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Ann Thorac Surg 2006;81:343-345
© 2006 The Society of Thoracic Surgeons

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Case report

Anterior Approach to Traumatic Mid Aortic Arch Transection

^a Department of Surgery, Division of Cardiothoracic Surgery, Philadelphia, Pennsylvania, USA
^b Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

Accepted for publication August 30, 2004.

^_* Address correspondence to Dr Gleason, 3400 Spruce St, Silverstein 6, Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA 19103 (Email: thomas.gleason{at}uphs.upenn.edu).

	Abstract

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The majority of nonpenetrating traumatic injuries to the thoracic aorta are fatal. Survivors of aortic transection tend to have injuries occurring at the isthmus. We report a rare, blunt traumatic complete transection of the mid aortic arch between the innominate and left common carotid arteries diagnosed by multidetector computed tomography of the chest. The repair was approached anteriorly and required aortic arch replacement.

	Introduction

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Blunt trauma to the thoracic aorta can occur during motor vehicle accidents or falls from significant heights. These lethal injuries are due to a combination of direct and indirect compression and deceleration forces, which typically cause a transverse disruption of all three layers of the aortic wall [1]. The aortic isthmus (limited in its mobility by the ligamentum arteriosum, the paired intercostal arteries, and the left main stem bronchus) is the site of disruption in 93% to 95% of all blunt thoracic aortic injuries that survive to treatment [2, 3]. In contrast, survival after disruption of the aortic arch is extremely rare [4].

We describe a case of complete transection of the mid aortic arch between the innominate and left common carotid arteries in a 40-year-old female after a high speed motor vehicle accident. The patient was transferred directly from the accident scene to the emergency room. She was unrestrained and intoxicated. Upon arrival she complained of chest, neck, and wrist pain. She was thin, medium in height (170 cm), with no Marfanoid features other than a mild pectus excavatum. Initial trauma evaluation identified a nondisplaced C2 spine fracture and a right radial fracture. Multidetector helical computed tomography of the chest demonstrated transection of the mid aortic arch (Fig 1A, 1B). She was emergently taken to the operating room for repair of the aortic injury.

View larger version (87K): [in this window] [in a new window]   Fig 1. (A) Axial image from a multidetector helical computed tomography of the chest in a 40-year old female after a high speed motor vehicle accident demonstrates aortic transection (arrow) with pseudoaneurysm and large periaortic hematoma containing the free aortic rupture. (B) Volume rendering demonstrates the location of the transection between the takeoff of the innominate artery (InA) and left common carotid arteries (LCCA).

View larger version (94K): [in this window] [in a new window]   Fig. 2. Completed repair of the aortic arch reconstruction. The aortic graft is 26 mm and the bifurcated branch graft is 20 mm x 10 mm x 2.

Postoperatively the patient had a normal neurologic examination except for a left recurrent laryngeal nerve palsy. This was treated with Cymetra (LifeCell, Branchburg, NJ) injection into the left vocal cord to achieve temporary cord apposition. Her radial fracture was reduced and casted, and the C2 fracture was treated with a collar. The remainder of the patient's hospital course was uneventful. She was discharged home on postoperative day 12. She is now doing well 6 months postoperatively with a normal appearing computed tomographic angiogram.

	Comment

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The majority of patients sustaining aortic injuries die at the scene of their accident. Of approximately 15% of the patients who do survive the initial injury, the leading cause of in-hospital mortality is exsanguinating aortic rupture occurring in 20% of these patients [3]. Survival depends upon prompt diagnosis and repair. Aortic injury should be considered in patients sustaining any type of sudden deceleration or compression trauma. Hemodynamically stable patients should undergo expedient cross-sectional imaging, and a high resolution, contrast-enhanced multidetector helical computed tomography of the chest which is the initial method of choice at our institution. Imaging studies revealing intimal disruption and a periaortic hematoma should go to the operating room for definitive repair. Equivocal results should prompt a subsequent study, and repeat multidetector helical computed tomographic angiography with very thin collimation (0.625 to 0.75 mm) followed by 3-dimensional volume rendering of the data are our preferred secondary study [5]. Transesophageal echocardiography is excellent for evaluating the ascending and descending thoracic aorta, but does not allow for adequate examination of the aortic arch. Magnetic resonance imaging is impractical in these multi-trauma patients who require concurrent monitoring and resuscitation. Digital aortography is approaching obsolescence for evaluation of these injuries, but continues to have a limited role in equivocal cases. Aortic injuries in hemodynamically unstable patients are probably best evaluated in the operating room or during initial resuscitation by transesophageal echocardiography, which is portable.

