Abstract

Thoracic aortic transection is a high mortality event which usually occurs after motor vehicle accidents and is caused by separation of the aortic layers. In this article, we present a 33-year-old, 8 weeks and 5 days pregnant by in vitro fertilization, multi-trauma patient with thoracic aortic transection after a motor vehicle accident. The patient with a complete transection distal to the subclavian artery was successfully treated with thoracic endovascular aortic repair method under general anesthesia, taking all necessary precautions. The patient had a healthy delivery with no problems in follow-up visits. Not one, but two lives were saved with thoracic endovascular aortic repair. In conclusion, this report emphasizes that thoracic endovascular aortic repair is a fast and safe critical treatment method in the treatment of life-threatening aortic transections.

Traumatic thoracic aortic injuries account for onethird of motor vehicle accident deaths and are the second most common cause of trauma-related death. Between 80 and 85% of patients die before reaching the hospital and 50% of those who reach the hospital die within 24 h.[1] Since these patients usually have multitrauma, there are no clinical findings specific to aortic injury, mostly retrosternal and interscapular persistent pain. Survival of patients with traumatic aortic injury depends on early diagnosis and prompt and effective treatment.[2] Stent repair of the damaged portion of the thoracic aorta, namely thoracic endovascular aortic repair (TEVAR), has recently become the current treatment of choice. The effect of radiation exposure during pregnancy depends on the gestational age of the fetus. Between two and seven weeks of gestation is the most radiation-sensitive period for the fetus. Fetal radiation exposure from angiography and fluoroscopy should only be performed in clinical emergencies.[3]

In this article, we present a case of thoracic aortic transection after a car accident who was 8 weeks and 5 days pregnant by in vitro fertilization and was successfully treated with TEVAR.

Case Presentation

A 33-year-old female patient who was two months pregnant with no previous medical problems was transferred to the Emergency Department (ED) after a severe vehicular traffic accident. On physical examination, subarachnoid hemorrhage in the left frontal region, right inferior and superior pubic ramus fracture, left inferior pubic ramus fracture, right 1^st and 6^th, left 3^rd, 4^th, 5^th, and 6^th rib fractures were detected. There was no abdominal pathology. No effusion or mediastinal enlargement was observed on chest radiography. Laboratory parameters showed no abnormal values. Treatment was started in the ED. The next day, the patient had confusion, hypotension and severe retrosternal pain. Thoracic computed tomography (CT) revealed a near complete transection of the distal left subclavian artery and the patient was rapidly transferred to our clinic (Figure 1a, b). On admission, the patient had confusion, right-left arm blood pressure difference, hypotension, and severe back pain. The patient was consulted with the Obstetrics and Gynecology Department for the condition of the baby. The patient's beta-human chorionic gonadotropin (b-hCG) value was determined as 26,400 mlU/mL. Approximately 14 h after the accident, examination and obstetric ultrasound performed by the gynecologist revealed that the baby was 8 weeks and 7 days, the fetal heart rate was 156/min and the amniotic fluid was normal. Since the patient required emergency intervention, abdominal protection with a lead vest and minimal doses of radiation and contrast media were recommended during fluoroscopy.

Figure 1. (a) Sagittal CT image of near complete transection. (b) Axial CT image of transection. CT: Computed tomography.

Since systemic heparin was to be administered to the patient during the procedure, the opinion of the Neurosurgery Department was requested for the presence of subarachnoid hemorrhage. The subarachnoid hemorrhage was minimal and limited and there would be no harm in administering heparin 5,000 U. The risks of the procedure, particularly for the infant, were explained to the patient and her relatives. Written informed consent was obtained from the patient.

After the necessary measurements were made on CT, the patient was quickly taken to the angiography unit for the TEVAR procedure. Abdominal protection was performed with a lead vest and barrier to protect the baby from radiation effects. Under general anesthesia, the right femoral artery was prepared as the access route and a pigtail catheter was inserted percutaneously from the left femoral artery for imaging. Hypotension was avoided as much as possible with volume replacement considering the condition of the baby and systolic blood pressure was maintained at 110 to 120 mmHg.

