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Ann Thorac Surg 2002;73:951-953
© 2002 The Society of Thoracic Surgeons

Case report

Traumatic aortic transection: evidence for the osseous pinch mechanism

Hossein Javadpour, FRCSIa, John J. O’Toole, FRCSc, J. Niall McEniff, FRCRb, David A. Luke, FRCSIc, Vincent K. Young, FRCS (CTh)*a

a Department of Cardiothoracic Surgery, St. James’s Hospital, Dublin, Ireland
b Department of Radiology, St. James’s Hospital, Dublin, Ireland
c Department of Cardiothoracic Surgery, Mater Misericordiae Hospital, Dublin, Ireland

Accepted for publication July 30, 2001.

* Address reprint requests to Dr Young, Department of Cardiothoracic Surgery, CREST Unit, St. James’s Hospital, James’s St, Dublin, Ireland
e-mail: vyoung{at}stjames.ie


   Abstract
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 Abstract
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Acute traumatic transection of the thoracic aorta is most commonly seen in vehicular trauma and is generally accepted to be due to differential deceleration. A second mechanism is proposed for this injury and that is the osseous pinch mechanism. We report a case where aortic transection occurred due to a crush injury and supports the latter mechanism.


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Traumatic aortic transection is an uncommon but life-threatening complication of major trauma. It is due to a tear in the inner layers of the aortic wall initially contained by the adventitia. The popular theory explaining the mechanism of aortic injury is the differential deceleration of aortic segments. However, there is a body of evidence to suggest another mechanism is involved in acute aortic rupture. We report a case of aortic transection where the injury clearly occurred due to a crush injury and not deceleration.

A 34-year-old man was brought to the Accident and Emergency Department complaining of severe chest and back pain after being crushed between a metal door and a forklift truck. On admission, his cardiovascular status was stable. He was tender over his thoracic spine T2 to T6. Both radial and femoral pulses were present and equal. His blood indices and renal profile were normal.

A chest roentgenogram showed a widened mediastinum. A computed tomographic scan of chest (with contrast), revealed mediastinal hematoma, bilateral effusions, and a transected aorta distal to the left subclavian artery (Fig 1A). Due to the unusual mechanism of injury, the diagnosis was confirmed on aortography (Fig 1B).



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  		Fig 1. (A) Contrast computed tomography showing transection of aorta after a crush injury. (B) Aortography of the same patient confirming the diagnosis.

 
Operative repair was carried out through a standard left posterolateral thoracotomy and one lung anesthesia. At the operation, the hematoma around the transection site was identified. A Gott shunt (Sherwood Medical, St. Louis, MO) was inserted from the ascending aorta to the descending aorta beyond the affected site. The arch clamped distal to the left subclavian artery, a second clamp was placed at the descending aorta. The aorta was found to be completely transected and was held together only with adventitia and hematoma. A 16-mm tube graft (Intergard, Intervascular, S.A., La Ciotat, France) was placed. Clamp time was 34 minutes. Two units of blood collected using a cell-saving device were transfused to the patient.

The postoperative course was uneventful. He was discharged 7 days after the operation. He was seen in the clinic after 6 weeks and is doing very well.


   Comment
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Blunt trauma to the thoracic aorta is seen most commonly in road traffic accidents when a fast moving vehicle suddenly comes to a stand still. Differential deceleration (whiplash), is the generally accepted mechanism of this injury.

Parmley and associates [1] in 1958 reported on 296 cases and suggested that abrupt forces of deceleration and compression (aortic bending over the rigid carina) produce aortic laceration. The most common site of injury is at the isthmus; the whiplash theory explains how, on sudden deceleration, the distal end of the transverse arch and proximal part of the descending aorta move forward while the upper descending thoracic aorta, fixed by the ligamentum arteriosum and the intercostal vessels, remains stationary.

However, the experimental evidence to support this theory is limited. It has not been possible to reproduce this injury experimentally using acute deceleration models. In fact, studies have shown that the tensile strength of the aorta exceeds the gravitational forces generated in vehicular trauma [2]. Parmley and colleagues also expressed doubt that the usual deceleration forces in car accidents were sufficient to rupture the aorta [1]. The whiplash theory fails to explain the other sites of aortic rupture; aortic lacerations proximal and distal to the isthmus, as well as injuries to the roots of the great vessels, can also occur [3]. In addition, investigators disagree as to which part of the aorta, the aortic arch [4] or descending aorta [1], is mobile on impact.

The osseous pinch mechanism is based on normal physiologic motion of the bony thorax, including the rotation of the ribs about their vertebral articulations. Blunt trauma to the chest causes the manubrium, first rib, and the medial clavicles to rotate posteriorly and inferiorly about the axes of the posterior rib articulations. This movement compresses the vascular structures between the anterior osseous elements and the vertebral column.

Crass and coworkers [5], in an experimental model of thoracic compression, showed that compression of the articulated skeleton in an antero-posterior direction resulted in postero-inferior displacement of the manubrium, first rib, and medial clavicle, which impinged on and caused near-transection of the aortic model. The level of injury was just distal to the subclavian artery. Cohen and associates [6], using calculations made from the cross-sectional anatomy shown on computed tomographic scans, demonstrated the point of aortic impingement and provided further evidence in support of the osseous pinch mechanism. Our case report clearly supports the osseous pinch theory. The transected aorta in our patient is unlikely to have resulted from any mechanism other than the impinging bony structures. However, it is not possible to conclude that "osseous pinch" is the mechanism of injury in all cases of aortic transection.


   References
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 Abstract
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 Comment
 References
 

  1. Parmley L.F., Mattingly T.W., Manion W.C., et al. Non-penetrating traumatic injury of the aorta. Circulation 1958;17:1086-1101.[Medline]
  2. Greendyke R.M. Traumatic rupture of aorta. JAMA 1966;195:119-122.[Abstract/Free Full Text]
  3. Fisher R.G., Hadlock F., Ben-Menachem Y. Laceration of the thoracic aorta and brachiocephalic arteries by blunt trauma. Radiol Clin North Am 1981;19:91-110.[Medline]
  4. Zehnder M.A. Delayed post-traumatic rupture of the aorta in a young healthy individual after closed injury: mechanical-etiological considerations. Angiology 1956;7:252-267.
  5. Crass J.R., Cohen A.M., Motta A.O. A proposed new mechanism of traumatic aortic rupture: the osseous pinch. Radiology 1990;176:645-649.[Abstract/Free Full Text]
  6. Cohen A.M., Crass J.R., Thomas H.A. CT evidence for the "osseous pinch" mechanism of traumatic aortic injury. AJR Am J Roentgenol 1992;159:271-274.[Abstract/Free Full Text]



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