Nonpenetrating trauma to the thoracic aorta

Twenty-seven patients underwent surgical repair for nonpenetrating injuries of the thoracic aorta. Emergency operation was performed in 19 patients with acute aortic injury and there were 12 survivors. Left heart bypass (LHB), external shunts, and simple aortic cross-clamping were methods employed during repair. All operative deaths occurred in the left heart bypass group. Morbidity, hospital stay, operative time, and blood loss all were markedly less in patients repaired with an external shunt or simple cross-clamping. Systemic heparinization related adversely to mortality and morbidity. Eight patients had repair of chronic post-traumatic descending aortic aneurysms. One of these had previous repair elsewhere with paraplegia and subsequent mycotic aneurysm at the graft repair site. He presented to us with massive hemoptysis. Surgical correction in the chronic group was performed using either left heart bypass, external shunt, or simple aortic cross-clamp with graft interposition. The only death occurred in a patient repaired on left heart bypass.     

Blunt injuries of the thoracic aorta.

We managed 51 patients with thoracic aortic injuries caused by blunt trauma between 1977 and 1990. Forty-nine injuries were located in the upper descending aorta and one each in the ascending aorta and aortic arch. Three patients arrived moribund and underwent thoracotomy for resuscitation, and all died. The diagnosis was confirmed by aortography in 48. One patient died of aortic rupture, 1 died of hypoxemia, and 1 refused operation and died. Forty-four patients had aortic repair, 42 with graft insertion. Gott shunts were placed in 23 with 3 cases of paraplegia (13%). Simple cross-clamping was used in 19 with 1 case of paraplegia (5.2%). We found statistically significant differences between the cross-clamp times of patients without paraplegia compared with those in whom paraplegia developed in both the shunt and no-shunt groups. Logistic regression analysis showed that the only factor significantly associated with paraplegia was cross-clamp time. There were two postoperative deaths (4.4%). Seven patients had medical therapy initially and aortic repair was delayed to allow other injuries to stabilize. Before aortic repair, 18 patients had intraarterial pressure monitoring and 34 received beta-blockers or antihypertensive drugs. We conclude that aortic repair with graft insertion is usually successful in nonmoribund patients, simple cross-clamping is associated with a relatively low risk of paraplegia, the incidence of paraplegia is directly associated with the duration of cross-clamp time, and selected patients can be managed medically while awaiting aortic repair.     

Clamp/repair: a safe technique for treatment of blunt injury to the descending thoracic aorta

Debate exists with regard to the use of pump bypass, shunt bypass, or clamp/repair techniques in treating injuries to the descending thoracic aorta. The objective in using any of these techniques is to minimize the complications of paraplegia and renal failure, while achieving the lowest possible mortality. During an eighteen-year period, 45 patients were seen with acute blunt injury to the descending thoracic aorta. The shunt bypass method of repair was used in 1; pump bypass in 8; and clamp/repair in 23. There were desperate unsuccessful attempts to resuscitate and control hemorrhage in 13 patients, 1 of whom was placed on portable pump bypass. Thirty-two patients survived resuscitation and operation, and 26 were long-term survivors. Among surviving patients with permanent paraplegia, 2 underwent pump bypass and 1, the clamp/repair technique. Four other patients were seen with paraplegia or paresis and had reversal of the paralysis. The clamp/repair technique was used in these patients with clamp times ranging from 35 to 62 minutes (mean, 47.4 +/- 13.3 minutes). Renal failure did not occur in any patient, despite clamp times of up to 62 minutes (mean, 37.5 minutes). Excluding patients seen in a moribund condition, mortality most often was secondary to neurological or multisystem injury. Debate continues concerning intraoperative management of this highly lethal vascular injury. The data presented here support the historical composite experience that clamp/repair is a safe and efficacious technique that minimizes paraplegia and mortality.     