A 30×100 mm Valiant™ thoracic stent graft (Medtronic Inc., MN, USA) was successfully placed to close the transection. To determine the location of the graft and to check after the graft was opened, a total of two shots were taken without using magnification and keeping the tube as far away as possible. A total of 55 mL of iodinated contrast material was used during the procedure and the procedure was completed with a total radiation rate of 113.42 mGy. Since the transection started approximately 5 cm distal to the left subclavian artery, the left subclavian artery was not closed. The patient was extubated and taken to intensive care unit. Postoperative obstetric controls performed by the Obstetrics and Gynecology Department showed that the baby was healthy. The patient was discharged after the recovery period and CT scan performed at one month showed that the aorta was completely healthy (Figure 2). The patient delivered her baby with a normal healthy delivery approximately seven months after the procedure.

Figure 2. First month after TEVAR control CT image.
TEVAR: Thoracic endovascular aortic repair; CT: Computed tomography.

Discussion

Blunt trauma is the primary etiology of traumatic thoracic aortic injuries. The diagnosis of traumatic aortic injury is usually made within 4 to 18 h after injury.[1] In this case, the diagnosis of transection was made approximately 12 h later. Aortic transection is a life-threatening emergency characterized by tear formation in the inner layer of the aorta and the most common symptoms are hypotension, back pain, and altered consciousness.[4] Prompt and effective treatment is critical for the life of the patient. In particular, in multi-trauma patients with rib, pelvic and acetabular fractures like our patient, the diagnosis may be difficult. The aorta is usually injured at the isthmus, the weakest point of the aortic arch.[5] It is recommended to consider and exclude the possibility of thoracic aortic injury in patients with motor vehicle accidents.[2]

It has been reported that chest X-rays are not sensitive enough and laboratory tests are not useful in the diagnosis of aortic injury. Thoracic CT angiography is recommended as the gold standard for diagnosis.[3] Therefore, thoracic CT should be performed, particularly in severe vehicle accidents. Although emergency surgical treatment used to be the only treatment option, this method has a mortality rate of up to 42% in patients with multiple traumas, leading to complications such as severe paraplegia, respiratory distress, and infection.[6]

The major advance in the treatment of traumatic aortic injuries is the widespread use of TEVAR. While the mortality rate in open surgery is 23.5%, the mortality rate of TEVAR is reported to be 7.2%. The rate of reintervention after TEVAR in traumatic cases was reported to be 1.8%.[1] Since the use of TEVAR, there has been a 50% decrease in mortality from blunt traumatic aortic injuries.[7] While selecting the graft, 10 to 20% over sizing according to the aortic diameter at the landing site and stents shorter than 150 mm are recommended. In our case, we closed the transection with a 100-mm graft without complications. Some studies have shown the efficacy and safety of TEVAR in blunt thoracic aortic trauma.[4,8] However, we could not find a case in the literature similar to our patient who had a first trimester pregnancy and underwent TEVAR. Most of the cases in the literature consist of patients with type B dissection in the advanced gestational week and underwent TEVAR after emergency cesarean section.

Potential effects of radiation on the unborn fetus include intellectual disability, intrauterine growth restriction, organ malformations and childhood cancers. The risk depends on several factors, including the week of gestation at which radiation exposure occurs, the dose of radiation absorbed, and the cellular repair mechanisms of the fetus.[9] The first trimester (particularly two to seven weeks) is the period, when the fetus is most sensitive to radiation. According to the United States (US) National Council on Radiation Protection and Measurements, fetal radiation exposure of less than 50 mGy is considered negligible, while levels exceeding 150 mGy significantly increase the risk of abnormalities.[9] Fluoroscopic procedures have been reported to exceed the threshold for induced malformations and require increased vigilance.[10] The use of lead and shielding has been reported to significantly reduce fetal exposure to radiation and can be used as reassurance.[11] In our case, we completed the procedure with a threshold value of 113.42 mGy by using lead shielding and minimal exposure.

