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Ann Thorac Surg 1999;68:628-629
© 1999 The Society of Thoracic Surgeons

Correspondence

Asymptomatic traumatic aortic rupture

Yoshio Misawa, MD, PhDa, Katsuo Fuse, MD, PhDa, Osamu Kamisawa, MDa

a Department of Thoracic and Cardiovascular Surgery, Jichi Medical School, Yakushiji 3311-1, Minami-Kawachi, Tochigi, 329-0498, Japan

e-mail: tcvmisa{at}jichi.ac.jp

To the Editor

We have read with great interest the paper entitled "Traumatic aortic rupture: Diagnosis and management" by Gammie and colleagues [1]. They mentioned 3 cases with normal admission chest radiographs. We have also experienced a case with initially normal chest radiograph.

Our patient was a 20-year-old man. He was injured in traffic accident. He had severe pain on the right elbow without chest pain, and he was admitted to the nearest hospital. His hemodynamic condition was stable. Radiographic examination revealed right elbow fracture. The chest radiograph did not show pleural effusion or rib fracture, but it showed a slight enlargement of the superior mediastinum. Chest computed tomograph (CT) was also performed simultaneously because of occult structural injury on the chest, even though he developed no complaints concerning the chest injury. The chest CT revealed traumatic rupture of the descending aorta, and he transferred to our hospital 4 h later.

His chest radiograph and CT on admission showed no interval changes (Figs 1, 2). White blood cell count was 30,300/mm3, red blood cell count was 381 x 104/mm3, and hemoglobin level was 11.9 g/dL. His hemodynamic condition remained stable, but his right arm got swollen with increasing sensory disturbance. Thus, open reduction of the fractured right arm was performed preceding the repair of the descending aorta. After the open reduction, pleural effusion increased although his hemodynamic condition remained stable. Therefore, the patient underwent bypass grafting of the ruptured descending aorta with partial left heart bypass [2]. The tear was located just distal to the ligamentum arteriosum, extending 3 cm distally. His postoperative course was uneventful.



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  		Fig 1. Chest radiograph on admission to our hospital. There was no interval change between the initial chest radiograph 4 h earlier and the one shown.

 


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  		Fig 2. Chest CT on admission to our hospital. There was also no interval change between the initial CT and the one shown.

 
Gammie and coauthors mentioned three cases initially without both clinical symptoms and signs and radiographic findings relating to traumatic aortic rupture. These patients were noted to have aortic rupture between the second and fifth day after admission because of interval mediastinal widening or a new pulse deficit in the arm. In our case, the grafting of the descending aorta might have preceded the open reduction of the right arm. However, his right arm got swollen and pale on admission to our hospital, whereas no interval changes of the chest CT findings were recognized. This is the reason why we chose open reduction of the right arm before repair of the descending aorta. Our case also showed development of interval mediastinal widening with pleural effusion after the open reduction, resulting in successful surgical management of the ruptured aorta.

Both Gammie and associates’ cases and ours implicate the careful awareness for occult trauma in case of trauma patients, and serial assessments are inevitable for accurate diagnosis and treatment without delay.

References

  1. Gammie J.S., Shah A.S., Hattler B.G., Kormos R.L., Peitzman A.B., Griffith B.P., Pham S.M. Traumatic aortic rupture. Ann Thorac Surg 1998;66:1295-1300.[Abstract/Free Full Text]
  2. Misawa Y., Fuse K., Kawahito K., Konishi H. Clinical experience with a new system, "CAPIOX EBS.". Jpn J Artif Organs 1998;27:578-581.



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H. Onda, Y. Kaminishi, Y. Misawa, and K. Fuse
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[Abstract] [Full Text] [PDF]

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