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Ann Thorac Surg 1998;65:461-464
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Surgical Indications and Timing of Repair of Traumatic Ruptures of the Thoracic Aorta

Department of Cardiac Surgery, University of Bologna, Bologna, Italy
Department of Radiology, University of Bologna, Bologna, Italy
Intensive Care Unit, University of Bologna, Bologna, Italy

Accepted for publication August 13, 1997.

Dr Galli, Cardiochirurgia—Policlinico S.Orsola, Via Massarenti, 9, 40138 Bologna, Italy.

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
Background. The outcome of patients with acute traumatic rupture of the thoracic aorta after motor vehicle accidents is strongly conditioned by injuries to other districts. The timing of repair is controversial when the patients arrive alive to the hospital.

Methods. A series of 42 patients with acute traumatic rupture of the thoracic aorta observed between January 1980 and June 1996 was divided into two groups: group I underwent immediate repair (21 patients) and in group II operation was performed after intensive medical treatment and management of the associated lesions and monitoring of the aortic tear.

Results. The mortality in group I patients was 19% and the morbidity was more significant than in group II where no deaths were reported and complications were minor.

Conclusions. Patients with acute traumatic rupture of the thoracic aorta may have a better fighting chance if aortic operation is postponed to the most favorable moment after undergoing life-sustaining measures and management of the major associated lesions. Needless to say, evolution should be closely monitored by computed tomographic scans and magnetic resonance imaging.

	Introduction

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In the past decades, the incidence of acute traumatic rupture of the thoracic aorta has increased progressively, primarily attributable to vehicular accidents [1]. Under these circumstances, approximately 25% of the deaths were caused by closed thoracic trauma and in a third of these cases an aortic rupture was determinant [2]. Greendyke [3] reported that approximately 16% of all automobile accident deaths are attributable to aortic rupture. The overwhelming majority of these patients die on site, and only 10% to 15% arrive alive to a hospital, usually with multiple associated lesions. In spite of prompt and appropriate surgical treatment, morbidity and mortality are high, ranging from 14% to 28% [4].

In the past, several cases were reported in which the surgical repair of an aortic rupture had been delayed, because of coexisting injuries, which rendered the surgical risk unacceptably high: severe head trauma, serious skeletal fractures, extensive burns, severe respiratory insufficiency, and sepsis [5] [6]. In 1985, a review of the English-language literature by Svensson and colleagues [7] found 44 such cases.

On the basis of these data a number of centers, including ours, have reconsidered therapeutic strategies, emphasizing the need to bring the patient to the operating room in optimal clinical conditions, after the management of the associated lesions [8] [9] [10] [11] [12].

The present report is a retrospective study on 42 consecutive patients referred to our center in the past 16 years. The last 21 patients have received intensive nonsurgical treatment, including cardiopulmonary and fluid resuscitation, postponing surgical repair of the aortic rupture when conditions were ideal.

	Material and Methods

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Forty-two patients with acute traumatic rupture of the thoracic aorta referred from local emergency wards were admitted in our center between January 1980 to June 1996. Thirty-two were men and 10 women; ages ranged from 6 to 66 years, with a mean age of 31.2 ± 14.7 years. Except for an industrial casualty, all the others had been victims of vehicular accidents. In 36 patients (85.1%) the lesion was limited to the isthmus; in 3, the rupture involved the subisthmic descending aorta (at the origin of the innominate artery), at the origin of the subclavian artery, and in correspondence to its concavity (1 patient each). The majority of the patients presented with one or more coexisting injury; 34 skeletal fractures (80.9%; ribs, 14; sternum, 4; pelvis, 6; lower limbs, 18; upper limbs, 9; maxillofacial, 5; vertebral column, 3), 11 lesions to abdominal organs (26.2%; liver, 5; spleen, 2; diaphragm, 1; gallbladder, 1; bowel, 2; bladder, 1), 6 neurologic complications (14.3%; coma, 5; paraplegia, 1), 6 thoracic lesions (14.3%; pulmonary, 5; myocardial, 1), and in only 3 patients the aortic rupture was solitary. The possibility of an aortic injury was suggested by either a widening of the mediastinum or a pleural effusion on plain chest roentgenograms. This was followed by computed tomographic scan (CT) of the chest (33 patients), aortogram (33), magnetic resonance imaging (MRI) (21 patients), and transesophageal echocardiography (14 patients). The CT and MRI proved exceptionally useful in detecting or confirming the presence of soft tissue injury, especially of the chest and abdomen (Table 1).