There is no evidence that the iodinated contrast agents we used in the procedure are teratogenic. The development of hypothyroidism has been reported as the most likely risk.[9] The US Food and Drug Administration (FDA) classifies iodinated contrast media as pregnancy Category B drugs, as they are considered safe for pregnant women and nursing mothers.[12] The American College of Obstetricians and Gynecologists (ACOG) recommends the use of iodinated contrast media in situations that affect the life of the mother and fetus.[13] Iodinated contrast media can be used in pregnancy, particularly in vital diagnostic situations, since they are tolerated and the frequency of side effects is low. One of the main reasons for proceeding with the procedure despite the risks in this case was that the patient was 33 years old and pregnant for the first time after in vitro fertilization.

Vascular surgery guidelines have also reported that treatment of aortic transections with TEVAR prolongs survival and reduces the risk of renal failure, spinal cord ischemia, graft and systemic infection compared to open surgery or no treatment.[14]

In conclusion, thoracic endovascular aortic repair in the treatment of aortic transection stands out as a rapid, safe and minimally complicated treatment method, particularly in experienced centers. It is a treatment modality which can be used safely and provides long-term survival, particularly in young and pregnant patients as in our case. A more multidisciplinary approach is required in pregnant patients and guideline recommendations should be taken into consideration. As in this case, we recommend thoracic endovascular aortic repair as a treatment method which can save not one, but two lives at the same time and can be used safely in pregnant women in life-threatening situations.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Idea, data collection, data interpretation, article writing: K.D.T.; Literature search, selecting/editing sources: E.K.T.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

References

1) Harper C, Collier SA, Slesinger TL. Traumatic Aortic Injuries. 2024 Mar 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.

2) Myers SB, Waseem M. Aortic trauma (Archived). 2024 Mar 21. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.

3) Yoon I, Slesinger TL. Radiation Exposure In Pregnancy. 2023 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.

4) Changlani N, Panjiyar BK, Jha SK, Khan SW, Kaushal A, Cherukuru S, et al. Endovascular aortic repair in traumatic descending thoracic aortic transection: A case report. Cureus 2024;16:e68787. doi: 10.7759/cureus.68787.

5) Procházka V, Roman J, Jal?vka F, Jonszta T, Vrtková A, Pleva L, et al. Endovascular repair of thoracic aorta injury: 17 Years of single-center experience. Med Sci Monit 2021;27:e934479. doi: 10.12659/MSM.934479.

6) Cardarelli MG, McLaughlin JS, Downing SW, Brown JM, Attar S, Griffith BP. Management of traumatic aortic rupture: A 30-year experience. Ann Surg 2002;236:465-9. doi: 10.1097/00000658-200210000-00009.

7) Erdoğan KE, Beşler MS, Canyiğit M, Hıdıroğlu M. Endovascular repair of a distal thoracic aortic transection in association with traumatic burst fracture. Indian J Thorac Cardiovasc Surg 2021;37:554-7. doi: 10.1007/s12055-021-01138-9.

8) Balcıoğlu Ö, Karaca S, Parıldar M, Kahraman Ü, Posacıoğlu H. Akut aort transeksiyonlarının endovasküler tedavisinde başarıyı etkileyen faktörler. EJM 2022;61:326-33.

9) Moirano J, Khoury J, Yeisley C, Noor A, Voutsinas N. Interventional radiology and pregnancy: From conception through delivery and beyond. Radiographics 2023;43:e230029. doi: 10.1148/rg.230029.

10) American College of Radiology. ACR practice guideline for imagingpregnant or potentially pregnant adolescents and women with ionizingradiation. Reston, Va: American College of Radiology; 2008.

11) Iball GR, Kennedy EV, Brettle DS. Modelling the effect of lead and other materials for shielding of the fetus in CT pulmonary angiography. Br J Radiol 2008;81:499-503. doi:10.1259/bjr/66819221.

12) Leek JC, Arif H. Pregnancy medications. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.

13) Jain C. ACOG Committee opinion no. 723: Guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol 2019;133:186. doi: 10.1097/ AOG.0000000000003049.

14) Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: Clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011;53:187-92. doi: 10.1016/j.jvs.2010.08.027.