Ann Thorac Surg 1998;66:611-612
© 1998 The Society of Thoracic Surgeons
Correspondence
Modern management of traumatic rupture of the aortic isthmus
James W. Pate, MDa
a Division of Thoracic Surgery, The University of Tennessee College of Medicine, G212 Coleman Bldg, 956 Court Ave, Memphis, TN 38163, USA
To the Editor
The recent article entitled: "Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta" by Galli and associates [1] illustrates the dramatic evolution in management and disease concepts of traumatic rupture of the aortic isthmus over the last decade. Galli and associates report 21 cases of traumatic rupture of the aortic isthmus, in which surgical repair was delayed from 1.5 to 18 months, with no deaths due to rupture before operation. There was only one paraplegia.
These results stand in stark contrast to those usually reported a decade ago, and still experienced widely today; the tragic occurrence of paraplegia, frequently in young adults, is all too common. These results have grown out of evolutionary changes in the approach to this injury that have occurred during this decade. Review of both American and European literature of the last 10 to 15 years, discussions with others, and my own experiences lead to some basic conclusions that should influence management of this injury.
- Medical management can markedly reduce the probability of rupture of the mediastinal hematoma with resultant massive hemorrhage and (usually) death. In addition to the cited article, several groups [2, 3] have clearly demonstrated the principle of pharmacologically reducing shear forces within the aortic wall. My colleagues and I have managed more than 90 consecutive patients with a protocol of ß-blockers and, frequently, added vasodilators, with no deaths in the hospital caused by hemorrhage before selective delayed operative repair [4]. Most deaths in patients who receive pharmacologic management are the result of other injuries or their complications.
- The length of time of aortic cross-clamping is related to the probability of paraplegia. The period of 25 to 35 minutes of cross-clamping (at normothermia) appears to be the important break point in the probability of paraplegia [5, 6].
- The use of some form of pump-perfusion of the body distal to the clamped aorta is usually protective of paraplegia and renal failure [7, 8]. Galli and associates used a centrifugal pump from the left atrium to the femoral artery, without full heparinization, a technique that appears to be rapidly gaining favor in the United States. We have, since 1964 [9], used femorofemoral cardiopulmonary bypass with an oxygenator and full heparinization, believing that this technique offers some protection to the left ventricle, lungs, and brain, as well as to the distal body. The recent article by Sweeney and associates [11] reports only 1 case of paraplegia among 75 patients operated on without some form of bypass; this uniquely successful experience is probably explained by aortic cross-clamp times of 14 to 36 minutes (mean, 24 minutes).
- There are no published data that clearly demonstrate a deleterious effect of total heparinization on hemorrhagic complications, except for pulmonary parenchymal damage and, probably, intracranial injury; both are considered contraindications to total heparinization.
Because proper medical management is so effective in preventing rupture and hemorrhagic death and appears to be better when patients are operated on by surgeons highly and currently skilled in thoracic trauma [1, 4, 6, 10, 11], the principles guiding management at this time might be the following:
- With an abnormal mediastinum in a patient who has suffered decelerating trauma, cardiopulmonary resuscitation and administration of ß-blockers, with vasodilators when indicated, are started immediately, with cardiovascular monitoring. Other life-threatening injuries are managed and the suspected ruptured aorta is diagnosed and repaired selectively after the patient’s condition is optimized.
- Transfer (with drugs and monitoring continued) to an appropriate trauma center with broad current experience with this injury may be justified when these are not available at the originating hospital.
The legal risk of this course should be secondary to the best interests (risk:benefit probability) of the patient.
References
- Galli R., Pacini D., Di Bartolomeo R., et al. Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta. Ann Thorac Surg 1998;65:461-464.[Abstract/Free Full Text]
- Akins C.W., Buckley M.K., Daggett W., et al. Acute traumatic disruption of the thoracic aorta: a ten year experience. Ann Thorac Surg 1981;31:305-309.[Abstract]
- Kipfer B., Leupi F., Schrupbach P., Friedli D., Althaus U. Acute traumatic rupture of the thoracic aorta: immediate or delayed surgical repair?. Eur J Cardiothorac Surg 1994;8:30-33.[Abstract]
- Pate JW, Gavant ML, Weiman DS, Fabian TC. Traumatic repair of the aortic isthmus: a program of selective management. World J Surg (in press).
- Zieger M.A., Clark D.E., Morton J.R. Reappraisal of surgical treatment of traumatic transection of the thoracic aorta. J Cardiovasc Surg 1990;31:607-610.[Medline]
- Von Oppell U.O., Dunne T.T., De Groot M.K., Zilla P. Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994;58:585-593.[Abstract]
- Higgins R.S., Sanchez J.A., DeGuidis L., et al. Mechanical circulatory support decreases neurologic complications in the treatment of traumatic injuries of the thoracic aorta. Arch Surg 1992;127:516-519.[Abstract/Free Full Text]
- Fabian T.C., Richardson J.D., Croce M.A., et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma 1997;42:374-383.[Medline]
- Pate J.W. Traumatic rupture of the aorta: emergency operation. Ann Thorac Surg 1985;39:531-537.[Abstract]
- Pate J.W., Fabian T.C., Walker W.A. Acute traumatic rupture of the aortic isthmus: repair with cardiopulmonary bypass. Ann Thorac Surg 1995;59:90-99.[Abstract/Free Full Text]
- Sweeney M.S., Young D.J., Frazier O.H., Adams P.R., Kapusta M.O., Macris M.P. Traumatic aortic transections: eight-year experience with the "clamp-sew" technique. Ann Thorac Surg 1997;64:384-389.[Abstract/Free Full Text]
