Acute traumatic rupture of the aorta. A re-emphasis of repair without a vascular prosthesis

[Acute traumatic rupture of the thoracic aorta and its branches. Results of surgical management]

STUDY AIM

The aim of this retrospective study was to report a series of 102 patients with acute traumatic rupture of the thoracic aorta and its branches (TRA) and to evaluate long-term results.

PATIENTS AND METHODS

From April 1977 to April 2000, 102 patients with RTA were admitted to our unit. Age ranged between 12 and 74 years (mean age: 33 years). Localisation was: ascending aorta (n = 3), aortic arch (n = 1), isthmus (n = 92), descending aorta (n = 1), innominate artery (n = 3), and left subclavian artery (n = 2). Associated injuries mainly included craniocerebral lesions (n = 76), rib fractures (n = 68), and thoracic (n = 38), and abdominal (n = 24) lesions. Average time between trauma and surgery was 37 hours. Aortography was used routinely for diagnosis. Five patients were inoperable; the procedure was delayed in three patients. In all but two patients with rupture of the isthmus, descending aorta and subclavian artery, the operation included venous arterial femorofemoral assistance. Rupture was partial in 37 patients (37 direct sutures), and complete in 55 patients (40 direct sutures). In two cases of left subclavian artery desinsertion, the operation included suture of the aortic tear and reimplantation of the artery. In patients with rupture of the ascending aorta and aortic arch, surgery was carried out under cardiopulmonary bypass with deep hypothermia for aortic arch rupture. Repair consisted of direct suture. In patients with rupture of the innominate artery, the lesion was treated under cardiopulmonary bypass by direct suture. In five cases, abdominal injuries required emergency procedure before aortic repair.

RESULTS

Four patients died. No postoperative paraplegia occurred. The high morbidity rate was in relation to the associated injuries. Among the 93 survivors, the aortic clinical status was satisfactory in 91 patients (two patients were lost to follow-up). Two patients died from cancer and myocardial infarction 2 and 7 years later respectively. One patient had prosthetic sepsis and was reoperated on with homograft. Angiographic control by aortography (n = 60) and angioMRI (n = 22) was normal in 76 patients. There were five stenoses at the level of the prosthesis, four with a gradient < 20 mmHg and one with a gradient > 50 mmHg and one aneurysm at the level of the isthmus. These last two patients were reoperated on with good result.

CONCLUSION

RTA remains a surgical emergency with multiple difficulties. Despite the development of new imaging modalities, angiography remains the gold standard for the work-up of these patients. Venous arterial femorofemoral assistance with a pump remains the best procedure in order to avoid paraplegia and vascular prosthesis implantation when possible. Endovascular stent graft insertion, although still under investigation, holds tremendous promise for non-surgical treatment of these patients.

Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia

A metaanalysis of articles concerning the surgical management of acute traumatic rupture of the descending thoracic aorta published in the English-language literature between 1972 and July 1992 was performed. The overall mortality of 1,742 patients who arrived at the hospital alive was 32.0%, one-third died before surgical repair was started. Paraplegia was noted preoperatively in 2.6% of these hospitalized patients, and paraplegia complicated the surgical repair in 9.9% of 1,492 patients who reached the operating room in a relatively stable condition. Patients then were analyzed according to the surgical intervention used. Simple aortic cross-clamping (n = 443) was associated with a hospital mortality of 16.0% and incidence of paraplegia of 19.2%, despite lower average mean cross-clamp times (32 minutes; p < 0.01 versus passive or active methods of providing distal perfusion). In a subset of 290 patients in whom individual data were available, the cumulative risk of paraplegia was shown to increase substantially if the duration of aortic cross-clamping exceeded 30 minutes, but only when distal perfusion was not augmented (p < 0.00001). "Passive" perfusion shunts (n = 424) were associated with a mortality of 12.3%, and the incidence of paraplegia decreased to 11.1% (p < 0.001). However, shunts inserted from the apex of the left ventricle had a contradictory high 26.1% incidence of paraplegia compared with shunts from the ascending aorta (8.2%; p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic tears of the thoracic aorta: improved results using the Bio-Medicus pump

Traumatic disruption of the descending thoracic aorta is a relatively rare but dramatic injury. Controversy remains regarding the use of shunts during operative repair. Discouraged by our results using the "no shunt" technique, we adopted the recently reported technique using the Bio-Medicus pump for left atrium-femoral artery bypass without heparin sodium. At Charlotte Memorial Hospital and Medical Center, 39 patients were treated for tears of the descending thoracic aorta between January 1979 and October 1988. Eight patients died before repair could be completed. Four patients underwent repair using femorofemoral bypass with 1 death and no instances of paraplegia. Fifteen patients had repair using the no-shunt technique with 4 deaths and three instances of paraplegia. Since January 1986, 12 patients have been treated using the Bio-Medicus heparinless pump with no deaths and no instances of paraplegia. We present our experience to confirm the reports of others regarding the efficacy of this technique. We believe it reduces the morbidity and mortality associated with this serious injury and aids in the hemodynamic management of the patient during aortic clamping.

