoleak. As such, a second 30 76-mm endograft was placed within the original device and extended proximally to optimize overlap and seal (Fig. 2B). A completion angiogram via the left pigtail catheter demonstrated exclusion of the pseudoaneurysm and
patency of the celiac trunk. The catheters were removed, and the femoral arteriotomy and punctures were repaired and the groins closed. The patient had a satisfactory recovery without device, access site, neurologic, or systemic complications. More than a year after repair, he is doing well and follow-up imaging demonstrated satisfactory pseudoaneurysm exclusion and no device complications (Fig. 2C).
DISCUSSION Aortic injury occurs in 90% of patients had associated injuries. As reviewed by Bechara-Zamudio et al.,8 16 of 22 (73%) injured patients who were later diagnosed with an aortic pseudoaneurysm underwent surgical exploration on initial presentation. In 63% of these cases, as with our patient, the pseudoaneurysm was not found intraoperatively.8 Aortic pseudoaneurysms diagnosed days to decades after penetrating injury have been described, all with symptoms or complications from the lesion.2e9 Most of these patients presented within 3 months of injury, while 4 cases with presentation delayed longer than 1 year have been reported.3e5,7 The differential diagnosis includes infectious aortitis, penetrating aortic ulcers, and true saccular aneurysms. Because management of each varies, such as the need for open surgical debridement and reconstruction in the setting of infectious aortitis, preoperative evaluation for infection or chronic cardiovascular disease is critical. Despite sustaining a transabdominal stab wound, this patient had no apparent associated trauma or
Vol. 28, No. 8, November 2014
Case reports 1933.e17
Fig. 2. Intra-and postoperative imaging. (A) Intraoperative right lateral aortogram with catheterization of the celiac trunk and hepatic artery. (B) Intraoperative left anterior oblique aortogram with deployment of endovascular
stent grafts. (C) 1-year postoperative CT angiogram with successful exclusion of the aneurysm (arrow) and no evidence of endoleak or other complication.
subsequent symptoms. To the best of our knowledge, this case is the first reported asymptomatic, incidentally diagnosed, traumatic pseudoaneurysm. Although asymptomatic, because this patient underwent laparotomy it may be classified as a missed aortic injury. With current practices of liberal imaging of trauma patients, similar lesions may be more likely to be detected acutely. Indeed, an increasing number of incidental aortic lesions have been reported after blunt trauma, most likely associated with the routine use of highly sensitive imaging techniques.10,11 As in this case, for lesions that either occurred before the current era of widespread use of CT in trauma or were missed by both surgical and radiographic exploration, diagnosis of incidental findings is becoming more common in general.12e14 As such, while delayed traumatic aortic pseudoaneurysms are likely to remain rare, more of these lesions may be detected at an earlier stage. Experience with blunt aortic injuries indicates minimal aortic injuries and appropriately selected small pseudoaneurysms can undergo initial nonoperative management, with blood pressure control and serial imaging to assess evolution of the lesion.11,15e17 Although the optimal surveillance of patients selected for definitive nonoperative management remains to be defined,17 imaging at 1, 6, and 12 months after injury or diagnosis, then annually thereafter if stable, has been proposed.16 However, consistent with prior reports and established guidelines, larger pseudoaneurysms, such as present in this case, should be considered for repair given the higher risk for rupture.16,18 Historically, open surgery has been the primary treatment for traumatic aortic pseudoaneurysms diagnosed more than a year after penetrating
injury.3e5,7 Although endovascular repair has been described for cases with shorter delays,6,8,9 and for late anastomotic pseudoaneurysm after aortic aneurysmorrhaphy,19 this report is the first to describe late endovascular repair for a traumatic pseudoaneurysm from penetrating injury. This pattern is biased by the rarity of the lesion, with many cases reported before widespread implementation of endovascular techniques,20 and by the advanced and clinically complicated presentation of most late pseudoaneurysms.3e5,7 With the wide adoption of endovascular techniques and their increasing use for traumatic and nontraumatic aortic emergencies,15,21,22 endovascular treatment will likely play a greater future role in managing delayed lesions. Similar to surveillance after endovascular aortic repairs in other settings, long-term clinical and radiographic follow-up is required for these patients. In conclusion, delayed aortic pseudoaneurysms after penetrating injury are rare. Because many of them are missed during initial exploratory laparotomy, a high index of suspicion is required for patients with a history of trauma and an aortic lesion. Early and interval imaging are recommended as elective endovascular repair is possible with minimal complications. REFERENCES 1. Demetriades D, Theodorou D, Murray J, et al. Mortality and prognostic factors in penetrating injuries of the aorta. J Trauma 1996;40:761e3. 2. Parmley LF, Mattingly TW, Manion WC. Penetrating wounds of the heart and aorta. Circulation 1958;17:953e73. 3. Queiroz AB, da Silva ES, Aun R, et al. Abdominal aortic pseudoaneurysm diagnosed 42 years after abdominal gunshot wound. Clinics 2011;66:1113e4.
