The renegade fact

[Treatment of traumatic rupture of the thoracic aorta]

INTRODUCTION

Interest for traumatic thoracic aorta rupture stems from the fact that its number continually increases, and it can be rapidly lethal.

OBJECTIVE

The aim of this study is to present early and long term results as well as experiences of our team in surgical treatment of traumatic thoracic aorta rupture.

METHOD

Our retrospective study includes 12 patients with traumatic thoracic aorta rupture treated between 1985 and 2007.There were 10 male and two female patients of average age 30.75 years (18-74).

RESULTS

In six cases, primary diagnosis was established during the first seven days days after trauma, while in 6 more than one month later. In 11 cases, classical open surgical procedure was performed, while endovascular treatment was used in one patient. Three (25%) patients died, while two (16.6%) had paraplegia. Nine patinets (75%) were trated without complications, and are in good condition after a mean follow-up period of 9.7 years (from one month to 22 years).

CONCLUSION

Surgical treatment requires spinal cord protection to prevent paraplegia, using cardiopulmonary by-pass (three of our cases) or external heparin-bonded shunts (five of our cases). Cardiopulmonary by-pass is followed with lower incidence of paraplegia, however it is not such a good solution for patients with polytrauma because of haemorrhage. The endovascular repair is a safe and feasible procedure in the acute phase, especilly because of traumatic shock and polytrauma which contributes to higher mortality rate after open surgery. On the other hand, in chronic postrauamatic aortic rupture, open surgical treatment is connected with a lower mortality rate and good long-term results. There have been no published data about long-term results of endovascular treatment in the chronic phase.

Surgical versus endovascular treatment of traumatic thoracic aortic rupture

OBJECTIVES

Blunt traumatic thoracic aortic rupture is a life-threatening surgical emergency associated with high mortality and morbidity. The recent development of endovascular stent-graft prostheses offers a potentially less invasive alternative to open chest surgery, especially in patients with associated injuries. We sought to compare the results of conventional surgical repair and endovascular treatment of traumatic aortic rupture in a single center.

METHODS

From July 1998 to January 2004, 20 patients with acute blunt traumatic aortic rupture underwent treatment at our institution. All patients had a lesion limited to the isthmus, and associated injuries. Initial management included fluid resuscitation, treatment of other severe associated lesions, and strict monitoring of blood pressure. Eleven patients (9 men, 2 women; mean age, 32 years) underwent surgical repair, including direct suturing in 6 patients and graft interposition in 5 patients. Ten patients were operated on with cardiopulmonary support (left bypass with centrifugal pump, n = 2; extracorporeal circulation, n = 8). The delay between trauma and surgery was 2.6 days (range, 0-21 days). Nine patients (8 men, 1 woman; mean age, 32 years) underwent endovascular treatment with commercially available devices (Excluder, n = 2; Talent, n = 7). In all patients 1 stent graft was deployed. In 2 patients the left subclavian artery was intentionally covered with the device. The delay between trauma and endovascular treatment was 17.8 days (range, 1-68 days).

RESULTS

One patient in the surgical group (9.1%) died during the intervention. Three surgical complications occurred in 3 patients (27%), including left phrenic nerve palsy (n = 1), left-sided recurrent nerve palsy (n = 1), and hemopericardium 16 days after surgery that required a repeat intervention (n = 1). No patient in this group had paraplegia. In the endovascular group successful stent-graft deployment was achieved in all patients, with no conversion to open repair. No patient died, and no procedure-related complications, including paraplegia, occurred in this group. Control computed tomography scans obtained within 7 days after endovascular treatment showed exclusion of pseudoaneurysm in all cases. Length of follow-up for endovascular treatment ranged from 3 to 41 months (mean, 15.1 months). Computed tomography scans obtained 3 months after endovascular treatment showed complete disappearance of pseudoaneurysm in all patients.

CONCLUSION

In the treatment of blunt traumatic thoracic aortic rupture, the immediate outcome in patients who receive endovascular stent grafts appears to be at least as good as observed after conventional surgical repair. Long-term follow-up is necessary to assess long-term effectiveness of such management.