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Ann Thorac Surg 2002;73:1149-1154
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis

^a Virginia Mason Medical Center, Seattle, Washington, USA
^b Harborview Medical Center, University of Washington, Seattle, Washington, USA

Accepted for publication November 26, 2001.

* Address reprint requests to Dr Karmy-Jones, University of Washington-Harborview Medical Center, Cardiothoracic Surgery, Box 356310, Seattle, WA 98195-6310 USA
e-mail: karmy{at}u.washington.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear.

Methods. A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group.

Results. One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 ± 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 ± 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 ± 22 versus 36 ± 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 ± 9 versus 32 ± 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms.

Conclusions. Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Traditionally, traumatic rupture of the thoracic aorta (TRA) has been considered an absolute surgical emergency with immediate repair being the standard of care. This approach is based on Parmley’s seminal study in 1958 that documented a death rate at the scene of as high as 85% and a subsequent mortality rate in nonoperated survivors of 1% per hour for the first 48 hours [1]. Subsequently, it has become recognized that acute mortality may be as low as 40% to 70% and that patients admitted with TRA fall into two broad categories [2, 3]. A small number, approximately 5%, are hemodynamically unstable or deteriorate within 6 hours of admission. All cause mortality in this group invariably exceeds 90%. The remainder are hemodynamically stable and afford time for workup and staging of any intervention. The mortality in this latter group, as low as 25%, is rarely from free rupture if blood pressure is controlled but more commonly a consequence of associated injuries.

It has been shown that maintaining the systolic blood pressure below 120 mm Hg or mean arterial pressure less than 80 mm Hg significantly reduces the risk of rupture [4–7]. This is valuable information because in a substantial number of cases, associated injuries or comorbidities make the risks of immediate operation prohibitive [4, 7–10]. A number of reports have documented that it is possible to delay operative repair for extended periods [4, 5, 7, 8, 10–12]. Some aortic injuries may resolve during a period of observation whereas other injuries may ultimately develop into chronic pseudoaneurysms with the apparent natural history of nontraumatic aortic pseudoaneurysms [4, 6, 8, 13–15]. However, there are essentially no data that document regular radiographic evaluation of TRA managed nonoperatively. While there is hope that "small" injuries will not require operation, there is still a risk that they may increase in size or even rupture (Fig 1). The primary goal of this study was to review the natural history of TRA managed nonoperatively in a contemporary setting.

View larger version (78K): [in this window] [in a new window]   Fig 1. The traumatic rupture of the thoracic aorta dilemma. (A) Intimal flap (arrow) in a 49-year-old man that resolved without operation. (B) Intimal flap (arrow) in a 33-year-old man that progressed to free rupture and death on postinjury day 5.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

Patients who were not operated upon within 24 hours of injury and diagnosis were considered as having undergone a period of nonoperative management. These patients were then divided into two groups: DELAY and NON-OP. DELAY patients were operative candidates for whom surgery was postponed, either because of a delay in diagnosis or because of severe associated injuries. NON-OP patients were never considered for operation because of high-risk criteria, including severe associated injuries, advanced age, or other severe premorbid conditions.

The presence of cardiac risk factors, closed head injury, pulmonary injury, and advanced age was determined by criteria similar to those previously reported by other investigators [7, 8]. Cardiac risk factors were defined by the presence of one or more of the following: echocardiographic or visual operative description of segmental ventricular wall motion abnormalities, necessity for inotropic support, prior coronary artery bypass, or ongoing treatment of angina pectoris. Closed head injury was determined by an abnormal head CT scan (hemorrhage or edema), elevated intracranial pressure, or a low Glasgow Coma Score (GCS). Pulmonary injury was defined as pulmonary contusion identified on chest imaging with one or more of the following: PaO₂/FiO₂ less than 300 mm Hg, inability to tolerate single-lung ventilation, or positive end-expiratory pressure requirements of at least 7.5 cm H₂O to maintain satisfactory oxygenation. Coagulopathy was defined by one or more of the following: extensive nonsurgical bleeding, international normalized ratio (INR) more than 1.5, or laboratory evidence of consumption (elevated fibrin split products, platelet count < 100,000). Advanced age was defined as older than 55 years.

Results are expressed as the mean ± standard deviation or median with ranges, as indicated. Univariate analysis was performed using the ² test for categorical data. When a 2 x 2 table had 1 or more cell with an expected frequency of less than 5, Fisher’s exact test was used. The independent pairs t test, with Levene’s test for equality of variances, was used for continuous variables. All statistical analyses were performed with SPSS 7.5 for Windows (SPSS, Inc, Chicago, IL). Approval was obtained from the respective institutional review boards before commencing the study.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Over the approximately 16-year study period, 145 patients were admitted to Harborview Medical Center with TRA. Urgent operative repair was performed in 107, with 34 deaths (32%). Recognizing that this population was extremely heterogeneous, among patients who survived long enough to have a neurologic examination the incidence of paralysis was none of 48 when mechanical circulatory support was used and 7 of 34 when the "clamp-and-sew" technique was utilized. Endovascular stent grafts were used in 8 patients, 3 of whom died because of closed head injury and a fourth owing to cardiac decompensation with hemorrhage during emergent placement. Thirty patients (20%) underwent a period of nonoperative management and comprise the study group.

