| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2002;73:1031
© 2002 The Society of Thoracic Surgeons
a Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
* Address reprint requests to Dr McLaughlin, Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Room N4W94, Baltimore, MD—21201, USA
e-mail: jmclaughin{at}smail.umaryland.edu
Renegade facts are those phenomena that are known to exist, but that deviate from common knowledge, result, or process for unknown reasons. Often narrow in scope and limited in practice, they are, nonetheless, factual and can be relied upon, in most instances, to produce a desired effect. Such is the case with nonoperative treatment of aortic injury.
The accepted and well-proven treatment of blunt aortic injury is operative repair [1]. This has been the standard of care for the past 30 years. Major discussions in the literature have primarily addressed the best techniques of operative repair in order to save lives and prevent paraplegia. Supporters of the "clamp and sew" method are able to show excellent results and survival rates with a low incidence of paraplegia (virtually zero if clamp time is kept under 30 minutes). Others advocate active lower body perfusion. Cardiopulmonary bypass protects the heart during cross clamping, but requires heparinization (a major disadvantage). Partial bypass with heparin-coated surfaces results in low mortality and less paraplegia, but the technique is not broadly available. Shunts have generally been abandoned. Endovascular techniques that are just now becoming common are promising, but their long-term and short-term benefits have yet to be proven [2].
The article by Holmes and associates in this issue of The Annals [3] describes a group of 145 patients with blunt aortic injury, 30 of whom were not operated upon during the first 24 hours of hospitalization. Fifteen of these were never surgical candidates because of advanced age or neurologic injury (NON OPERATIVE Group). Five of the fifteen died from severe head injuries. Of the ten survivors, five had injuries that resolved completely. The other fifteen underwent surgical intervention after a 24 or more hour delay (DELAY Group). Three of these patients died from aortic rupture, one preoperatively and two in the operating room.
It is common knowledge that a small percentage of patients with blunt aortic injury will present with what appears to be minimal injury, primarily intimal flaps. It is well documented that some of these will resolve or, at least, not progress—the renegade fact. The dilemma occurs when trying to differentiate between those patients with self-resolving or nonprogressive lesions and those whose aortas will disrupt. Based on the presented series, the authors recommend surveillance with helical computed tomography every 48 hours to interrogate the descending aorta. In spite of this, three of the fifteen patients in the delay group died from aortic rupture either prior to or during their operative procedures. In a prospective study of blunt aortic injury in the multi center trial sponsored by the American Association for the Surgery of Trauma, 274 patients were evaluated [4]. The overall mortality was 31% with 63% of the deaths resulting from aortic rupture. Twenty-two patients presented in extremis and died in spite of emergency room thoracotomy. Twenty-four patients experienced rupture during diagnostic work-up and died. Twenty-one patients were considered nonoperative due to age or associated injury. Eleven of these patients died from causes other than aortic rupture. Of the 207 stable patients who were operated upon, eight died from aortic rupture. It is clear that in-hospital rupture is still a major cause of death in this group of patients.
How does one deal with a renegade fact? One applies the preponderance of evidence to the situation. The overwhelming majority of patients with blunt aortic injury will die before reaching the hospital (up to 80% to 85% of these patients die at the scene of their accidents). With modern transportation and trauma services, approximately 1,000 patients make it to the hospital each year, many in extremis and others doomed due to other injuries. Some of these patients are not suitable candidates for operation, primarily because of closed head injury and brain death. The remaining patients are viable surgical candidates and, unless circumstances dictate otherwise, these individuals should undergo operation. The presence of a "minor" injury is no guarantee that rupture will not occur, the renegade fact not withstanding.
References
This article has been cited by other articles:
|
|
 |
|
  J. Kokotsakis, I. Kaskarelis, P. Misthos, T. Athanasiou, K. Kanakakis, C. Athanasiou, C. Romana, E. Skouteli, and A. Lioulias Endovascular Versus Open Repair for Blunt Thoracic Aortic Injury: Short-Term Results Ann. Thorac. Surg., December 1, 2007; 84(6): 1965 - 1970. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
