Surgical management of penetrating mediastinal arterial trauma

An unusual occurrence of penetrating aortic arch injury by a ball-point pen: a case report and review of the literature

BACKGROUND

Aortic arch injuries account for about 8% of thoracic aortic injuries. Penetrating zone I neck injuries account for 18% of vascular injuries in the neck and have great potential to traverse to involve thoracic vascular structures as well. The hard and soft signs of vascular injury facilitate triage of patients on an individual basis. We present a case of a ball-point pen traversing through zone I of the neck and causing penetrating aortic arch injury with minimal mediastinal haemorrhage.

CASE PRESENTATION

We present a polytrauma patient who was admitted with traumatic brain injury and a ball-point pen lodged above the sternal notch in zone I of the neck following a road traffic accident. He underwent mediastinal exploration via a median sternotomy. The ball-point pen was found penetrating the anterior wall of the aortic arch and resting in its lumen. The ball-point pen was successfully explanted and primary repair of the penetrating aortic arch injury was done. He had an uneventful recovery without any added secondary neurological complications.

CONCLUSION

Penetrating aortic arch injuries are rare compared to injuries of the ascending aorta and descending aorta. They require a high index of suspicion, rapid investigation and urgent intervention in view of their high associated fatality. The ball-point pen in this case assumed the shape of a plug which acted as a seal at the site of injury preventing catastrophic exsanguination.

Conservative management of aortic arch injury following penetrating trauma

Aortic arch injuries following penetrating trauma are typically lethal events with high mortality rates. Traditionally, the standard of care for patients presenting with penetrating injury and aortic involvement has included surgical intervention. We report the case of a 31-year-old man who was managed non-operatively after sustaining multiple stab wounds to the left chest and presenting with mid aortic arch injury.

Endovascular treatment of iatrogenic aortic graft injury after sternal puncture

We report the case of a 71-year old woman who had previously undergone supra-aortic trunk transposition via a median sternotomy, along with endovascular thoracic aortic stent-graft repair. During the diagnostic sternal puncture for a recently discovered acute lymphoblastic leukaemia, an accidental graft injury occurred. For this patient, who was not a surgical candidate, endovascular treatment with a covered stent (endograft) was performed, with uneventful postoperative follow-up. This case report illustrates the limitations of sternal puncture in patients with a previous sternotomy, and discusses the possibility of endovascular treatment in the event of aortic graft injury, given easy accessibility and favourable aortic neck anatomy.

Stab to the chest causing severe great vessel injury

Penetrating trauma has increased in developed and urban environments. Pulmonary artery injury is rare, but can be associated with significant morbidity. We report a case of delayed cardiac arrest following a stab injury to the chest. The patient had active great vessel bleeding and required extensive surgical intervention. Clinicians should have a high index of suspicion for life-threatening thoracic injuries following a stab injury to the chest, despite initial clinical stability or negative baseline radiological findings.

Aorto-innominate fistula by gun-shot injury: a case report

We report an aorto-innominate fistula caused by gun-shot injury. The fistula was diagnosed by aortography and repaired under hypothermic circulatory arrest.

Repair of stab-wound laceration of the aortic arch using deep hypothermia and circulatory arrest

The surgical management of a 56-year-old patient with a single thoracic stab wound penetrating the left innominate vein and the aortic arch is described. Repair was successfully achieved using extracorporal circulation and circulatory arrest during deep hypothermia. Clinical features and surgical approach are described and discussed in detail.

[A serious complication of sternal puncture: penetrating injury of the ascending thoracic aorta]

INTRODUCTION

Penetrating thoracic aorta wounds are rare but responsible for a high mortality when medical and surgical management is delayed.

OBSERVATION

We report the case of a 71 year-old patient with malignant lymphoma who sustained an accidental penetrating injury of the ascending thoracic aorta while undergoing trephine biopsy of the sternum. He was successfully treated with emergency sternotomy and aortic suture-repair.

CONCLUSION

This case report highlights the limits of sternal trephine biopsy, notably in patients whose bones are weakened by a malignant haematological process, and proposes preventive measures in order to avoid accidents.

Major mediastinal injury from crossbow bolt

We treated a 26-year-old male who sustained a self-inflicted injury to the mediastinum with a crossbow bolt. Injuries involved penetration of the sternum 1 cm below the sternomanubrial joint, right lung, pericardium, ascending aorta, right pulmonary artery, esophagus, and azygos vein. He was treated successfully with cardiopulmonary bypass and hypothermia. Exposure was achieved with a combination of a sternotomy and right thoracotomy.

Complex thoracic vascular injury repair using deep hypothermia and circulatory arrest

A 61-year-old man with a penetrating injury to the innominate artery, left common carotid artery, and left subclavian artery at their origins from the aortic arch with associated injuries to both innominate veins and an innominate artery to vein fistula after a single stab wound is described. The patient was managed successfully using cardiopulmonary bypass together with deep hypothermia and circulatory arrest. Presentation and management are discussed.