Ann Thorac Surg 1998;65:1797
© 1998 The Society of Thoracic Surgeons
How to Do It
Proximal Aortic Control in Traumatic Rupture of the Thoracic Aorta
Thomas E. Williams, Jr, MDa
a The Ohio State University and Grant Hospitals, Columbus, Ohio, USA
Accepted for publication December 10, 1997.
Address reprint requests to Dr Williams, 300 E Town St, 12th Fl, Columbus, OH 43215
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Abstract
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A technique is described for gaining proximal control of a ruptured thoracic aorta that avoids entering the hematoma while providing a deep medial corner suitable for sewing in a graft.
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Introduction
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In repair of traumatic rupture of the thoracic aorta located in the usual position distal to the left subclavian artery at the ligamentum arteriosum, the technical problems are twofold: (1) gaining proximal control of the aorta without causing rupture by entering the hematoma and (2) making sure that there is enough aorta on the deep medial corner for adequate sewing room when a graft is inserted. The injured aorta is exposed in the left side of the chest by a high posterolateral thoracotomy in the fourth interspace. Proximal control can be gained by developing clamp room between the left common carotid and left subclavian arteries from outside the pericardium. Sometimes this can lead to entering the hematoma inadvertently. It may produce a shortened deep medial corner.
A transpericardial exposure for placement of the proximal clamp usually assures control without entering the hematoma and a deep medial corner suitable for sewing in a graft.
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Technique
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The pericardium is opened anterior or posterior to the phrenic nerve. The ascending aorta is dissected free from the right pulmonary artery. A tape is passed around the ascending aorta. The pericardial reflection on the deep (right) side of the aorta is dissected free. Often this can be done with a thumb and forefinger. The proximal and distal walls of the innominate artery are identified, the artery is then dissected, and the tape that is already beneath the aorta is passed to the clamp behind the innominate artery, thereby gaining control between the innominate artery and the left common carotid artery. This space is then developed on its lower side, which is only loosely adherent. Once this is done a similar dissection of the left common carotid artery permits transfer of the tape between the left common and subclavian arteries. The aorta is then elevated enough to make clamp room and a proximal clamp is applied. The tape can be transferred anterior or posterior to the phrenic nerve as deemed advisable by the operating surgeon.
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Comment
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This approach has been reported in repair of innominate artery disruption and in penetrating aortic injuries [1, 2]. It has been used by me or my partners in approximately 15 cases. Care must be used for this dissection in the uncommon elderly patients who might sustain embolization from the proximal aorta as the dissection is developed.
This method seems to achieve both technical goals because the hematoma rarely extends this far forward on the bottom of the aortic arch and a long length of sewing cuff is made available because of the anterior position of the clamp tip on the inside curvature of the aortic arch.
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References
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- Mattox K.L. Approaches to trauma involving the major vessels of the thorax. Surg Clin North Am 1989;69:77-91.[Medline]
- Pate J.W., Cole F.H., Walker W.A., Fabian T.C. Penetrating injuries of the aortic arch and its branches. Ann Thorac Surg 1993;55:586-592.[Abstract]
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Abstract
Introduction
