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Ann Thorac Surg 1997;64:384-387
© 1997 The Society of Thoracic Surgeons
Division of Thoracic and Cardiovascular Surgery, The University of Texas-Houston Medical School and Hermann Hospital, Houston, Texas
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. To determine the safety and efficacy of the "clamp-sew" method, we retrospectively reviewed our 8-year experience treating 75 patients who had aortic injuries secondary to blunt trauma. Seventy-one of these patients were treated surgically. The clamp-sew method was used in all of these operations.
Results. Aortic cross-clamp time averaged 24 minutes (range, 14 to 36 minutes), with 4/71 having times in excess of 30 minutes. One patient (clamp time, 28 minutes) became paraplegic. Significant associated injuries were seen in 51/75 patients (48/71 patients with operation), including intrathoracic (35 patients), orthopedic (28 patients), intraabdominal (24 patients), and central nervous system (17 patients) damage. No patient died within 24 hours of operation. Overall 30-day mortality was 12% (9/75), with 7/9 having two or more aforementioned associated injuries. Of these 7, 5 had central nervous system injuries. Two of 9 died within 30 days without two or more associated injuries: 1 Jehovah's Witness of low hemoglobin, and 1 patient of sepsis.
Conclusions. Although any of several maneuvers may be appropriate in managing traumatic aortic injuries, the simple "clamp-sew" technique is a safe and effective method for the treatment of traumatic aortic transections.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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It has been reported that only 14% to 23% of patients survive and reach the hospital after sustaining an acute traumatic aortic transection [1–3]. Moreover, it is estimated that half of these survivors will die within 24 hours, and almost 75% within a week, if no definitive treatment is offered [4]. Since Klassen's first successful repair in 1959 [5], operations for blunt aortic transection have been partnered with high mortality rates, significant morbidities, and more than enough controversy. Debate, often with implications for litigation, has surrounded particularly the issues of operative technique and surgical experience, with the (perhaps) unintended and unhelpful consequence of inferring superiority.
This report retrospectively reviews an 8-year experience treating patients with aortic injuries secondary to blunt trauma. Hermann Hospital is a level I regional trauma center and a primary teaching venue for The University of Texas Medical School in Houston. Operations were performed with the resident staff and one of four attending surgeons, and uniformly employed the "clamp-sew" technique. Although other strategies may also be efficacious, our experience confirms that this technique is as safe and as appropriate as any of a variety of maneuvers.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Ages ranged from 16 to 53 years (mean, 33.7 years), and 66/75 (88%) of the patients were male. All patients had initial laboratory surveys and chest roentgenograms, and at least one of three investigations of aortic integrity: aortography (72/75), computed tomography (24/75), or transesophageal echography (18/75). Aortography was the only pretreatment aorta-specific evaluation in 49/75, and transesophageal echocardiography was the sole evaluation method in 2/75. Neither chest roentgenography nor computed tomography alone was used to construct a treatment plan. Four patients (2 male, 2 female) were treated nonoperatively with antihypertensive and antishear medications. Each of these patients' injuries was defined by aortography and computed tomography, and 2/4 ultimately had transesophageal echocardiography.
Seventy-one patients were treated with operations involving left thoracotomy, no shunts or bypass, minimal (
1 mg/kg in 9/71) or no heparin, and Dacron interposition grafts. Double-lumen endotracheal tubes were used to facilitate exposure in most patients. The mean time elapsed before operation was 212 minutes, with 40/71 patients operated on within 4 hours of admission (31/71 beyond 4 hours). The first-year cardiothoracic surgery resident was listed as the primary surgeon in 61/71 (86%) of the operations; in each of these cases the attending surgeon was the first assistant.
Aortic cross-clamp times averaged 24 minutes (range, 14 to 36 minutes), with 4/71 patients having times in excess of 30 minutes. Once proximal control of the aorta was obtained, further mobilization of the distal aorta was minimized, and every effort was made to avoid interruption of intercostal arteries beyond the immediate area of injury. An average of 7.1 units of packed red blood cells were transfused during operation (range, 4 to 11 units), and estimated blood loss for the procedure averaged 3,220 mL. Intraoperative autotransfusion devices (Cobe Laboratories, Inc, Lakewood, CA) were uniformly used to return autologous blood.
Significant associated injuries were not uncommon, and were seen in 51/75 patients (48/71 patients who underwent operation). These injuries, grouped into intrathoracic (35 patients), orthopedic (28 patients), intraabdominal (24 patients), and central nervous system (17 patients) damage, are detailed in Table 1
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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None of the 71 patients treated with an operation died within 24 hours of the operation. The overall 30-day mortality for the patients who underwent operation was 12.6% (9/71) (12%, 9/75, for the entire group), with 7/9 having two or more categories of major associated injuries (Table 2). Of these 7, 5 had intracranial damage as one of their injuries. Four of these patients had subdural or epidural hematomas, each required drainage, and only 1 ultimately survived (ie, 3 of the 5 deaths associated with central nervous system damage were in this cohort). Intracranial parenchymal contusions were not operated on, and although 2 of these patients ultimately died (pulmonary embolus, persistent intraabdominal hemorrhage), neither had extension of his intracranial hematoma. Two of the 9 deaths occurred within 30 days of operation without two or more associated injuries: 1 Jehovah's Witness died of low hemoglobin, and 1 patient died of sepsis.