Fifteen patients, representing the DELAY group, underwent operation after a median of 3 days (range 2 to 90). Their mean age was 36 ± 18 years with a mean ISS of 32 ± 8. The most common reason for delayed surgical intervention was missed diagnosis (47%, n = 7), all of whom were transferred from outside institutions. Seven patients (47%) had surgery postponed to allow for treatment or resolution of concomitant severe injuries—7 pulmonary injuries, 2 cardiac contusions, and 4 closed head injuries. In a single patient, the diagnosis of TRA was uncertain.

During the observation period antihypertensive agents were used in 6 DELAY cases. Serial radiographic evaluations using either CT or angiography were performed on all 15 patients. In 3 cases this documented that the injury was increasing in size (Table 1 and Fig 2), and emergent attempts at repair were performed. Three of 15 patients (20%) in the DELAY group ultimately died: 1 owing to preoperative rupture and 2 owing to intraoperative cardiac arrest. Of note, 2 of the 3 deaths occurred in patients whose initial TRA had progressed. The patient who ruptured, a 33-year old man, was clinically stable and a late transfer with an intimal flap that had been missed at the referring hospital (Fig 1B). He was not given antihypertensive therapy but his systolic blood pressure ranged from 110 to 140 mm Hg throughout hospitalization. A sudden change in his mediastinal silhouette on postinjury day 5 prompted an angiogram but while awaiting repair, the injury acutely ruptured. All cases of injury progression or rupture occurred within 5 days of injury.

View larger version (99K): [in this window] [in a new window]   Fig 2. A DELAY group patient, a 40-year-old man, with progression of traumatic rupture of the thoracic aorta. (A) Admission helical chest computed tomography (CT) scan with pseudoaneurysm (arrow) in descending thoracic aorta. (B) Four-day follow-up chest CT demonstrating enlargement of pseudoaneurysm by 1 cm (arrow).

Five of 15 patients (33%) in the NON-OP group died, all owing to head injuries. There were no TRA-related deaths among the NON-OP patients. Six patients were treated with antihypertensive drugs. During follow-up, no NON-OP patient has experienced progression of the initial TRA (Table 2) or required surgical intervention. At median follow-up of 2 and a half years (range 6 months to 5 years), all 10 survivors in the NON-OP group are alive and well. Five of the injuries are stable as asymptomatic chronic pseudoaneurysms (Fig 3), and 5 have radiographically resolved.

View larger version (104K): [in this window] [in a new window]   Fig 3. A NON-OP group patient, a 69-year-old woman, with intimal flap and stable pseudoaneurysm. (A) Admission computed tomography (CT) scan with flap and small pseudoaneurysm (arrow). (B) Ten-day follow-up CT with stable small pseudoaneurysm (arrow). (C) CT at 2 months postinjury without change (arrow).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
In the past decade there has been a change in the philosophy of managing TRA with emphasis on blood pressure control and assessing the need for emergent repair against the risks of operation due to associated injuries or premorbid conditions [3]. Certain patients appear to be at acute risk of free rupture [16]. On the other hand concomitant injuries, in particular intraabdominal solid organ injuries associated with frank bleeding, often take precedence over the immediate repair of an aortic injury [17]. Reported indications for delay or complete avoidance of surgery include significant head, cardiac, or pulmonary injuries and advanced age [4, 7–10, 18]. Warren and associates [19] documented that 7 of 37 (19%) patients admitted with TRA underwent delayed intervention ranging from 1 day to 4 months to allow recovery from associated injuries. Pierangeli and associates [20] noted that of 29 patients with TRA who were initially managed medically, 21 (72%) underwent elective repair at a mean of 8.6 months; an acute rupture developed in 1 patient and 2 required emergent operation because of enlargement. Likewise, Pate and colleagues [4] noted that 15 of 47 (32%) patients underwent delayed operative repair of TRA ranging from 2 days to 25 months to allow stabilization of associated injuries. Further, Maggisano and associates [8] reported that 31 of 59 (53%) patients with TRA underwent delayed repair ranging from 1 day to 7 months to allow resolution of concomitant severe injuries.

Careful blood pressure control in stable patients with TRA is central to nonoperative management. Formal pharmacologic protocols were utilized in the above-mentioned studies before operation. Their combined experience included 4 free ruptures (5%) that occurred within 72 hours of injury. It has been argued that during any period of delay in stable patients the administration of antihypertensive medications to prevent extension of injury has become the standard of care [21]. In summarizing the surgical literature, Mattox and Wall [2] found more than 500 patients who were managed with a deliberate delay in surgery, 10% of whom were still not operated on at the time of their review. Approximately 2% of these patients experienced rupture, all of whom developed blood pressure increases above preinjury levels.