In 18 group I patients, an aortic prosthesis was positioned about the isthmus in 15 patients and in the thoracic descending aorta in 3. In 2 patients we performed direct suturing of the aortic arch and of the isthmus, respectively. One patient, who had a lesion of the arch at the origin of the innominate artery, was treated with patch suturing and an innominate artery–aorta prosthetic bypass. Ten patients were operated without cardiopulmonary support, using simple clampings, in 7 a left bypass with centrifugal pump was used. In 3 patients a circulatory bypass was adopted, with hypothermic cardiocirculatory arrest in 1. In 1 patient a temporary aortoaortic shunt was preferred.

In the 21 group II patients immediate continuous monitoring of arterial blood pressure (either through the radial or the femoral arteries), of central venous pressure (through a subclavian or a jugular catheter), and of vital signs and electrocardiogram was set up. Ten patients needed orotracheal intubation and ventilator support, and in 6, chest tubes were positioned to drain a hemothorax. Conservative treatment consisted primarily in the administration of beta-blockers (metoprolol) and vasodilators (sodium nitroprusside, calcium channel blockers, and nitrates), often in combination, to maintain a systolic blood pressure of about 100 mm Hg. All major associated injuries were treated surgically before repairing the aorta. Thirteen patients underwent osteosynthesis for compound fractures. Laparotomy was necessary in 5 patients, because of hepatic lacerations in 2 (in 1 patient a cholecystectomy was also carried out), to perform splenectomy in 1, repair of the diaphragm in 1, and to resect a damaged small bowel loop with peritoneal lavage in 1 patient. Pericardiocenthesis was performed in 1 patient to evacuate a significant effusion that caused tamponade.

The evolution of the aortic rupture was carefully monitored in all patients with serial chest roentgenograms, MRIs, and angio-CT scans (Fig 1).

View larger version (109K): [in this window] [in a new window]   Sagittal spin-echo magnetic resonance imaging of circumferential aortic rupture. (A) Anterior and posterior intimal flaps associated with a posttraumatic aneurysm are present. Periaortic effusion is visible also (12 hours after the trauma). (B) A 12-mm increase of the posttraumatic aneurysm was detected at the follow-up magnetic resonance imaging examination (1 month later).

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
This study considers all patients arrived in our unit. In group I patients (acute traumatic rupture of the thoracic aorta repair at diagnosis), there were 3 intraoperative deaths; a fourth patient died after 30 days (operative mortality, 19%). The cause of the intraoperative mortality was uncontrollable hemorrhage in 2 patients and an irreversible cardiac arrest in 1. The cause of death in the polytraumatized patient who died 30 days after operation was sepsis.

Furthermore, significant complications occurred only in group I patients. These were paraplegia (3 patients), paraparesis (1), and acute renal failure (1 patient). In none of these patients the centrifugal pump was used. Deep coma attributable to generalized brain ischemia secondary to a prolonged hypothermic cardiac arrest developed in 1 patient. In group I we also noted 3 patients with laryngeal nerve lesions and 1 case of bleeding requiring reintervention.

In group II patients there were no deaths and only minor complications: chylothorax; postpericardiotomy pericarditis, and lesion of the laryngeal nerve (1 patient each) (Table 2).