1933.e18 Case reports
4. Chase CW, Layman TS, Barker DE, Clements JB. Traumatic abdominal aortic pseudoaneurysm causing biliary obstruction: a case report and review of the literature. J Vasc Surg 1997;25:936e40. 5. Miller JS, Wall MJ, Mattox KL. Ruptured aortic pseudoaneurysm 28 years after gunshot wound: case report and review of the literature. J Trauma 1998;44:214e6. 6. Tucker S Jr, Rowe VL, Rao R, et al. Treatment options for traumatic pseudoaneurysms of the paravisceral abdominal aorta. Ann Vasc Surg 2005;19:613e8. 7. Cherry JK, Bennett DE. False aneurysm of the aorta following penetrating trauma: report of a case with secondary infection and delayed rupture. Arch Surg 1966;93:404. 8. Bechara-Zamudio L, Olive G, Barone H, et al. Traumatic abdominal aortic pseudoaneurysm treated with balloonexpandable bifurcated endoprosthesis. J Vasc Surg 1998;28:345e8. 9. White R, Donayre C, Walot I, et al. Endograft repair of an aortic pseudoaneurysm following gunshot wound injury: impact of imaging on diagnosis and planning of intervention. J Endovasc Surg 1997;4:344e51. 10. Malhotra AK, Fabian TC, Croce MA, et al. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. J Trauma 2001;51:1042. 11. Harris DG, Drucker CB, Brenner ML, et al. Patterns and management of blunt abdominal aortic injury. Ann Vasc Surg 2013;27:1074e80. 12. Burt JR, Iribarren C, Fair JM, et al. Incidental findings on cardiac multidetector row computed tomography among healthy older adults: prevalence and clinical correlates. Arch Intern Med 2008;168:756. 13. Jacobs PC, Willem PT, Grobbee DE, van der Graaf Y. Prevalence of incidental findings in computed tomographic
Annals of Vascular Surgery
14.
15.
16.
17.
18.
19.
20.
21.
22.
screening of the chest: a systematic review. J Comput Assist Tomogr 2008;32:214e21. Paluska TR, Sise MJ, Sack DI, et al. Incidental CT findings in trauma patients: incidence and implications for care of the injured. J Trauma 2007;62:157e61. Shalhub S, Starnes BW, Tran NT, et al. A single institution’s experience with blunt abdominal aortic injury and a contemporary review of the literature. J Vasc Surg 2012. Rabin J, DuBose J, Sliker CW, et al. Parameters for successful nonoperative management of traumatic aortic injury. J Thorac Cardiovasc Surg 2014;147:143e50. Gunn ML, Lehnert BE, Lungren RS, et al. Minimal aortic injury of the thoracic aorta: imaging appearances and outcome. Emerg Radiol 2014;21:1e7. 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;53:187e92. Gargiulo M, Gallitto E, Freyrie A, Stella A. Fenestrated endograft for recurrent paravisceral aortic pseudoaneurysm after thoracoabdominal aortic aneurysm open repair. J Vasc Surg 2013;58:790e3. Raghavendran K, Singh G, Arnoldo B, Flynn WJ. Delayed development of infrarenal abdominal aortic pseudoaneurysm after blunt trauma: a case report and review of the literature. J Trauma 2004;57:1111e4. 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;64:561e71. Giles KA, Pomposelli FB, Hamdan AD, et al. Comparison of open and endovascular repair of ruptured abdominal aortic aneurysms from the ACS-NSQIP 2005e07. J Endovasc Ther 2009;16:365e72.