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lists the major morbidities encountered. Important pulmonary problems (pneumonia, acute respiratory distress syndrome) were the most common nonlethal complications experienced. Acute renal failure occurred in 6/71 (8.4%) patients who underwent operation, only 1 of whom had an aortic cross-clamp time of more than 30 minutes. Each of these patients required at least temporary dialysis.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Our primary intraoperative objectives include (1) rapid exposure of the proximal aorta, (2) minimal dissection of the injured and distal aorta, (3) avoiding unnecessary interruption of adjacent intercostal arteries, (4) replacement of the damaged aortic segment with a Dacron interposition graft, and (5) avoiding inordinate fluctuations in blood pressure when clamping and unclamping the aorta. Communication with the anesthesiologists and nursing staff is essential to ensure both adequate exposure of the operative field and proper pharmacologic and volume replacement strategies. Our impression, and that of others [12–16], is that systemic heparinization increases the morbidity and mortality rates in patients with multisystem traumatic injuries (especially concomitant head injuries), and we avoid this scheme in our patients. Similarly, we avoid pump-support strategies that employ significant amounts of heparin. Heparin-bonded shunts have been used by others to protect against distal ischemia while eliminating the requirement for systemic heparinization [17–20], but we have not employed them.
In a comprehensive review of the English-language literature, von Oppel and associates [21] used sophisticated statistical analyses to support the recommendation of using partial bypass to augment distal perfusion during aortic cross-clamping. In their literature search, the average cross-clamp time required for aortic repair averaged 41 minutes, and the incidence of paraplegia dropped from 19.2% to 6.1% if distal perfusion was used. Although such large, multicenter reviews are often helpful, it seems worthwhile to note that in von Oppel and associates' 20-year review, the average number of patients with aortic transection admitted at any center was 2.6 per year. Although this study importantly canvasses the general ways in which surgeons have managed patients with aortic injuries, it is possible that statistical analyses have less impact when so many surgeons, so many years, and so few patients per center are involved. We have no quarrel with von Oppel and associates' technique or recommendations unless they are used by others to imply that alternative methods of managing aortic transections are unacceptable.
Mattox and associates [22] have championed a more open-minded philosophy, and have also demonstrated the efficacy of the clamp-sew technique. Their collected review includes 387 patients with acute aortic injuries treated at 18 trauma centers, most of which had experience with the pump, clamp-sew, and shunt techniques of repair. Mortality rates for pump, clamp-sew, and shunt methods were 32.6%, 13.3%, and 15.1%, respectively, and paraplegia rates were 4.5%, 8.3%, and 10.3%, respectively. Their own large experience in managing aortic injuries augments these data and confirms their belief that "the development of paraplegia relates to many variables, the least of which may be clamp time or prevention of ischemia to the spinal cord with a shunt." In fact many variables seem capable of influencing successful outcomes, including the patient's age and general health before the accident, the availability of well-trained rescuers at the accident scene, and the ability to quickly transport the victim to an appropriate hospital. Our study indicates that hospital outcomes may be strongly related to the presence or absence of associated major injuries, particularly those involving the central nervous system.
Although many issues influencing mortality and morbidity after acute aortic injuries may be beyond the supervision of the surgeon, it appears that among those variables within the surgeon's control, the most important may be the surgeon himself. Albrink and colleagues [23] have clearly demonstrated the impact of the individual surgeon as a variable, as improved results are predictably obtained when aortic transection injuries are managed by designated thoracic trauma surgeons. In our series, whether the surgical resident was on the left or right side of the operating table, it seems likely that the prompt availability of one of four experienced cardiovascular/thoracic surgeons influenced our results in a positive way.
Long a leader in the field, Pate has championed the use of extracorporeal circulatory support during operations to repair traumatically transected aortas and has regularly published his results [24, 25]. The recent evolution in his thinking is noteworthy [26, 27] and may represent a true advance in the overall management of patients with transected aortas. The use of an organized medical protocol, implemented immediately after diagnosis, allows time for the patient to be stabilized and for other life-threatening injuries to be treated before aortic repair. This strategy creates the potential for repair of the aortic injury under more optimal conditions and even raises the possibility of transferring the patient to an experienced trauma center where good results are routinely obtained. Our experience with 4 medically managed patients seems to support this approach. We agree with Pate that it is probably incorrect to assume that traumatic rupture of the aorta should always take priority over all other injuries.
The intent of this report is neither to claim superiority of one technique nor to condemn others. Such an approach at best is merely misleading, and at worst implies that an unsatisfactory result may be due to poor planning or failure to adhere to standards of care. Most operations for traumatic aortic transection occur between 11 PM and 6 AM, when even level I trauma centers may be stressed. At such operations, it seems wisest for the surgeons to use the techniques with which they are most efficient. We concur with others who recommend the clamp-sew technique as one of the appropriate schemes for managing acute traumatic aortic transections.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Sweeney, Division of Thoracic and Cardiovascular Surgery, The University of Texas-Houston Medical School, 6431 Fannin, Suite 1.220, Houston, TX 77030.
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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