Most traumatic aortic disruptions that present for repair occur at the aortic isthmus near the ligamentum arteriosum and just distal to the left subclavian artery. These injuries are best approached through a posterolateral thoracotomy in the 4th intercostal space. The pivotal preoperative data point in this case was the recognition that the transection appeared more proximal than usual. Scrolling review of the axial images at the time of presentation (see Fig 1a) depicted aortic transection near the left common carotid arterial takeoff, and this prompted an anterior approach to the injury. Retrospective 3-dimensional volume rendering of the original multidetector computed tomographic images clearly show the injury is proximal to the left carotid; however these images were not initially generated at the time of primary evaluation. The anterior approach facilitated superb control of the aortic arch and better myocardial and cerebral protection using combined continuous antegrade cerebral perfusion and antegrade cardioplegia during arch reconstruction than could be achieved through the left chest.

Left recurrent laryngeal nerve injury during aortic arch reconstruction occurs at a rate that is poorly defined in the literature but is probably underreported. In this case the nerve was not identified due to the extensive hematoma surrounding the transection and an inability to locate it. We advocate aggressive management of recurrent laryngeal nerve injury after aortic arch surgery with temporary Cymetra (LifeCell) medialization, subsequent surveillance, and eventual permanent medialization of the left vocal cord if no recovery is seen by 6 to 12 months postoperatively. This strategy has markedly reduced perioperative complications of dysphagia and aspiration related to recurrent laryngeal nerve injury in our institution.

Survival after aortic transection is dependent on both the extent of other associated injuries and the rapidity with which operative repair can be initiated. There are rare cases in which advanced patient age or associated injuries preclude safe operative repair (eg, extensive pulmonary contusions, intracranial hemorrhage, or exsanguinating pelvic injury). These patients should be managed medically with ß-blockade as tolerated to reduce aortic wall stress (p/t) until the aortic injury can be surgically repaired.

Endovascular thoracic aortic stent grafting for aortic transection is being studied actively in the United States and is performed routinely in many other parts of the world with good results. This less morbid, less invasive technique may ultimately become the standard of care if results prove equivalent to open repair; however endovascular repair would not be possible with mid-arch transection as in this case.

This case was unusual with regard to the location of the aortic injury and the anterior approach used for repair. We conclude that multidetector helical chest computed tomography is currently the optimal modality for initial evaluation of traumatic thoracic aortic injuries. Moreover, mid aortic arch transection is best approached anteriorly, as it provides excellent proximal aortic control and facilitates easy access for both myocardial and cerebral protection during arch reconstruction.

	References

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1. Parmley L, Mattingly T, Manion W. Nonpenetrating traumatic injury of the aorta Circulation 1958;17:1086.[Medline]
2. Razzouk AJ, Gundry SR, Wang N, et al. Repair of traumatic aortic rupturea 25-year experience. Arch Surg 2000;135:913.[Abstract/Free Full Text]
3. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injurymulticenter trial of the Amercan Association for the Surgery of Trauma. J Trauma 1997;42:374.[Medline]
4. Panagiotou MS, Protoyeros DM, Palatianos GM. Complete aortic arch transection after a blunt chest trauma Eur J Cardiothorac Surg 2001;19:84.[Free Full Text]
5. Tatli S, Yucel EK, Lipton MJ. CT and MR imaging of the thoracic aortacurrent techniques and clinical applications. Radiol Clin North Am 2004;42:565-585.[Medline]

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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): Thomas G. Gleason Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Leshnower, B. G. Articles by Gleason, T. G. Search for Related Content PubMed PubMed Citation Articles by Leshnower, B. G. Articles by Gleason, T. G. Related Collections Great vessels