Ann Thorac Surg 2004;78:2157-2159
© 2004 The Society of Thoracic Surgeons
Case report
Combined Blunt Aortic and Bronchial Injury
Poo-Sing Wong, FRCS (CTh)a,*,
Ramesh R. Koirala, MDa,
Chuen-Neng Lee, FRACSa
a Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, National University of Singapore, Singapore
Accepted for publication August 6, 2003.
* Address reprint requests to Dr Wong, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, National University of Singapore, 5 Lower Kent Ridge Rd, Singapore 119074
surwps{at}nus.edu.sg
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Abstract
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We report the case of a 29-year-old man with left blunt chest trauma resulting in an intimal tear of the proximal descending aorta, for which he underwent successful thoracic endovascular graft stenting. He subsequently developed progressive left lung collapse, and bronchoscopy revealed left bronchial disruption. A left thoracotomy with end-to-end anastomosis of the left bronchus was performed successfully. The literature from 6 other similar cases of concomitant aortic and bronchial injuries was reviewed.
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Introduction
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One half of all trauma fatalities involve some form of chest injury, with 20% of these fatalities attributed to blunt aortic injury [1]. In a victim of a major accident with suspected thoracic injury, there must be prioritization of the treatment of potentially fatal injuries. We present the case of a patient with blunt aortic injury with concomitant left bronchus injury. The latter was diagnosed only 7 days after the accident.
A 29-year-old Chinese man had a motorcycle collision with a bus coming from the opposite direction. On admission, he was conscious and well orientated, with a normal Glasgow coma score. He had multiple soft-tissue abrasions, a displaced fracture of the left clavicle, left fourth to eighth ribs flail segment, and left hemopneumothorax. Despite these injuries, the patient maintained stable respiratory status and adequate blood pressure. A left chest tube was inserted with the initial drainage of 800 mL blood and a minor air leak. Because of a widening of the mediastinum seen on a chest roentgenogram, contrast chest computed tomography (CT) was performed. This showed a dissection flap involving the aorta just after the origin of the left subclavian artery (Fig 1), with extension into the abdominal aorta. There was extensive mediastinal hematoma. Propranolol infusion was started to keep the patient's systolic blood pressure at about 90 mm Hg. Urgent endoluminal stenting of the descending thoracic aorta with a size 30, 100-mm thoracic endovascular stent graft (Talent, Medtronic AVE, Santa Rosa, CA) was successfully deployed across the tear covering the origin of the left subclavian artery. A postprocedure angiogram demonstrated patent right innominate and left common carotid arteries. The air leak from the chest drain resolved, with full expansion of the left lung. The patient continued to be on supplementary oxygen, keeping his oxygen saturation above 92%. However, serial chest roentgenograms showed progressive left lung collapse. Oxygen saturation deteriorated to 75% despite continuous positive airway pressure mask ventilation. A flexible bronchoscopy was therefore performed, but the scope was unable to negotiate through an "occluded" distal left bronchus. In view of the mucosal flap obstructing the left bronchus, the patient was then sent for rigid bronchoscopy. It showed a complete transection of the distal left bronchus. So, on the 7th day after admission, the patient underwent a left thoracotomy. It was found that he had a completely collapsed left lung, with contusion and consolidation of the upper and lingular lobes, total transection of the left bronchus between the upper lobe takeoff and lower lobe bronchi. The margins were freshened, and bronchial anastomosis was performed with 3-0 polypropylene in continuous manner. There was also extensive mediastinal hematoma. Postoperatively, the patient's condition improved dramatically. He was extubated on the 4th postoperative day, and he was discharged home on the 13th postoperative day, with the chest radiograph showing resolving left lower lobe collapse. Computed tomography performed 10 weeks after discharge showed a fully expanded left lung and a stable aortic stent position, with no endoleak. The patient was well 9 months after the injury.
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Fig 1. Contrast computed tomography showing the intimal flap involving the proximal descending aorta (large arrow) and retrospectively revealing the transection of the left bronchus after the origin of the upper lobe bronchus (small arrow). There was also extensive pulmonary contusion, hemothorax, and mediastinal hematoma. (Reprinted from Pasic M, et al. Chest 2000;117:1508–10 [6], with permission.)
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Comment
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Aortic rupture is a major cause of fatalities in all motor vehicle collisions. Blunt traumatic aortic rupture was found to occur in 21% of car occupant deaths in a study of road traffic accidents in the United Kingdom, and the possible mechanisms of injury are well documented [1]. A recent review of 265 patients with blunt tracheobronchial injury showed that 59% were due to motor vehicle accidents, and injuries to the right main bronchus were treated sooner but were associated with a higher mortality than left-sided injuries [2].
Concomitant thoracic aortic and major tracheobronchial injuries are rare. In our review of the medical literature, we found a total of 6 other similar patients [3–8]. All were male and of young age (7 to 37 years), and the mechanism of injury was rapid acceleration-deceleration. At presentation, 4 patients had pneumothoraces, 1 patient presented late (7 weeks) with the complete collapse of the right lung, and another presented with pneumomediastinum. None of the patients had persistent air leaks with lung collapse or the classic "fallen lung sign." The degree of respiratory distress depends on the amount and rate of air loss, which in turn depends on the degree the airway is disrupted and whether or not there is free communication between the site of disruption and the pleural space. Five cases had bronchial injuries on the left side: 2 at the origin, 1 at 2.5 cm beyond the carina, and 2 with transection after the upper lobe bronchus. The 7-year-old patient had a distal tracheal tear extending into the left main bronchus.
It was noted that in all 6 cases, the modes of diagnosis were different. Thorax CT is a good noninvasive investigation but should not be used as a solitary study for blunt aortic injury. It was negative for an aortic tear in 1 case, and for bronchial injuries, it was negative in all cases. Aortography is still the gold standard for the diagnosis of aortic injury. Transesophageal echocardiography was done in only 1 case at initial presentation, and it was not diagnostic. In this series review, 4 patients had bronchoscopy because of a high level of suspicion and were diagnosed before their operations. One patient was diagnosed as having an injury to the left lower lobe bronchus during thoracotomy for aortic repair, which was not suspected preoperatively, and another patient had his bronchial injury diagnosed preoperatively, albeit 7 weeks after the initial injury, using chest tomography in the 1960s. However, in our case, a flexible bronchoscopy examination should have been performed earlier. Retrospective review of the thorax CT showed the transection of the left bronchus after the upper lobe bronchus takeoff (Fig 1).
We found wide variations regarding the time of intervention and the site of incision, mainly due to the preference of the surgeon and gravity of the injuries. The problem faced by surgeons in managing these patients with multiple injuries is that the associated injuries are often serious in their own right, and they can be further complicated by various aspects of standard surgical repair of the aorta, including positioning, lateral position for thoracotomy, single-lung ventilation, systemic anticoagulation, cardiopulmonary bypass, and cross-clamping of the aorta.
Until now, there have been too few reports on these types of concomitant aortic and tracheobronchial injuries to narrate a consensus for managing such cases. All had different presentations, timings, and ways of management, though all the reported cases had favorable outcomes. However, we can say that in cases of major blunt chest trauma, suspicion should focus not only on the aorta but also on the nearby mediastinal structures, and patients with suspected tracheobronchial injuries should therefore undergo immediate bronchoscopy to evaluate their airway.
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References
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Abstract
Introduction
