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Ann Thorac Surg 1996;61:875-878
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Mortality and Neurologic Morbidity After Repair of Traumatic Aortic Disruption

Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin

Accepted for publication November 14, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Traumatic disruption of the thoracic aorta frequently results in death before operative repair. The determinants of mortality after repair, however, are uncertain. In addition, intraoperative strategies for reducing the incidence of spinal cord injury remain controversial.

Methods. The records of 45 consecutive patients undergoing repair of traumatic disruption of the thoracic aorta at a single institution during a 9-year period were reviewed in a retrospective fashion. Patient age ranged from 15 to 81 years (mean age, 33.9 years). Twenty-two patients (49%) had multiple associated injuries, and 8 (18%) had isolated aortic injuries. Nine patients (20%) experienced preoperative hypotension (systolic blood pressure of less than 90 mm Hg). Repair was performed with partial bypass in 22 patients, a heparinized shunt in 2, and no distal perfusion (clamp and sew technique) in 21.

Results. Nine patients (20%) died after operation. Multivariate logistic regression analysis of preoperative and intraoperative variables identified advancing age and preoperative hypotension as independent predictors of operative death. The presence of associated injuries was not an independent predictor of operative death. All 4 patients with injuries proximal to the aortic isthmus died. Ten patients were excluded from analysis of spinal cord injury either because of preoperative neurologic deficit or because of death before postoperative evaluation. Six (17%) of the remaining 35 patients had development of paraplegia: 5 of the 15 patients having the clamp and sew technique, 1 of the 2 patients with a shunt, and 0 of the 18 patients with bypass (p < 0.05, clamp and sew versus bypass). In the clamp and sew group, patients in whom paraplegia developed had significantly longer aortic clamp times than those without neurologic injury (40.6 +/- 4.4 minutes versus 28.7 +/- 2.9 minutes, respectively; p < 0.05).

Conclusions. Advancing age, preoperative hypotension, and perhaps injury location are important determinants of death after repair of traumatic disruption of the thoracic aorta. Adjunctive perfusion with partial bypass should be used during repair to reduce the incidence of spinal cord injury.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Traumatic disruption of the thoracic aorta (TDTA) is a highly lethal injury. Williams and associates [1] recently demonstrated that aortic disruption was responsible for 90 of 530 consecutive motor vehicle deaths. Kodali and co-workers [2] found that 57% of patients with TDTA delivered alive to the hospital died prior to surgical repair. Mortality from TDTA has been correlated with a number of preoperative variables including patient age [3], severity of associated injuries [4], and delays in diagnosis or operative repair [2, 5]. The impact of these risk factors on surgical mortality remains unclear, however, as many analyses have included preoperative in-hospital deaths. Operative mortality was 18% in a recent metaanalysis of 1,742 patients by von Oppell and colleagues [6], but these investigators did not attempt to identify risk factors for this outcome.

Spinal cord ischemia resulting in paraplegia is probably the most serious nonlethal complication of operation for TDTA. Debate continues regarding the need of adjunctive perfusion techniques during operative repair to reduce the incidence of spinal cord injury. Many groups [6–12] support the use of some form of bypass for lower-body and spinal cord perfusion although several centers continue to use a ``clamp and sew'' technique with acceptable results [13–16].

This study was undertaken to identify preoperative variables associated with increased operative mortality and to examine the impact of distal perfusion on the incidence of paraplegia in patients who arrive in the operating room alive and undergo repair of TDTA.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The records of 45 patients who underwent operation for TDTA at the Medical College of Wisconsin between April 1986 and February 1995 were retrospectively reviewed. There were 34 men and 11 women. Mean patient age was 33.9 years (range, 15 to 81 years); 35 patients (78%) were less than 50 years of age. The mechanism of injury was a motor vehicle accident for 44 patients and severe crush injury for 1 patient. Twenty-two patients (49%) had injuries to multiple other organ systems, 15 (33%) had an injury to one other organ system, and 8 (18%) had isolated aortic injuries. Nine patients experienced a documented period of hypotension preoperatively (defined as systolic blood pressure of less than 90 mm Hg); this resulted from the aortic injury in 4 patients and from associated injuries in 5. The mean time from injury to diagnosis was 9.6 hours (range, 1 to 72 hours). Excluding 1 patient whose operation was delayed for 4 months after diagnosis because of severe associated injuries, the mean time from diagnosis to operation was 3.3 hours (range, 0 to 72 hours). The location of the injury was the aortic isthmus in 41 patients (91%) and the ascending or arch aorta in 4.