Traumatic rupture and aneurysm of the aortic isthmus: late results of repair by direct suture

Between 1979 and 1986, 28 patients underwent surgery for subadventitial rupture of the aortic isthmus from blunt trauma; 16 had an acute lesion which was operated within three days after the trauma, three had a delayed repair between the first and third months, while nine had a chronic post-traumatic aneurysm (2 to 27 years after the initial accident). Transection was complete in 13 cases. A left atrium-to-descending thoracic aortic bypass or ilioiliac extracorporeal bypass were used in 14 (50%) patients whereas simple clamping was employed in the 14 remaining patients. Aortic repair was performed in 22 cases by direct suture (78.5%), more often in acute ruptures (84%) than in chronic aneurysms (66%). Five of the 16 patients operated on within three days of their accident died during the first postoperative month from associated lesions. There were no in-hospital or late deaths among the patients operated on for chronic aneurysm. All of the 23 surviving patients (82%) were followed postoperatively for six to 90 months (mean: 36 months). Of the 19 who had direct suture, 15 underwent digital subtraction arteriography which demonstrated an excellent reconstruction of the aortic isthmus. Of the techniques available for repair of traumatic aortic lesions, direct suture allows the shortest clamping time (mean: 25 minutes in our series). The long-term risks of prosthetic replacement, i.e. late infection, false aneurysm due to suture breakdown, and secondary embolism arising from mural thrombosis, can therefore be avoided.

Primary repair of traumatic aortic disruption

From 1979 to 1985, 22 patients (18 male) underwent repair of acute traumatic rupture of the aorta. Ages ranged from 15 to 75 years (mean, 35 years). All patients sustained deceleration injuries in automobile accidents. The majority had injuries to multiple systems and evidence of mediastinal widening on routine chest roentgenograms. Aortography confirmed transection in the descending thoracic aorta near the ligamentum arteriosum in 20. Primary repair was achieved in 15 patients; it was performed in the last 10 consecutive patients. Seven patients had repair with a prosthetic graft. Survival was 82%. Postoperative morbidity usually was related to associated injuries. Primary repair of aortic transection can be accomplished in most patients without the use of prosthetic material.

Management of injuries of the thoracic and abdominal aorta

Thirty-five patients had surgery for injuries of the aorta at the Los Angeles County-USC Medical Center over a 4 1/2 year period. There were 27 survivors. The principles of management were to operate without delay if there was evidence of continued bleeding after initial fluid replacement as occurred in 11 patients. For the 24 patients who became stable after initial resuscitation, a more deliberate plan of management was used. Blood pressure was carefully monitored and controlled to avoid hypertension. Priorities for associated injuries were established and in several cases, they took treatment precedence over the aortic injury. Delay was sometimes necessary to utilize the more experienced personnel. In no instance did a stabilized patient hemorrhage during the delay. The most common injury seen was a blunt disruption of the proximal descending aorta. The details of the operative technique for this injury have been reported herein, along with a justification for not using either pump bypass or shunt to perfuse the distal aorta during the period of aortic cross-clamping.

Primary repair of acute traumatic aortic disruption

A technique that facilitates primary repair of acute traumatic aortic disruption is described. With this technique, primary repair has been possible in 5 of our most recent 9 patients with this injury, whereas all 46 of our previous patients were treated by insertion of a prosthetic graft. Primary repair of traumatic aortic disruption is feasible in many more patients than we initially thought possible and should always be considered, particularly in the young patient with a healthy, elastic aorta that is only partially transected.

Suspecting thoracic aortic transection

Deceleration accidents produce a complex of potentially fatal thoracic injuries. Because early detection is the key to successful management of blunt trauma to the great vessels, emergency physicians must be knowledgeable of signs indicative of these complex injuries. Among more than 10,000 patients presenting to the Ben Taub Emergency Center over an 11-year period with thoracic injuries, 100 had clinical or radiographic clues suggestive of blunt trauma decelerative injury to the great vessels. Of these 100 patients, 23 had transection of the descending thoracic aorta and five had avulsion of the innominate artery. One patient had a double transection. Six patients died in the Emergency Center before proximal control could be achieved.

The treatment of acute traumatic rupture of the aorta: a 10-year experience

Forty-three patients with aortic rupture secondardy to blunt trauma have been treated at the University of Micigan within the past 10 years with an overall salvage rate of 70%. The diagnosis should be suspected in anyone who has sustained a high speed decelerating injury, if the chest roentgenogram shows media-stinal widening, whether or not there is hypertension of the upper extremities; systolic murmur, or external evidence of chest injury. Aortography should be employed to confirm the diagnosis and to determine the site or sites of rupture. Repair of the lesion should be undertaken as soon as possible and takes priority in most instances over associated injuries. Repair in almost all cases can be accomplished safely and quickly using a bypass shunt without the aid of extracorporeal circulation.