Our experience is consistent with the literature to date in many respects yet provides some new insight about the treatment of TRA. Of all patients admitted with TRA approximately 20% underwent either delayed operative intervention or no operation. The primary reasons were missed TRA or associated injuries in the DELAY group and associated injuries coupled with other high-risk criteria in the NON-OP group. Although the NON-OP patients were significantly older than the DELAY patients, age was never solely used as a criterion to direct treatment. The 6 NON-OP patients with advanced age (range 69 to 86 years) invariably sustained multiple other injuries and had premorbid chronic diseases. Age alone probably should not determine whether to defer or withhold operating for TRA; however, our numbers are too small to allow meaningful analysis of outcome with nonoperative management after TRA as a function of age. Nonetheless, advanced age in a patient suffering TRA should make one keenly aware of the potential for physiologic frailty or high-risk premorbid conditions common to this age group to exacerbate concomitant injuries and adversely affect operative outcomes.

It is clear that select patients with TRA can be managed without operation. These include patients sustaining concomitant cardiac, pulmonary, head, or intraabdominal injuries with or without high-risk premorbid conditions to include age more than 55 years, aortic arteriosclerosis, or ischemic heart disease. Intuitively, the case for nonoperative management of TRA becomes stronger as more high-risk criteria accumulate with a given patient. We propose that if nonoperative therapy is pursued the TRA should be followed serially with the same radiologic test as was employed to make the original diagnosis. We now preferentially use helical CT every 48 to 72 hours for the first 7 days postinjury, believing that it is very effective in interrogating the descending thoracic aorta [11, 22]. While goals such as a mean arterial pressure of less than 80 mm Hg or systolic blood pressure of 120 mm Hg or less may be ideal, it is often more practical to use the admission blood pressure, or preinjury blood pressure if this can be documented, as a base line. Then, utilizing ß-blockers and vasodilators the blood pressure should be maintained below the established base line provided that the patient’s hemodynamic status will tolerate it.

All-cause mortality was comparable between the NON-OP and DELAY groups, 33% and 20%, respectively (p = 0.70). However, if one looks at TRA-related mortality there is a trend toward lower mortality in the NON-OP group (0% versus 20%; p = 0.22). Apart from the 5 patients who succumbed to head injury between 3 and 30 days postinjury, the remaining 10 NON-OP patients have done well. Half of the patients have evolved stable, asymptomatic, chronic pseudoaneurysms (Fig 3), while the TRA has healed in the other half as demonstrated on subsequent follow-up imaging. In other words, all salvageable yet severely injured patients who we considered too high risk for surgery survived without operation and have suffered no untoward aortic-related events. That appears to validate our selection criteria and management protocol for nonoperatively treating TRA. Continued follow-up is obviously required for the patients with chronic pseudoaneurysms, and operative repair may eventually be necessary for patients who become symptomatic. We currently recommend and employ stringent, long-term blood pressure control and at least annual chest CT after discharge to follow patients we have managed nonoperatively. The true long-term natural history of a posttraumatic aortic pseudoaneurysm is still unclear.

Our data are clearly limited by the small numbers and the retrospective nature of the study. Nonetheless the results demonstrate that delayed free rupture can still occur even with "small" injuries. This finding reinforces the importance of aggressively pursuing the diagnosis of TRA. The data also suggest that the major risk of injury progression or rupture is within the first 5 days after TRA. We hypothesize that soon after this time period, the intense inflammatory changes that occur in the peri-aortic soft tissues result in formation of a more stable pseudoaneurysm. Despite the small but finite risk of free rupture, the data do support the concept that nonoperative management of TRA can be utilized safely in selected cases. In some cases of smaller aortic tears the lesion may heal on its own. However, given that progression and rupture were documented only in patients with small injuries, the reason for avoiding operation should not be based solely on the size of the lesion but also on reported high-risk, physiologic criteria.

TRA remains a severe injury with a significant risk of death. As many as 20% of patients, however, may not be candidates for immediate repair. These patients typically have multiple severe associated injuries or high-risk premorbid conditions. They can be managed nonoperatively, including radiologic surveillance, and experience acceptable outcomes. To this end antihypertensive agents should be employed judiciously to reduce the risk of free rupture. Serial radiographic evaluations, preferably with helical CT or the same modality used for the initial diagnosis, should be performed at 2- to 3-day intervals for the first week after injury, as this is the period of greatest risk for TRA progression.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): R. Alan Hall Riyad C. Karmy-Jones Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Holmes, J. H. Articles by Karmy-Jones, R. C. Search for Related Content PubMed PubMed Citation Articles by Holmes, J. H., IV Articles by Karmy-Jones, R. C. Related Collections Great vessels