All patients with isthmic injuries underwent operative repair through a left thoracotomy, and patients with more proximal injuries underwent median sternotomy. Repair with a graft was performed in 41 patients (91%), and primary repair was accomplished in 4. Twenty-two patients underwent operation with either partial cardiopulmonary bypass or left heart bypass for distal aortic perfusion, and 2 patients underwent operation with a heparinized, passive shunt. Twenty-one patients had no form of adjunctive distal perfusion (clamp and sew technique). The decision regarding use of adjunctive perfusion was based on surgeon preference, although 2 patients had repair by the clamp and sew method because of exsanguinating hemorrhage.

Operative neurologic injury was defined as a lower-extremity sensorimotor deficit (partial or total) that was not present preoperatively. Ten patients were excluded from analysis of postoperative neurologic deficit either because a preoperative deficit was present or because death or profound coma prevented postoperative evaluation.

Preoperative and intraoperative factors were assessed by multivariate logistic regression analysis as predictors of death and neurologic injury. Comparisons of aortic cross-clamp times were made between groups by unpaired t test. Significance was defined as a probability of less than 0.05.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
There were nine operative deaths (20%). The results of univariate analysis for operative mortality are presented in Table 1. Multivariate logistic regression analysis identified patient age (p = 0.006) and preoperative hypotension (p = 0.013) as independent predictors of operative death. Mortality risk increased by a factor of 2.2 with each decade increment in age (95% confidence interval, 1.3 to 3.9) and by a factor of 30.3 with the presence of preoperative hypotension (95% confidence interval, 2.1 to 445). Mortality for the 10 patients older than 50 years was 60%. Three of the 9 patients who died had experienced preoperative hypotension attributable to the aortic injuries. Two were hypotensive from rupture at the isthmus and underwent operation without an angiogram, and the other had an aortogram on admission that was interpreted as normal, but an ascending aortic disruption was found 24 hours later when he underwent emergency sternotomy for cardiac tamponade. Two other patients experienced hypotension preoperatively as a result of associated injuries.

Ten patients were excluded from analysis of neurologic injury either because of a preoperative neurologic deficit that persisted after operation or because of death prior to postoperative evaluation. Thirty-five patients were thus included in the analysis of risk factors for paraplegia: 15 of the 21 patients who underwent repair using the clamp and sew method, both patients who had a shunt, and 18 of the 22 patients who had some form of bypass. There were 5 patients (33%) with postoperative neurologic deficit in the clamp and sew group, 1 patient in the shunt group, and no patient in the bypass group, for an overall paraplegia rate of 17%. The difference in the incidence of neurologic injury between the clamp and sew group and the bypass group was significant (p < 0.05). Three patients in each of these two groups had experienced a period of preoperative hypotension; it resulted from aortic rupture in 2 patients in the clamp and sew group but no patient in the bypass group. Mean aortic cross-clamp times did not differ significantly between the two groups (33.2 +/- 11.0 minutes for clamp and sew versus 44.1 +/- 17.7 minutes for bypass). However, in the clamp and sew group, patients with neurologic injury had significantly longer clamp times than those without (40.6 +/- 4.4 minutes versus 28.7 +/- 2.9 minutes; p < 0.05). Seven patients in the bypass group had clamp times of at least 50 minutes, including a 78-year-old patient with a clamp time of 84 minutes. Neurologic outcome and clamp times by method of repair are summarized in Table 2.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

The present data suggest that increasing age is a significant risk factor for death after repair of TDTA. These results support the conclusions of Sturm and associates [3], who found that age was the only significant predictor of operative death in an analysis of 37 patients undergoing repair of TDTA. Preoperative hypotension was also identified as an independent predictor of mortality in the current study, but the extremely wide confidence interval (2.1 to 445) for the odds ratio (30.3) associated with this variable modify its significance. Preoperative hypotension, which can result from bleeding from the aortic injury or from associated injuries, was found by Cowley and coauthors [4] to be an independent predictor of mortality.

A number of other factors have been demonstrated to be predictive of mortality from TDTA in other reports, but many of these analyses included in-hospital deaths that occurred prior to operation. For example, Cowley and colleagues [4] found injury severity score to be a significant predictor of mortality from TDTA in a study that included both preoperative and postoperative deaths. Neither the current investigation nor the analysis by Sturm and co-workers [3], both of which included only patients undergoing operation, could demonstrate the extent of associated injuries to be a predictor of mortality.