Penetrating injuries to the aorta usually result in immediate life-threatening hemorrhage. Because these lesions are typically either fatal or identified and controlled surgically, chronic pseudoaneurysms after penetrating aortic trauma are rare. Most of these patients present with rupture or local complications, and management before the endovascular era has historically been open repair. As such, there are limited data to guide the modern management of an asymptomatic, posttraumatic aortic pseudoaneurysm. Here, we describe a 54-year-old man who was diagnosed with an incidental, supraceliac aortic pseudoaneurysm 14 years after an abdominal stab wound. He underwent successful and uncomplicated endovascular repair.
Penetrating aortic injuries are infrequent but are associated with significant early mortality. Most patients present in shock1 but some have limited hemorrhage, typically due to pseudoaneurysm formation with effective tamponade of the injury.2 Historic autopsy data and contemporary case series suggest the natural history of traumatic aortic pseudoaneurysms is delayed onset of symptoms or rupture.2e8 Here, we describe the diagnosis and endovascular repair of an asymptomatic, traumatic aortic pseudoaneurysm in a patient 14 years after an abdominal stab wound.
1 Division of General Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD. 2 R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, University of Maryland, Baltimore, MD. 3 Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD. 4 Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, MD.
Correspondence to: Donald G. Harris, MD, Division of General Surgery, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1933.e15e1933.e18 http://dx.doi.org/10.1016/j.avsg.2014.06.077 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 22, 2014; manuscript accepted: June 19, 2014; published online: July 11, 2014.
CASE REPORT The patient is a 54-year-old man with chronic hepatitis C infection and hypertension who was stabbed with a knife in the upper abdomen 14 years prior. Per the patient’s history, he underwent exploratory laparotomy and although hemoperitoneum was noted, no definitive injuries were found. The patient recovered uneventfully and without sequelae. Six months before his current presentation, he had a diagnostic abdominal computed tomography (CT) to evaluate for cirrhotic changes secondary to chronic hepatitis. A supraceliac aortic aneurysm was incidentally diagnosed and he was referred for vascular surgery consultation. On physical examination, a well-healed midline laparotomy scar was noted. Otherwise, his abdominal and vascular exams were unremarkable. A current CT angiogram demonstrated a saccular pseudoaneurysm approximately 4 cm in diameter, arising from a mural defect on the anterior aspect of the distal descending thoracic aorta. The calcified wall extended inferiorly to within 1.5 cm of the celiac trunk. These findings were confirmed by contrast aortography (Fig. 1). This was felt to be a posttraumatic pseudoaneurysm based on the patient’s history of trauma. Importantly, the patient had no symptoms or signs such as fever, leukocytosis, positive blood cultures, or findings concerning endocarditis to implicate an infectious etiology. Given the patient’s young age and the risk for progressive enlargement leading to local complications or rupture,
1933.e15
1933.e16 Case reports
Annals of Vascular Surgery
Fig. 1. Preoperative imaging. (A) Axial CT demonstrating saccular aneurysm of the supraceliac aorta (arrow), with a calcific rim. (B) Right sagittal image. (C) Preoperative
diagnostic aortogram demonstrating contrast filling of the aneurysm neck (arrow). Note the short distance to the celiac trunk in images (B and C).
elective repair was recommended. Preoperative computerized aortic reconstruction was used to help with planning and device sizing. The patient was admitted for endovascular exclusion of the pseudoaneurysm. Under general anesthesia, the femoral arteries were exposed bilaterally to facilitate aortic and celiac catheterization. After heparinization, the left common femoral artery was punctured and a 0.035 Bentson guidewire (Cook, Bloomington, IN) passed into the descending thoracic aorta followed by exchange for a 5F Pinnacle sheath (Terumo, Somerset NJ). To enable additional access for cannulation of the celiac access, a double-puncture was performed on the left to place a 7F Pinnacle sheath, which was used to position a 5F pigtail catheter into the descending thoracic aorta. The right femoral artery was then punctured and a 0.035 Lunderquist (Cook) wire advanced into the aortic arch via a 5F Pinnacle sheath. An aortogram was performed via the pigtail catheter to define the pseudoaneurysm and the visceral branches. The initial left 5F sheath was exchanged for a 7F Flexor Ansel sheath (Cook), which was used to select and cannulate the celiac trunk. This was used as a marker for the distal endograft landing site and to maintain secure celiac access in case placement of a chimney prosthesis was required for device extension. To ensure wire purchase, the hepatic artery was catheterized with a 5F Cobra (Terumo) catheter and a Rosen wire advanced just distal to its tip (Fig. 2A). The right femoral sheath was removed and an arteriotomy made to pass a 30 58 mm Zenith endograft (Cook) oversized by 15% over the Lunderquist wire into the descending thoracic aorta. The device was deployed, but the proximal end prolapsed into the aneurysm sac, resulting in poor apposition and a type I endoleak. As such, a second 30 76-mm endograft was placed within the original device and extended proximally to optimize overlap and seal (Fig. 2B). A completion angiogram via the left pigtail catheter demonstrated exclusion of the pseudoaneurysm and
patency of the celiac trunk. The catheters were removed, and the femoral arteriotomy and punctures were repaired and the groins closed. The patient had a satisfactory recovery without device, access site, neurologic, or systemic complications. More than a year after repair, he is doing well and follow-up imaging demonstrated satisfactory pseudoaneurysm exclusion and no device complications (Fig. 2C).