Reappraisal of surgical treatment of traumatic transection of the thoracic aorta

Since Crawford's report in 1973, repair of traumatic transection of the thoracic aorta without shunt or bypass has emerged as a popular technique which simplifies the operation and avoids use of heparin. Growing evidence, however, indicates that the incidence of paraplegia is higher with this method and may outweigh its advantages. With this in mind, we have examined our experience with 40 patients who underwent repair of aortic transection from 1975-1988. The operated patients in our series all survived. Fourteen were repaired using some type of bypass or shunt, none of whom developed paraplegia. The remaining 26 patients were repaired without a shunt and 9 (34.6%) developed paraplegia or paraparesis (p less than 0.02). Paraplegia was related to aortic occlusion time (p less than 0.002). It did not occur in 11 patients with times less than 27 minutes, but happened in 2 of 8 patients with times between 28 and 35 minutes and in all 7 patients with clamp times over 35 minutes. These data suggest that shunt or bypass should be used in most cases of aortic transection.     

Thoracic aortic injury. A ten-year experience

Between 1974 and 1983, 41 patients arrived alive at Loma Linda (Calif) University Medical Center after sustaining a traumatic disruption of the thoracic aorta. Four patients died during the resuscitation attempts and the 37 patients who survived underwent thoracotomy for attempted definitive repair. There were six hospital deaths (16.22%) among those who underwent definitive repair; associated injuries (mostly orthopedic and neurologic) were contributing factors. Four patients were discharged with spinal cord injuries, two were paraplegic on arrival at the hospital, and two became paraplegic postoperatively (surgical spinal cord injury, 5.41%). Most injuries were distal to the left subclavian artery (97.56%). Cardiopulmonary (left heart) bypass was gradually abandoned in favor of more simple techniques, including ventriculoaortic and aorto-aortic heparinized shunts or a "clamp and sew" method. Experience has demonstrated that most traumatic aortic disruptions can be repaired safely by direct suture technique (without graft interposition) if accomplished during the acute episode.     

Operative technique, paraplegia, and mortality after blunt traumatic aortic injury

HYPOTHESIS: The use of mechanical circulatory support (MCS) during repair of traumatic aortic injuries is associated with a decreased incidence of postoperative paraplegia and mortality. DESIGN AND SETTING: Historical cohort study with contemporaneous but nonrandomized controls in a tertiary care hospital from July 1, 1988, through December 31, 1999. PATIENTS AND INTERVENTIONS: Consecutive cases undergoing operation for traumatic aortic injuries. Use of MCS (with or without systemic heparinization) determined by surgeon preference. MAIN OUTCOME MEASURES: Incidence of postoperative paraplegia and mortality. RESULTS: Twenty-two patients underwent repair of traumatic aortic injuries using MCS, resulting in no paraplegia but 4 deaths, 3 of them from cerebral ischemia. Thirteen patients had their traumatic aortic injuries repaired using a "clamp-and-sew" or passive shunt technique with no deaths but paraplegia in 2. Compared with an earlier report from our group from January 1, 1975, through June 30, 1988, the annual incidence of traumatic aortic injuries has decreased, whereas the age of patients and proportion of operations using MCS have increased. A review of the recent literature on traumatic aortic injuries reveals an average postoperative paraplegia incidence of 1% with MCS and 16% without MCS. Overall mortality is similar, but others have also reported cases of cerebral ischemia after aortic repair. CONCLUSIONS: The use of MCS during repair of traumatic aortic injuries is associated with a decreased incidence of postoperative paraplegia. The occasional occurrence of cerebral ischemia deserves further study.     

