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Ann Thorac Surg 1995;60:1120-1121
© 1995 The Society of Thoracic Surgeons

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Case Reports

Simultaneous Repair of Multiple Traumatic Aortic Tears

Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts

Accepted for publication April 20, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
A 34-year-old man suffered simultaneous tears of his distal ascending and mid-descending thoracic aorta secondary to blunt trauma. Repairs of both injuries were performed via a median sternotomy approach followed by a left lateral thoracotomy using two separate methods of cardiopulmonary bypass.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Thoracic injuries have been identified as the primary cause of death in more than 25% of motor vehicle accidents, and thoracic aortic rupture is present in slightly less than half of these cases. Multiple sites of injury have been reported to occur simultaneously in 6% to 20% of cases, and there are few reports in the literature of survivors in this subgroup. We present a patient who suffered from simultaneous tears of the distal ascending aorta and mid-descending thoracic aorta whose injuries were repaired in consecutive procedures shortly after his accident.

A 34-year-old unbelted male driver was admitted to our Level I Trauma Center after a head-on high-speed motor vehicle accident. Extensive damage to the car was reported including significant deformation of the steering wheel. His presenting blood pressure was 140/68 mm Hg with a heart rate of 110 beats/min. Initial assessment revealed a clear sensorium and facial lacerations. Breath sounds were clear bilaterally, and a contusion was present overlying his sternum. Cardiac examination revealed neither muffled heart tones nor murmurs. His admission electrocardiogram revealed sinus tachycardia and T-wave inversions in V₂ through V₆. Head and abdominal computed tomographic scans were notable only for a right maxillary sinus fracture.

His initial chest roentgenogram had demonstrated a large right pneumothorax, which was decompressed with a pleural tube. When a repeat roentgenogram demonstrated an indistinct aortic knob, a thoracic aortogram was obtained and revealed an intimal disruption of the distal ascending aorta just proximal to the origin of the innominate artery as well as a similar lesion in the mid-descending thoracic aorta (Fig 1).

View larger version (87K): [in this window] [in a new window]   Fig 1. . Thoracic aortogram in left anterior oblique view demonstrating intimal defects in the distal ascending aorta and mid-descending aorta (arrows).

He was extubated within 24 hours, and his postoperative course was notable only for a persistent air leak from the right lung, which resolved. His convalescence remained unremarkable at the time of outpatient follow-up.

	Comment

Top Footnotes Abstract Introduction Comment References

 
Nearly 20% of fatal traumatic aortic tears occur in the ascending aorta, usually just above the annulus, with acute pericardial tamponade and immediate death the common result. It has been theorized that a blow to the chest plays a more important role than deceleration in their etiology. Injuries to the mid-descending thoracic aorta below the level of the isthmus have also been identified as the site of injury in up to 20% of fatal aortic tears. The mechanism is thought to be direct trauma to the aorta from extreme hyperextension or fracture-dislocation of the spine. A recent review of the literature identified 11 survivors with injuries between the level of T-7 and T-10 [1].

Immediate operative intervention for all cases except those with severe concomitant injuries has become the accepted approach. Although many centers are reporting good results with injuries at the isthmus, few have reported on survivors with multiple tears. Until recently, most reports on such injuries were autopsy studies in which the injuries occurred most commonly in the proximal ascending aorta and isthmus simultaneously.

Simultaneous repairs have been performed on injuries to the innominate artery and isthmus [2], to the aortic arch and isthmus [3], and to the isthmus and descending aorta [4, 5]. Single reports of staged delayed repair of simultaneous injuries to the ascending aorta and isthmus have also been documented [6, 7].

Repair of the ascending injury was undertaken first so that this area would not be exposed to high pressure with distal aortic occlusion, as it would have had the order of repair been reversed. Others have reported the use of hypothermic circulatory arrest for repair of these injuries [7], and primary repair of a traumatic tear has also become an accepted alternative to placement of an interposition graft [8].

Lack of exposure of the mid-descending thoracic aorta through a median sternotomy mandated a more direct approach via a left lateral thoracotomy. The use of a heparinized bypass circuit avoided repeating systemic anticoagulation, thus minimizing the risk of bleeding from the previous operative site and other areas of injury.

Whereas concomitant extrathoracic injuries as well as the presence of severe pulmonary contusions (making single-lung anesthesia impossible) may mandate delayed repair of one if not both injuries, the significant mortality rate in the early postinjury period for the survivors dictates early repair if possible. Being flexible both in operative approaches and in methods of cardiopulmonary bypass will allow one to devise and complete a successful operative course for these high-risk patients.

	Footnotes

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Address reprint requests to Dr Lancey, Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655-0304.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Rabinsky I, Sidhu GS, Wagner RB. Mid-descending aortic traumatic aneurysms. Ann Thorac Surg 1990;50:155–60.[Abstract]
2. Asfaw I, Ramadan H, Talbert JG, Arbulu A. Double traumatic rupture of the thoracic aorta. J Trauma 1985;25:1102–4.[Medline]
3. DelRossi AJ, Cernaianu AC, Cilley JH, Madden L, Spence RK. Multiple traumatic disruptions of the thoracic aorta. Chest 1990;97:1307–9.[Abstract/Free Full Text]
4. Cimochowski GE, Barcia PJ, DeMeester TR, Griffin LH, Fishback ME. Multiple transections of the thoracic aorta secondary to blunt trauma. Ann Thorac Surg 1973;15:536–40.[Medline]
5. Stothert JC, McBride L, Tidik S, Lewis L, Codd JE. Multiple aortic tears treated by primary suture repair. J Trauma 1987;27:955–6.[Medline]
6. Lowery RC, Ergin A, Galla J, Lansman S, Greipp RB. Successful treatment of multiple simultaneous great vessel disruptions. Ann Thorac Surg 1986;41:672–4.[Abstract]
7. Iannettoni MD, McCurry KR, Rodriguez JL, Williams DM, Deeb GM, Bolling SF. Simultaneous traumatic ascending and descending thoracic aortic rupture. Ann Thorac Surg 1994;57:481–4.[Abstract]
8. Orringer MB, Kirsh MM. Primary repair of acute traumatic aortic dissection. Ann Thorac Surg 1983;35:672–5.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert A. Lancey George P. Davliakos Thomas J. Vander Salm Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lancey, R. A. Articles by Vander Salm, T. J. Search for Related Content PubMed PubMed Citation Articles by Lancey, R. A. Articles by Vander Salm, T. J.