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Ann Thorac Surg 1996;62:731-732
© 1996 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Department of Cardiothoracic Surgery, School of Medicine, University of Cape Town, 7925 Cape Town, South Africa, E-mail: UVONOPP{at}UCTGSH1.UCT.AC.ZA

See also page 724.

Traumatic aortic rupture occurs rarely in children, and Trachiotis and co-workers suggest that young patients (8 to 17 years of age) constitute a unique group. Only a few articles specifically differentiating this age group (11 patients including this publication) are cited, although numerous published series include patients of this age group. Conclusions should therefore be guarded.

Nevertheless, comparative points of note between these young patients and predominantly older patients include a lack of associated rib fractures in these young patients, possibly because of a more compliant pediatric chest wall. In addition, there is a higher incidence of preoperative paraplegia; 4 of the 11 cited patients (36%) were noted preoperatively to have paraplegia or paraparesis, compared with the norm of 2.6% [1]. Trachiotis and co-workers also documented complete transections in all of their 5 patients sustaining isthmic ruptures. Further- more, an apparent high incidence of pseudocoarctation (2 patients; 40%) possibly contributed to the more frequent occurrence of preoperative paraplegia/paraparesis in these young patients. Pseudocoarctation has been documented only occasionally in older patients [2–4], and therefore the observed increased occurrence of pseudocoarctation might be related to the greater aortic elasticity of young patients.

Trachiotis and co-workers argue for the preferential use of computed chest tomography and transesophageal echocardiography in the diagnosis of this injury in their young patients. This approach may allow a more rapid diagnosis; however, the specificity and sensitivity of this approach compared with angiography must still be determined.

Young patients might well constitute a unique group as a result of their greater tissue elasticity, however, it is unlikely that their postoperative risk of ischemic spinal myelopathy as a result of thoracic aortic cross-clamping differs from the norm. Trachiotis and co-workers do not substantiate their preference for the "clamp and sew" technique. A large metaanalysis clearly shows that new postoperative ischemic spinal myelopathy is directly related to both the lack ("clamp and sew"; incidence of new paraplegia, 19.2%) or provision of distal perfusion ("passive" or "active" shunts/bypass; incidence of new paraplegia, 6.1%), as well as the duration of aortic cross-clamping ("clamp and sew"; >30 minutes) [1, 5]. The technique associated with the lowest risk of new paraplegia at 2.3% in hemodynamically stable patients is active shunts/bypass. Full systemic heparinization has, however, been associated with increased mortality in these polytraumatized patients. Nevertheless, full heparinization is not necessary as partial heparinless left atrial to descending thoracic aorta bypass with a centrifugal vortex pump and standard tubing is a well-established technique [1, 5].

Trachiotis and co-workers routinely used an interposition Dacron graft in repairing this injury; however, although understandably the most important issue is patient survival, primary suture repair might be preferable and easily accomplished in young patients [6, 7].

This study highlights the need for more information in this specific subgroup of young patients.

References

1. Von Oppell UO, Dunne TT, De Groot KM, Zilla P. Traumatic aortic rupture: Twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994;58:585–93.[Abstract]
2. Von Oppell UO, Thierfelder CF, Beningfield SJ, Brink JG, Odell JA. Traumatic rupture of the descending thoracic aorta. S Afr Med J 1991;79:595–8.[Medline]
3. Gazzaniga AB, Khuri EI, Mir-Sepasi HM, Bartlett RH. Rupture of the thoracic aorta following blunt trauma. Arch Surg 1975;110:1119–23.[Abstract/Free Full Text]
4. Mattox KL, Holzman M, Pickard LR, Beall AC Jr, DeBakey ME. Clamp/repair: a safe technique for treatment of blunt injury to the descending thoracic aorta. Ann Thorac Surg 1985;40:456–63.[Abstract]
5. Von Oppell UO, Dunne TT, De Groot KM, Zilla P. Spinal cord protection in the absence of collateral circulation: meta-analysis of mortality and paraplegia. J Cardiac Surg 1994;9:685–691.[Medline]
6. Orringer MB, Kirsh MM. Primary repair of acute traumatic aortic disruption. Ann Thorac Surg 1983;35:672–5.[Abstract]
7. Schmidt CA, Wood MN, Razzouk AJ, Killeen JD, Gan KA. Primary repair of traumatic aortic rupture: a preferred approach. J Trauma 1992;32:588–92.[Medline]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ulrich O. Von Oppell Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Von Oppell, U. O. Search for Related Content PubMed Articles by Von Oppell, U. O. Related Collections Related Article