Ann Thorac Surg 2006;82:e1-e2
© 2006 The Society of Thoracic Surgeons
Case report
Right Diaphragm Rupture With Extended Traumatic Dissection of the Descending Aorta
Charalambos Zisis, MD, PhD
a
,
*
,
Sokratis Fragoulis, MD
a
,
Ioannis Kaskarelis, MD, PhD
b
,
Panayiotis Dedeilias, MD
a
,
Konstantinos Bolos, MD
a
,
Ion Bellenis, MD, PhD
a
a Department of Cardiothoracic Surgery, "Evangelismos" Hospital, Athens, Greece
b Department of Interventional Radiology, "Evangelismos" Hospital, Athens, Greece
Accepted for publication March 27, 2006.
* Address correspondence to Dr Zisis, 17A, Patriarchou Grigoriou str, 16674 Glyfada, Greece (Email: chzisis{at}otenet.gr).
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Abstract
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A 45-year-old man, with severe thoracic injury from a motor accident, is reported with traumatic aortic dissection type B and projection of the liver into the thoracic cavity due to a large rupture of the right hemidiaphragm. The patient was successfully managed with endoluminal stent placement in the descending thoracic aorta, and right thoracotomy for the repair of the diaphragmatic hernia. His postoperative course was uneventful. The co-existence of aortic traumatic dissection and right diaphragmatic rupture in trauma patients has never been reported in the literature previously, to our knowledge. Furthermore, the initial x-ray examination findings advocated injury of the right hemithorax and could be misleading. The diagnostic assessment must have a high index of suspicion, whereas the surgical manipulation needs to be fast and targeted to the major thoracic injuries of the patient.
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Introduction
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Blunt injury of the chest due to a car accident can be very violent and crushing forces that develop can be disastrous. Both acute traumatic diaphragmatic hernia and traumatic aortic dissection are serious injuries to occur. The triad of pelvic fractures, left hemidiaphragmatic rupture, and blunt injury to the thoracic aorta is well described. The diagnostic assessment of the trauma patients needs to be cautious, and treatment has to be particularly customised to the necessities of the managed case.
A 45-year-old policeman, with a history of intermittent alcohol abuse, had a serious motor accident, when his car capsized. He was initially admitted to a district hospital and referred to our clinic because of the severity of his condition. The chest x-ray revealed fractures of the right 8th–10th ribs with hemothorax, elevation of the homolateral hemidiaphragm, and mediastinal widening (Fig 1). Computed tomography of the chest after an intravenous contrast injection showed the rib fractures on the right with projection of the liver into the right pleural cavity and traumatic dissection of the descending aorta, starting from the left subclavian artery and extending distally (Figs 2,
3).
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Fig 2. Chest computed tomographic scan demonstrating the projection of the liver into the right pleural cavity and the traumatic dissection of the descending aorta.
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Fig 3. Chest computed tomographic scan showing the dissection along the thoracoabdominal axis of the aorta in sagittal plane.
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Hence, he was admitted to our hospital Emergency Department 8 hours after the accident. On arrival, he was hemodynamically stable, in respiratory distress and pain, with a tube thoracostomy of the right pleural space. The patient was taken to the operating room and was successfully managed in three consecutive steps: 1) placement of an intraluminal stent graft into the descending aorta; 2) laparoscopy, in which all abdominal organs were found intact with no signs of intrabdominal bleeding, and efforts concentrated on repairing the diaphragmatic rupture; and 3) reconstruction of the right hemidiaphragm with right thoracotomy through the sixth interspace. A large radial defect (nearly 10 cm) was discovered, and the ruptured diaphragmatic rims were grasped with Babcock clamps and sutured with Silk 1.0 in 2 rows. Spending 3 days in the intensive care unit (Fig 4), the patient was discharged from hospital on the 10th postoperative day after an uneventful course and is doing well 3 months later.
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Fig 4. Postoperative x-ray of the patient (4th postoperative day) with the endoluminal stent graft in the descending aorta and the right diaphragm repaired in its normal position.
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Comment
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To our knowledge, it is the first time such a case of right diaphragmatic rupture and traumatic descending aortic dissection is presented. Only one case of endovascular treatment of traumatic aortic dissection combined with diaphragmatic rupture has been published in the literature, but both injuries were inflicted on the same side (left). In that case the left hemidiaphragm was repaired first and the thoracic aorta dissection was subsequently treated with endovascular stent graft [1]. In our case, the traumatic aortic dissection was a life-threatening condition that could cause serious complications or further extension of the intimal tear; for that reason, its management took priority over the diaphragmatic rupture to avoid hemodynamic destabilization of the patient, neurologic implications or impairment in the functional integrity of vital structures such as the liver, the intestine, and the kidneys. Emergency endovascular stent grafting of a traumatic thoracic aortic dissection in a patient with multiple injuries has been reported [2], and the policy of endoluminal stent graft placement has been established as the valid option with low mortality rate, whereas the surgical procedure presents significant morbidity and mortality, with similar therapeutic result in middle-term follow-up [3]. Therefore, such a policy would also be chosen even if no other injuries existed in this patient. Both anaesthetic management and surgical manipulations were essentially facilitated afterwards, and the transthoracic approach offered good access for diaphragmatic reconstruction.
Predictors of blunt diaphragmatic rupture have been described, such as the age, the Injury Severity Score, and the patient's hemodynamic status [4], whereas data about prognosis of the traumatic descending aorta dissection are not sufficient. This lucky patient had some happy coincidences: there was no high-volume active bleeding to destabilize him; an early careful assessment of his x-ray showed that his trauma was multiple, complicated and potentially lethal; his management was as fast as possible and presented no complications; the intensive care unit helped him with a fast successful resuscitation.
Readiness, high suspicion index, comprehension of the trauma mechanism, and coordination of all implicated specialties can guarantee a good outcome for the patient.
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References
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- Zeebregts CJ, Klaase JM, Geelkerken RH. Endovascular treatment of traumatic thoracic aortic rupture combined with diaphragmatic rupture-a case report Vasc Endovascular Surg 2003;37:219-223.[Abstract/Free Full Text]
- Stamenkovic SA, Taylor PR, Reidy J, Roxburgh JC. Emergency endovascular stent grafting of a traumatic thoracic aortic dissection Int J Clin Pract 2004;58:1165-1167.[Medline]
- Bortone AS, De Cillis E, D'Agostino D, de Luca Tupputi Schinosa L. Endovascular treatment of thoracic aortic diseasefour years of experience. Circulation 2004;110:262-267.
- Athanassiadi K, Kalavrouziotis G, Athanassiou M, et al. Blunt diaphragmatic rupture Eur J Cardiothorac Surg 1999;15:469-474.[Abstract/Free Full Text]
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Abstract
Introduction