DISCUSSION Aortic injury occurs in 90% of patients had associated injuries. As reviewed by Bechara-Zamudio et al.,8 16 of 22 (73%) injured patients who were later diagnosed with an aortic pseudoaneurysm underwent surgical exploration on initial presentation. In 63% of these cases, as with our patient, the pseudoaneurysm was not found intraoperatively.8 Aortic pseudoaneurysms diagnosed days to decades after penetrating injury have been described, all with symptoms or complications from the lesion.2e9 Most of these patients presented within 3 months of injury, while 4 cases with presentation delayed longer than 1 year have been reported.3e5,7 The differential diagnosis includes infectious aortitis, penetrating aortic ulcers, and true saccular aneurysms. Because management of each varies, such as the need for open surgical debridement and reconstruction in the setting of infectious aortitis, preoperative evaluation for infection or chronic cardiovascular disease is critical. Despite sustaining a transabdominal stab wound, this patient had no apparent associated trauma or
Vol. 28, No. 8, November 2014
Case reports 1933.e17
Fig. 2. Intra-and postoperative imaging. (A) Intraoperative right lateral aortogram with catheterization of the celiac trunk and hepatic artery. (B) Intraoperative left anterior oblique aortogram with deployment of endovascular
stent grafts. (C) 1-year postoperative CT angiogram with successful exclusion of the aneurysm (arrow) and no evidence of endoleak or other complication.
subsequent symptoms. To the best of our knowledge, this case is the first reported asymptomatic, incidentally diagnosed, traumatic pseudoaneurysm. Although asymptomatic, because this patient underwent laparotomy it may be classified as a missed aortic injury. With current practices of liberal imaging of trauma patients, similar lesions may be more likely to be detected acutely. Indeed, an increasing number of incidental aortic lesions have been reported after blunt trauma, most likely associated with the routine use of highly sensitive imaging techniques.10,11 As in this case, for lesions that either occurred before the current era of widespread use of CT in trauma or were missed by both surgical and radiographic exploration, diagnosis of incidental findings is becoming more common in general.12e14 As such, while delayed traumatic aortic pseudoaneurysms are likely to remain rare, more of these lesions may be detected at an earlier stage. Experience with blunt aortic injuries indicates minimal aortic injuries and appropriately selected small pseudoaneurysms can undergo initial nonoperative management, with blood pressure control and serial imaging to assess evolution of the lesion.11,15e17 Although the optimal surveillance of patients selected for definitive nonoperative management remains to be defined,17 imaging at 1, 6, and 12 months after injury or diagnosis, then annually thereafter if stable, has been proposed.16 However, consistent with prior reports and established guidelines, larger pseudoaneurysms, such as present in this case, should be considered for repair given the higher risk for rupture.16,18 Historically, open surgery has been the primary treatment for traumatic aortic pseudoaneurysms diagnosed more than a year after penetrating
injury.3e5,7 Although endovascular repair has been described for cases with shorter delays,6,8,9 and for late anastomotic pseudoaneurysm after aortic aneurysmorrhaphy,19 this report is the first to describe late endovascular repair for a traumatic pseudoaneurysm from penetrating injury. This pattern is biased by the rarity of the lesion, with many cases reported before widespread implementation of endovascular techniques,20 and by the advanced and clinically complicated presentation of most late pseudoaneurysms.3e5,7 With the wide adoption of endovascular techniques and their increasing use for traumatic and nontraumatic aortic emergencies,15,21,22 endovascular treatment will likely play a greater future role in managing delayed lesions. Similar to surveillance after endovascular aortic repairs in other settings, long-term clinical and radiographic follow-up is required for these patients. In conclusion, delayed aortic pseudoaneurysms after penetrating injury are rare. Because many of them are missed during initial exploratory laparotomy, a high index of suspicion is required for patients with a history of trauma and an aortic lesion. Early and interval imaging are recommended as elective endovascular repair is possible with minimal complications. REFERENCES 1. Demetriades D, Theodorou D, Murray J, et al. Mortality and prognostic factors in penetrating injuries of the aorta. J Trauma 1996;40:761e3. 2. Parmley LF, Mattingly TW, Manion WC. Penetrating wounds of the heart and aorta. Circulation 1958;17:953e73. 3. Queiroz AB, da Silva ES, Aun R, et al. Abdominal aortic pseudoaneurysm diagnosed 42 years after abdominal gunshot wound. Clinics 2011;66:1113e4.
