Ann Thorac Surg 2002;74:2191-2192
© 2002 The Society of Thoracic Surgeons
Case report
Median sternotomy and extended left anterior thoracotomy for repair of traumatic aortic transection with ruptured right atrium
Dong Kang, MDa*,
Duncan S. Thomson, FRACSa,
Kiyoshi Doi, MDa,
Allen N. James, FRACSa
a Department of Cardiothoracic Surgery, John Hunter Hospital, New South Wales, Australia
Accepted for publication July 12, 2002.
* Address reprint requests to Dr Kang, Department of Cardiothoracic Surgery, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, NSW2310, Australia.
e-mail: kangdong{at}hotmail.com
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Abstract
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A 22-year-old man presented with traumatic aortic transtion associated with rupture of the right atrium and underwent urgent median sternotomy to repair the right atrium. A T-shaped extended left anterior thoracotomy was performed, and ruptured descending thoracic aorta was repaired under total bypass. A Y-shaped connector was inserted in the arterial catheter to allow cannulation of both ascending aorta and femoral arteries. A 4-cm long Hemoshield graft was used to repair the aortic transection. The patient made a full recovery and was discharged 13 days after the accident.
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Introduction
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Traumatic aortic rupture is highly lethal and often associated with other major injuries. The repair is normally through a left thoracotomy. The technique of repair includes a clamp-and-sew partial or total bypass. Paraplegia is still a risk after this procedure.
A 22-year-old man was involved in a high-speed motor vehicle accident and presented to the Emergency Department within half an hour of the accident. His blood pressure was 80/60 mm Hg; pulse was 125 beats/minute with elevated jugular venous pressure. Chest roentgenogram revealed widened mediastinum. Contrast-enhanced computed tomography of the chest indicated a rupture of the descending thoracic aorta distal to the origin of the subclavian artery. There was also a large mediastinal hematoma, left hemothorax, and a moderate-sized hemopericardium (Fig 1).
Aortogram confirmed the diagnosis of ruptured aorta (Fig 2).
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Fig 1. Computed tomographic scan indicating rupture of the descending thoracic aorta distal to the origin of the subclavian artery, as well as a large mediastinal hematoma, left hemothorax, and moderate-sized hemopericardium.
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In the operating room, a single-lumen endotracheal tube was used. The left femoral artery was cannulated while median sternotomy was performed using a Cooley retractor. The pericardial cavity was full of blood and clot. There was a 1-cm long tear in the right atrium just below the appendage on the superior surface. Bypass was established with two-stage venous cannulation into the right atrium and an arterial catheter to the femoral artery. The atrial tear was closed with a continuous 4.0 Prolene suture (Ethicon, Somerville, NJ) because it was not in a good site for atrial cannulation. Cooling was commenced to 30°C. The ascending aorta was also cannulated, and a Y-shaped connector was used in the arterial catheter to perfuse both the upper and lower body through the aorta and femoral artery. The sternotomy incision was then extended into the left thoracic cavity through the third intercostal space. Blood was found in the left pleural cavity, and there was a large mediastinal hematoma. While we attempted to dissect out the aorta in the region of the left subclavian artery, the false aneurysm was entered and the patient bled into the left chest. At this stage the core temperature was 30°C, so the heart-lung machine was turned off for 3 minutes until the two ends of the transected aorta could be identified. The proximal and distal ends of the ruptured aorta were mobilized and clamped. Bypass was then recommenced. A 4-cm section of a 20-mm diameter Hemoshield graft (Boston Scientific, Wayne, NJ) was used to repair the aorta. The suture lines were then sealed with Bioglue (Boston Scientific, Wayne, NJ) with good hemostasis. The patient was rewarmed, and the bypass was withdrawn easily. Total bypass time was 111 minutes, and clamp time was 47 minutes. The patient made a full recovery and was discharged 13 days after the procedure.
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Comment
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Traumatic aortic transection is a highly lethal injury that is commonly associated with other organ injuries. The incision is performed routinely through a left thoracotomy. Techniques include clamp-and-sew or partial or total bypass. Paraplegia remains a devastating complication. Sweeney and associates [1] reported that the clamp-and-sew technique carries no higher risk of paraplegia than other techniques. Other studies found that partial or total bypass reduced the risk of paraplegia, and clamp time longer than 30 minutes increased the risk of paraplegia [2–4]. The timing of the operation remains controversial. It has been reported that most patients will die before reaching the hospital, and it is estimated that half of the survivors will die within 24 hours, with 75% within a week if no definitive treatment is offered [5]. However a few studies showed good results of delayed repair in some circumstances [6]. The operative mortality rate for aortic transection was 18% in a study by Von Oppell and colleagues [5].
In conclusion, this was a unique case of traumatic aortic transection associated with rupture of the right atrium. The decision to perform immediate median sternotomy was made on both clinical grounds of tamponade and from the computed tomographic scan of the chest. Transesophageal echocardiography was not routine in our institution. Femoral cannulation enabled us to commence bypass promptly after the chest was opened. The repair of the ruptured right atrium was made easier on bypass through the sternotomy incision.
Cannulation of the ascending aorta and femoral artery provided perfusion to the upper and lower body and might have reduced the risk of paraplegia. It also allowed us to retrieve the situation when the patient bled into the left chest. The ruptured aorta was repaired through a T-shaped incision (Fig 3).
Although the exposure was difficult, it was feasible in this situation. Left heart bypass would have been difficult in this case when single-lumen intubation was used and the patient was in supine position.
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References
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- Sweeney M.S., Young D.J., Frazier O.H., et al. Traumatic aortic transection. Eight-year experience with the "clamp sew" technique. Ann Thorac Surg 1997;64:384-389.[Abstract/Free Full Text]
- Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury. Multicenter trial of the American Association for the Surgery of Trauma. J Trauma 1997;42(3):374–83
- Nicolosi A.C., Almassi G.H., Bousamra M., II, et al. Mortality and neurological morbidity after repair of traumatic aortic disruption. Ann Throac Surg 1996;61:875-878.
- Attar S., Cardarelli M.G., Downing S.W., et al. Traumatic aortic rupture. Recent outcome with regard to neurologic deficit. Ann Thorac Surg 1999;67:959-965.[Abstract/Free Full Text]
- Von Oppell U.O., Dunne T.T., De Groot K.M., Zilla P., et al. Traumatic aortic rupture: 20-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994;58:585-593.[Abstract]
- Galli R., Pacini D., Di Bartolomeo R., et al. Surgical indication and timing of repair of traumatic ruptures of the thoracic aorta. Ann Thorac Surg 1998;65:461-464.[Abstract/Free Full Text]
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Abstract
Introduction
