Ann Thorac Surg 2004;77:703-704
© 2004 The Society of Thoracic Surgeons
Case report
Repair of stab-wound laceration of the aortic arch using deep hypothermia and circulatory arrest
Rainald Seitelberger, MDa*,
Jan Bialy, MDa,
Maria A. Rajek, MDb
a Department of Cardiothoracic Surgery, Vienna, Austria
b Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Allgemeines Krankenhaus, Vienna, Austria
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Seitelberger, Allgemeines Krankenhaus Wien, Abteilung Herz-Thoraxchirurgie, Waehringerguertel 18-20, 1090 Wien, Österreich, Austria
e-mail: seitel{at}magnet.at
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Abstract
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The surgical management of a 56-year-old patient with a single thoracic stab wound penetrating the left innominate vein and the aortic arch is described. Repair was successfully achieved using extracorporal circulation and circulatory arrest during deep hypothermia. Clinical features and surgical approach are described and discussed in detail.
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Introduction
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Penetrating injuries to major arteries within the area of the thoracic inlet are rarely encountered and offer a major surgical challenge due to the difficulties in preoperative diagnosis, choice of incision, and management of torrential bleeding [1]. In most reported cases of lacerations to the aortic arch with and without additional injuries of arch vessels, surgical repair has usually been performed without the use of cardiopulmonary bypass [2, 3]. However, operative mortality has been particulary high in patients with aortic arch injuries, usually due to the inability to properly control massive hemorrhage upon opening of the chest [2, 3]. The use of circulatory arrest during deep hypothermia in patients with injuries to the aortic arch may have a favorable impact in selected cases [4]. We discuss our management approach to a patient who presented with an isolated stab wound penetrating the left innominate vein and the aortic arch.
A 56-year-old patient, with an isolated stab wound about 3-cm long located parasternally at the level of the second intercostal space, was primarily admitted to a community hospital outside Vienna. At presentation, the patient was hemodynamically stable with a slightly lowered red blood cell count. However, the chest roentgenogram revealed a substantially widened mediastinum and the patient was transfered to a trauma unit within Vienna. Although the clinical situation was unchanged, doctors opted to transfer the patient to our hospital because their hospital did not include a cardiothoracic surgery department.
Upon arrival at our unit, which was about 3.5 hours after the initial trauma, the patient was conscious and hemodynamically stable, but presented with a decreased hemoglobin value (11.8 g/dL). A chest roentgenogram confirmed the widening of the mediastinum and an aortic angiography was scheduled. However, immediately before the patient was transferred to the Radiology Department, he suddenly deteriorated hemodynamically without any obvious reason, such as high blood pressure, physical agitation, or pain. An immediate intubation was required. Under moderate catecholamine support, stable hemodynamics were established. He was immediately taken to the operating room without prior angiography, where the surgical procedure started about 25 minutes after intubation.
Both femoral vessels were exposed and prepared for immediate cannulation. Upon opening of the chest through a median sternotomy, massive hemorrhage was encountered from the mediastinum, which was quickly controlled by applying digital pressure to the mediastinal tissue surrounding the aortic arch. Following systemic heparinization and opening of the pericardium, the femoral artery and the right atrium were cannulated and extracorporal circulation was instituted. The patient was cooled to 16°C and cold, antegrade blood cardioplegia was administered after the onset of ventricular fibrillation and consecutive aortic cross clamping.
Digital compression of the area surrounding the aortic arch laceration had to be continuously applied during the cooling period in order to avoid massive bleeding. Further inspection of the operating field during cooling also revealed an almost total transection of the left innominate vein. The vein was completely transected surgically and clamped on both sides to facilitate optimal visualization and surgical approach to the aortic arch until final reconstruction.
After hypothermic circulatory arrest was instituted at 16°C, the aortic arch was dissected from surrounding tissue to facilitate optimal exposure. The laceration of the aortic arch had a length of about 2 cm and extended laterally and distally from the origin of the right innominate artery to the origin of the left carotid artery. In order to establish full visual access to the posterior wall of the aortic arch, the laceration was surgically extended to a length of about 3 cm. Upon inspection an additional small, nontransmural laceration of the aortic wall was detected at the posterior wall of the aortic arch, opposing the site of the laceration and obviously caused by the very tip of the stab. This laceration was secured from inside the aortic lumen using a 5-0 polypropylene suture. The laceration-aortotomy was closed using a running 4-0 polypropylene suture after extensive deairing of the aortic arch by slowly restarting extracorporal circulation at low flow. The total duration of circulatory arrest was 8 minutes. During rewarming, reconstruction of the left innominate vein was accomplished by end-to-end reanastomoses of the vein. At 24°C, the aortic cross clamp was removed after deairing of the left heart and sinus rhythm was achieved soon thereafter. The patient could easily be weaned off bypass at normothermia and the surgery was completed under stable hemodynamic conditions. A total of 6 blood units were given during the surgery. He was extubated the next day without exhibiting any signs of a neurologic deficit, and transfered to the referring trauma unit on the seventh postoperative day, from where he was discharged home after another 5 days. Until 6 month postoperatively, no further complications occurred.
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Comment
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The management of penetrating injuries to major arteries within the thoracic inlet remains a surgical challenge. Under ideal conditions, the entry site of the laceration should be evaluated by angiography in order to plan the optimal surgical approach and select the site of incision. However, especially in cases of injuries to the aortic arch, initial control of massive bleeding upon opening of the chest is extremely difficult and usually the primary cause of surgical failure [3]. Various surgical methods (insertion of local shunts, tangential partial or intermittent complete aortic occlusion, caval occlusion, or induction of ventricular fibrillation) have been used to control bleeding or facilitate repair [2, 3, 5]. In general, most patients with aortic arch injuries have been managed without the use of cardiopulmonary bypass and deep hypothermia, which may, in part, explain the significantly higher mortality when compared with injuries confined to aortic arch branches [2, 3].
Deep hypothermia and circulatory arrest offers optimal exposure of the aortic arch in a bloodless field and enables the surgeon to inspect the entire aortic arch from within the lumen. This is of particular advantage in patients with injuries to the posterior wall of the aortic arch, which are extremly difficult to expose and repair from outside the lumen or may even remain undetected. In addition, this technique is associated with a very low complication rate within a period of 45 minutes of circulatory arrest.
The sudden hemodynamic deterioration in our patient forced us to opt for immediate surgery without prior angiography. Because the site of the stab wound associated with a widened mediastinum strongely indicated an injury including the aortic arch, we decided to perform a median sternotomy after exposure of both femoral vessels. The initiation of cardiopulmonary bypass before sternotomy has been associated with uncontrollable hypotension during cooling, probably due to uncontrolled blood loss to the mediastinum or pericardial space [4]. Therefore, we decided to open the sternum before going on bypass. Although initial hemorrhage was massive, we were able to quickly control bleeding by digital compression, immediately start extracorporal circulation and procede with systemic cooling under stable hemodynamic conditions. The advantage of repairing the laceration under conditions of ciculatory arrest and full intraluminal inspection of the aortic arch is also illustrated by the fact that we were able to detect and repair a second laceration at the posterior wall of the aortic arch. Although this laceration was not complete, it could have eventually induced the formation of a false aneurysm or an aortic dissection [3].
In conclusion, the experience from this single patient indicates that cardiac arrest during deep hypothermia is a valuable option with injury of the aortic arch. The exposure of femoral vessels before or during the thoracic incison facilitates rapid instigation of cardiopulmonary bypass in cases of massive hemorrhage upon opening of the thorax.
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References
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Abstract
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