1933.e18 Case reports
4. Chase CW, Layman TS, Barker DE, Clements JB. Traumatic abdominal aortic pseudoaneurysm causing biliary obstruction: a case report and review of the literature. J Vasc Surg 1997;25:936e40. 5. Miller JS, Wall MJ, Mattox KL. Ruptured aortic pseudoaneurysm 28 years after gunshot wound: case report and review of the literature. J Trauma 1998;44:214e6. 6. Tucker S Jr, Rowe VL, Rao R, et al. Treatment options for traumatic pseudoaneurysms of the paravisceral abdominal aorta. Ann Vasc Surg 2005;19:613e8. 7. Cherry JK, Bennett DE. False aneurysm of the aorta following penetrating trauma: report of a case with secondary infection and delayed rupture. Arch Surg 1966;93:404. 8. Bechara-Zamudio L, Olive G, Barone H, et al. Traumatic abdominal aortic pseudoaneurysm treated with balloonexpandable bifurcated endoprosthesis. J Vasc Surg 1998;28:345e8. 9. White R, Donayre C, Walot I, et al. Endograft repair of an aortic pseudoaneurysm following gunshot wound injury: impact of imaging on diagnosis and planning of intervention. J Endovasc Surg 1997;4:344e51. 10. Malhotra AK, Fabian TC, Croce MA, et al. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. J Trauma 2001;51:1042. 11. Harris DG, Drucker CB, Brenner ML, et al. Patterns and management of blunt abdominal aortic injury. Ann Vasc Surg 2013;27:1074e80. 12. Burt JR, Iribarren C, Fair JM, et al. Incidental findings on cardiac multidetector row computed tomography among healthy older adults: prevalence and clinical correlates. Arch Intern Med 2008;168:756. 13. Jacobs PC, Willem PT, Grobbee DE, van der Graaf Y. Prevalence of incidental findings in computed tomographic
Annals of Vascular Surgery
14.
15.
16.
17.
18.
19.
20.
21.
22.
screening of the chest: a systematic review. J Comput Assist Tomogr 2008;32:214e21. Paluska TR, Sise MJ, Sack DI, et al. Incidental CT findings in trauma patients: incidence and implications for care of the injured. J Trauma 2007;62:157e61. Shalhub S, Starnes BW, Tran NT, et al. A single institution’s experience with blunt abdominal aortic injury and a contemporary review of the literature. J Vasc Surg 2012. Rabin J, DuBose J, Sliker CW, et al. Parameters for successful nonoperative management of traumatic aortic injury. J Thorac Cardiovasc Surg 2014;147:143e50. Gunn ML, Lehnert BE, Lungren RS, et al. Minimal aortic injury of the thoracic aorta: imaging appearances and outcome. Emerg Radiol 2014;21:1e7. 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;53:187e92. Gargiulo M, Gallitto E, Freyrie A, Stella A. Fenestrated endograft for recurrent paravisceral aortic pseudoaneurysm after thoracoabdominal aortic aneurysm open repair. J Vasc Surg 2013;58:790e3. Raghavendran K, Singh G, Arnoldo B, Flynn WJ. Delayed development of infrarenal abdominal aortic pseudoaneurysm after blunt trauma: a case report and review of the literature. J Trauma 2004;57:1111e4. 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;64:561e71. Giles KA, Pomposelli FB, Hamdan AD, et al. Comparison of open and endovascular repair of ruptured abdominal aortic aneurysms from the ACS-NSQIP 2005e07. J Endovasc Ther 2009;16:365e72.