Ruptured descending and thoracoabdominal aortic aneurysms

BACKGROUND: Advances in end-organ protection have dramatically reduced the incidence of the life-threatening complications associated with the elective repair of thoracoabdominal and descending thoracic aortic aneurysms. However, in the setting of a ruptured thoracic aneurysm, one may not have the luxury of complex end-organ support. We analyzed our experience with ruptured thoracic aneurysms to define morbidity and mortality in the present era. METHODS: One hundred seventy-two patients with thoracoabdominal or descending thoracic aneurysms were operated on between July 1997 and October 2001. Forty presented with either a contained or free rupture. Three techniques were used for aortic reconstruction: clamp and sew, left heart bypass, and hypothermic circulatory arrest. Adjuncts for neurologic and renal support were used when circumstances and anatomy permitted. RESULTS: Seven of 40 patients died in the hospital (17.5%). Four patients died intraoperatively, all of acute myocardial infarction. Five of the seven deaths were in patients who presented in shock. Two patients (5%) experienced paraplegia, 3 (7.5%) had renal failure requiring hemodialysis, 8 (20%) required a tracheostomy, and 6 (15%) had recurrent nerve palsies. There was one stroke (2.6%). Mean diameter of ruptured aneurysms was 8.5 cm. CONCLUSIONS: Ruptured thoracic aneurysms can be repaired with a gratifying rate of salvage. Rapid diagnosis and triage for repair is necessary to avoid progressive deterioration into shock. The incidence of myocardial infarction, and the mortality associated with this event, underscores the need for aggressive cardiac evaluation in the elective thoracic aneurysm patient. The size at rupture also emphasizes the need for earlier referral for elective aneurysm repair.     

Management of blunt thoracic aortic injuries: endovascular stents versus open repair

BACKGROUND: Endovascular stent graft (EV) technology has been successfully adapted to the repair of blunt traumatic aortic injuries. The purpose of this study was to compare the outcomes of patients treated with EV repair and open repair after blunt thoracic aortic trauma. METHODS: A review of a tertiary trauma center's prospective trauma registry identified all patients who suffered a blunt traumatic thoracic aortic injury over an 11-year period (1991-2002). Operative interventions and outcomes were then compared. RESULTS: Over an 11-year period, 18 patients underwent repair of a blunt thoracic aortic injury (EV, 6; open, 12). There were no significant differences in demographics, injury, or crash statistics between groups. The open group had a 17% early mortality rate (n = 2), a paraplegia rate of 16% (n = 2), and an 8.3% incidence of recurrent laryngeal nerve injury (n = 1). This is in contrast to a 0% rate of mortality, paraplegia, and recurrent laryngeal nerve injury in the EV group. A definite trend toward decreased morbidity, mortality, intensive care unit length of stay, and number of ventilator-dependent days was seen with EV repair. CONCLUSION: We observed a clear trend toward improved outcomes after EV repair of thoracic aortic injuries compared with standard open repair. EV repair is emerging as the preferred method of repairing blunt thoracic aortic injuries in trauma patients with multiple injuries.     

Surgical treatment of acute traumatic tear of the thoracic aorta.

Acute traumatic tear of the thoracic aorta is a severe injury with a high mortality rate. This condition requires expeditious evaluation and prompt surgical intervention in order to improve patient survival. The experience at the authors' institution from 1971 to 1987 includes 41 patients who sustained acute traumatic tear of the thoracic aorta and reached the hospital alive. The purpose of the study was to evaluate the surgical management of this injury with regards to mortality rate and the incidence of spinal cord injury. Five patients died from exsanguination before definitive repair could be undertaken. Thirty-six patients had repair of traumatic aortic tear in the area of the isthmus. Nine patients were operated upon with the clamp and sew technique, 20 patients had a heparin-bonded shunt placed, and seven patients were treated by repair with cardiopulmonary bypass. There were five operative deaths that were not related to the technique employed. Two patients without preoperative evidence of spinal cord injury developed paraparesis. No patient had postoperative paraplegia. Despite rapid transport, expeditious evaluation, and emergency thoracotomy, some patients die from exsanguination prior to definitive repair. Even with the provision of distal aortic perfusion during clamping, the risk of spinal cord injury is not eliminated.     

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Primary repair of traumatic aortic rupture: a preferred approach.