There was no association between either time from injury to diagnosis or time from diagnosis to repair and survival in the present study. Five of the 36 survivors had combined times greater than 12 hours, including 1 patient whose combined time was 5 days. These data do not include 1 patient whose repair was delayed for 4 months after diagnosis until she recovered from a severe closed-head injury. In their series of 33 patients, Cernaianu and colleagues [5] demonstrated that survival after TDTA is significantly associated with time from injury to arrival at the hospital but not with either time from arrival to diagnosis or time from diagnosis to repair. It appears, therefore, that patients with TDTA who survive the prehospital period are a select group with more stable injuries. Pate [17] recently suggested that the common fear of impending rupture may cause some of these patients to be hurried to operation without proper attention to associated injuries. The present data support the idea that operation on patients with TDTA who arrive at the hospital alive can be delayed if necessary. Careful monitoring of blood pressure and avoidance of hypertension are important measures in these patients, and ß-adrenergic blocking agents may be useful in this regard. For most patients, however, we continue to recommend immediate operation after confirmation of the diagnosis.

Injury location was not an independent predictor of death in this study, but it is noteworthy that all 4 patients with injuries in the ascending or arch aorta died and accounted for nearly half the deaths in this series. The severity of these more proximal injuries has not been well appreciated, despite the fact that injuries proximal to the isthmus tend to account for more injuries in autopsy series than they do in operative series [1, 18]. The 4 patients with proximal injuries in our series were elderly (age range, 77 to 81 years). This suggests that the atherosclerotic aorta may be affected differently by deceleration forces than is the normal aorta of younger patients. Proximal injuries also increase the magnitude and difficulty of operative repair, as they often require use of circulatory arrest with its attendant morbidity.

The present data support the use of distal aortic perfusion during operative repair of TDTA to reduce the incidence of spinal cord injury and paraplegia. Thirty-three percent of the patients having repair by the clamp and sew technique in this series had development of paraplegia compared with none of the patients undergoing bypass. One of the 2 patients treated with a shunt became paraplegic. Therefore, we recommend using pump support for repair of TDTA whenever circumstances allow. The methods used in this series varied among different forms of left heart (left atrial-aortic or left atrial-femoral) and partial (femoral-femoral) cardiopulmonary bypass. The only major advantage of left heart bypass is that it can be done with less anticoagulation.

Aortic cross-clamp time was a significant factor in the development of paraplegia among patients who had repair by the clamp and sew technique. Patients who underwent repair with some form of distal perfusion by pump support, on the other hand, were able to tolerate longer cross-clamp times. In 2 patients in the series, the aorta was clamped for 84 minutes without neurologic sequelae. Other nonrandomized, retrospective series [6–13] have suggested a protective effect on the spinal cord of distal aortic perfusion with pump support during repair of TDTA. Katz and associates [7] demonstrated that the risk of paraplegia after repair of TDTA without distal aortic perfusion increases rapidly after approximately 30 minutes of aortic cross-clamping. Several series [14–16] continue to advocate using the clamp and sew method, however, for treatment of TDTA. Mattox and colleagues [14] reported that paraplegia occurred in only 3 (13%) of 23 patients having repair by this technique despite clamp times of up to 62 minutes. These authors argued that the etiology of paraplegia is multifactorial and cannot be predicted by clamp time alone. Hilgenberg and coauthors [16] also advocated the clamp and sew method for repair of TDTA, but the risk of paraplegia in their series was significantly related to the duration of aortic cross-clamping.

In conclusion, operative repair of TDTA continues to carry a relatively high operative mortality. Preoperative factors, particularly age and hypotension and also perhaps injury location, are important determinants of operative mortality. Intraoperative factors, particularly the use of distal aortic perfusion with pump support during cross-clamping, determine the incidence of spinal cord injury and postoperative paraplegia.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Timothy McAuliffe, PhD, for his invaluable statistical analysis.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Nicolosi, Department of Cardiothoracic Surgery, Medical College of Wisconsin, 8700 W Wisconsin Ave, Milwaukee, WI 53226.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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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): Alfred C. Nicolosi G. Hossein Almassi Michael Bousamra, II George B. Haasler Gordon N. Olinger Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nicolosi, A. C. Articles by Olinger, G. N. Search for Related Content PubMed PubMed Citation Articles by Nicolosi, A. C. Articles by Olinger, G. N.