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Ann Thorac Surg 1997;64:387-388
© 1997 The Society of Thoracic Surgeons
DR JAMES W. PATE (Memphis, TN): Doctor Sweeney and associates are to be congratulated on their uniquely near-perfect results with these difficult patients. Experienced surgeons in a major trauma center can have good results using the clamp-and-sew technique. (However, their series excludes patients with extension into the arch or great vessels.)
Their most important conclusion is: "...the most important variable is the surgeon" in paraplegia. Many patients are operated on by "occasional trauma thoracic surgeons" or "trauma surgeons" inexperienced in bypass techniques. Competence in cardiac or aneurysm surgery is not adequate for the current experience needed in major trauma. This report and earlier larger series from Memphis and elsewhere demonstrate that control of blood pressure and left ventricular ejection slope can help prevent preoperative rupture of the hematoma.
This report must not be misinterpreted as proving that the "cut-and-sew" technique is as safe as bypass techniques and thus encouraging its use by surgeons not currently experienced in aortic trauma. Fear of heparinization in major trauma patients is greatly exaggerated. At the University of Tennessee-Presley Trauma Center, we have operated on more than 130 cases of acute traumatic rupture of the aortic isthmus with full heparinization in most. Fabian and associates have used a full heparin dose in many patients with blunt carotid and popliteal artery injuries. In spite of a careful search for detrimental effects, over 16 years, we have been unable to clearly identify any, except in patients with pulmonary lacerations or intracranial hemorrhage.
Aortic cross-clamp time is critical! The American Association for the Surgery of Trauma established the first prospective, multiple-center study with uniform data collection about 30 months ago. The editor of their report, Tim Fabian, was kind enough to lend me the data on those 274 patients. Aortic cross-clamp time of less than 30 minutes was associated with new paraplegia in 1 of 60 (1.7%); with cross-clamp times longer than 30 minutes, in 15 of 111 (13.0%); p < 0.02). Looking only at the 207 patients who were hemodynamically stable at the beginning of the operation, 1 of 28 patients with the "clamp-and-sew" technique and a clamp time of less than 30 minutes became paraplegic, but paraplegia developed in 9 of 23 (39.1%) of those whose clamp time exceeded 30 minutes; with bypasses, paraplegia developed in 0 of 31 patients with clamp times of less than 30 minutes and 6 of 88 (6.8%) who were clamped more than 30 minutes. However, bypass data are biased because that group included a number with tears extending into the arch or involving the carotid or innominate artery. Of all 73 stable patients in whom the clamp-and-sew technique was used, 19.1% became paraplegic; in 134 patients with some form of bypass, 4.5% did (p = 0.01). (In addition to the previously mentioned bias, both patients in whom paraplegia developed after partial bypass had one or more fractures of the spine.)
Sweeney and associates confirm that medical therapy in selected cases and repair in a level I trauma center can markedly improve results. Should we use drug therapy to allow transfer of these patients to trauma centers, rather than operating in hospitals and by surgeons with little current trauma experience?
DR SWEENEY: Well, I would not, Dr Pate. I was present in Hilton Head at this Society's meeting more than 10 years ago, admired your work then, and recognize you are one of the significant contributors in the field.
I think you are right, but that does not mean that I am wrong. And I think that is a significant message. I am at the midpoint of my surgical career, and I have begun to wonder in this issue and others, myocardial protection for instance, whether we are learning more and more about less and less until we miss the big truths involved. So in Houston, at the Willie Nelson Trauma Center, we will probably continue to use the clamp-and-sew technique.
DR ROBERT L. FULTON (Louisville, KY): I think we were one of the largest contributors to the study that was just quoted by Dr Pate. And yes, if you go way over 30 minutes you are going to have a lot of paralysis, so I would agree with mainly what you say about using some sort of bypass, maybe.
By and large what we use is clamp-and-sew. We have very, very similar results to those seen in Houston. I do think there is an indication for using some sort of shunting. I use a centrifugal pump with an oxygenator. And that is in the older patient. Your oldest patient was only 53 years old. I operated last month on a patient who was 83 years old. He is home and walks. I think the older patient with known or suspected coronary or cardiac disease will benefit from the shunt, not to prevent paraplegia so much as to prevent heart failure doing the cross-clamping, and pulmonary edema.
Our experience with transesophageal echocardiography and computed tomographic scanning as a sole method of diagnosing this injury has been defective, very defective, and I would not treat a patient based on either one of them alone. We perform arteriography in many patients; 10% of them have a ruptured aorta.
The question I have for you, which I would like you to elaborate upon if you have time, is how do you choose the patients for medical treatment? I would be very scared to try that for more than a couple of hours.
DR SWEENEY: I do not have much time, so I will cut to the chase. In the 4 patients treated nonoperatively, strategies for therapy were not always ours to control. We support and use what Dr Pate has championed, that judicious use of antihypertensives and antishear medications can buy time in treating such patients. Frankly, the first of the 4 patients was a Jehovah's Witness who did not give us a choice, and she has become the patient with the longest follow-up in our series. The other patients all had multiple injuries and aortic injuries that were essentially limited to intimal flaps. They have been followed up very carefully with medical treatments and have seemed to do well thus far. The last patient is 8 months after the injury and is physically quite active. The answer to your question is "I do not know," but I do not think it necessarily wrong to delay operation in selected patients who are carefully managed and followed up, particularly if their injuries are limited to intimal flaps and their aortic adventitia is well preserved.
Related Article
Ann. Thorac. Surg. 1997 64: 384-387.
This article has been cited by other articles:
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  T. G. Gleason and L. C. Benjamin Conventional Open Repair of Descending Thoracic Aortic Aneurysms Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 110 - 121. [Abstract] [PDF]
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