	Comment

Top Abstract Introduction Material and Methods Results Comment References

This philosophy, shared by nearly all trauma centers, has been supported by the classic autopsy study of Parmley and colleagues [16] on 296 cases of traumatic rupture of the thoracic aorta. Nevertheless, as already noted by Pate [17], the study by Parmley and associates [16] spans the period from 1862 to 1957 and refers primarily to war injuries, including airplane crashes, collected under the definition of "nonpenetrating injuries of the aorta." Moreover, at least half of the patients exhibited multiple fatal injuries and there is no discussion on the impact of the aortic rupture on mortality. Another important characteristic that distinguishes Parmley’s patients from those seen at present is that isthmic ruptures were reported in only 45% of their series, as compared with more than 90% observed today.

In recent years, many investigators have overestimated late ruptures in patients undergoing resuscitation under controlled hypotension (we have no information on pretrauma blood pressure) (Table 3). Hartford and colleagues [18] reported on 86 autopsies performed on vehicular accident victims. Among these, 37 died at the scene of the accident, 16 arrived alive to the hospital and were evaluated, 7 died without aortic repair, and only 1 died because of a complete rupture. The data of Kalmar and co-workers [19] also imply that the risk of rupture is not excessively high if the patient arrives alive to the hospital, especially if the tear is not circumferential. Their data are based on an autopsy series of 168 subjects with traumatic rupture of the aorta; 166 patients died within 2 hours of the accident (thus making surgical repair improbable) and only 1 died of late rupture of a periaortic hematoma.

Other considerations on how to approach these injuries derive on one hand from the recent technical and organizational improvements relative to the immediate care of major trauma victims and on the other hand from the increased mortality of emergency repair of ruptures of the isthmic aorta. This has led some trauma centers to reconsider surgical strategy, operating only in case of significant clinical deterioration, based on data from CT and MRI, which allow adequate monitoring and fine detailed information on the evolution of the lesion giving ample time for rapid intervention. As far as the recently introduced transesophageal echocardiography is concerned, considered a simple, rapid means of serial monitoring applicable also at bedside, we must admit that, although an excellent screening tool to confirm the suspicion of aortic rupture, it has its limitations as far as the image is concerned, as it cannot encompass the entire mediastinum or the left hemithorax.

In view of the elevated morbidity and mortality typical of emergency operations (group I), we have modified our operative strategy. Since 1992 we have delayed surgical repair in all patients who have arrived alive to the hospital, giving priority to cardiorespiratory and fluid resuscitation associated with a strict hypotensive regimen. Vital signs and instrumental data capable of detecting clinical deterioration were monitored carefully. Among the indices of immediate operation we considered a rapid increase of either the mediastinal hematoma or of the pleural effusion (if present), anuria persisting for more than 6 hours, limb ischemia, and free leaking of contrast media in the thorax.

Operation was first aimed at other life-threatening conditions (cerebral decompression, stopping massive abdominal hemorrhages, repairing visceral injuries, reducing composed fractures). This approach has consistently allowed us to maintain a stable hemodynamic status, without encountering signs of massive rupture or even a resumption of aortic bleeding. The aortic lesion was monitored with daily chest roentgenograms and with CTs and MRIs every 3 to 5 days for 3 weeks [22]. After discharge, the patients were followed with angio-CTs or MRIs every 3 to 4 months, until the repair of the pseudoaneurysm was programmed.

Following this strategy, in group II patients there were no deaths, either in the hospital or at home, including patients operated on or those awaiting operation. The criteria that prompted elective repair of the aorta have been either an enlargement of the aneurysm or major difficulties in controlling arterial pressure.

Elective operation was conducted with the help of a left bypass using a centrifugal pump to minimize the risk of either spinal or renal ischemia.

In conclusion, on the basis of the data presented and of those available in the literature, we believe that, in ruptures of the aortic isthmus, an initial conservative management is rational, safe, and allows management of coexisting life-threatening conditions. This approach should make use of CT scans and of MRIs to adequately follow the evolution of the lesions and to be in a position to detect any event that would mandate immediate operation.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Full Text (PDF) 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): Roberto Galli Davide Pacini Roberto Di Bartolomeo Bruno Turinetto Angelo Pierangeli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Galli, R. Articles by Pierangeli, A. Search for Related Content PubMed PubMed Citation Articles by Galli, R. Articles by Pierangeli, A.