Eighty patients with traumatic rupture of the thoracic aorta were treated. Seven patients died during the initial resuscitation. Forty-three patients underwent surgical repair using the clamp-and-sew technique; 14 patients had a heparin-bonded shunt placed, and 16 patients were repaired using cardiopulmonary bypass. An interposition Dacron graft was used in only 19 patients (26%). The last 32 consecutive patients underwent primary repair of the ruptured aorta. Overall mortality was 19.2% (14 of 80); 9 of 14 patients (64%) had laparotomies along with the aortic repair, and 13 of 14 patients (92%) had three or more associated major injuries. Paraplegia occurred in four cases (5.6%). Traumatic aortic rupture remains a difficult surgical problem. Primary repair, without graft interposition, is the preferred technique and can be accomplished even when the two aortic ends have retracted several centimeters.     

Thoracoabdominal aortic aneurysm repair through redo left-sided thoracotomy

BACKGROUND: The outcome of thoracoabdominal aortic aneurysm repair through redo-left thoracotomy after operations for descending thoracic aortic aneurysms was investigated. METHODS: Between May 1982 and March 2003, 100 patients underwent thoracoabdominal aortic aneurysm repair in elective surgery without profound hypothermic circulatory arrest. Thirty of these patients had previously undergone operations for descending thoracic aortic aneurysms. To evaluate the influence of previous descending thoracic aortic aneurysm repairs on the results of thoracoabdominal aortic aneurysm replacements, patients were divided into two groups: (1) patients who had previously undergone descending thoracic aortic aneurysm repair (group I; n = 30), and (2) patients who had not previously undergone descending thoracic aortic aneurysm repair (group II; n = 70). RESULTS: The distal aortic perfusion time and operation time were both longer in group I than in group II, but there was no significant difference between the two groups in total selective visceral and renal perfusion time or aortic clamp time. In-hospital mortality rates were 13% in group I and 19% in group II (p = 0.52). Major postoperative complications included paraplegia (10% of patients in group I and 4.3% of patients in group II; p = 0.36), renal failure requiring hemodialysis (20% of patients in group I and 11% of patients in group II; p = 0.35), respiratory failure (30% of patients in group I and 19% of patients in group II; p = 0.22). CONCLUSIONS: Previously descending thoracic aortic aneurysm and redo-left thoracotomy do not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Traumatic lesions of the thoracic aorta. A report of 73 cases

In a 24 year period we treated 73 traumatic lesions of the thoracic aorta; 36 of these were acute ruptures and 37 post traumatic pseudo-aneurysms. All these cases were associated with violent, sudden deceleration and in 68 instances the cause of this was a traffic accident. Fifty two patients (70%) had severe associated lesions involving the cranium, abdomen, thorax or leg fractures and dislocations but in 5 patients the aortic rupture was the only injury observed. Thirty four patients with acute aortic lesions were operated upon; 30 with extracorporeal circulatory assistance (CA) and 4 with aortic cross clamping alone. Twenty one were repaired by direct suture, 13 by prosthetic graft interposition and there were 8 deaths (23.5%) and one case of post-operative paraplegia. Thirty six traumatic aneurysms were operated upon; 34 with CA and 2 with cross clamping. Only two were repaired by direct suture, 5 by prosthetic angioplasty and 29 required prosthetic interposition grafts; there were no deaths or paraplegias in this group. Aortic rupture demands early diagnosis and immediate surgery. Associated abdominal injuries are easily missed and therefore exploratory laparotomy should be considered after every acute aortic repair.     

Delayed paraplegia 10 months after endovascular repair of thoracic aortic aneurysm

Spinal cord ischemia after treatment of thoracic pathologies remains a devastating problem. A 74-year-old man with a history of infrarenal abdominal aortic aneurysm repair presented with bilateral common iliac and left femoral aneurysms as well as a thoracic aortic aneurysm. He underwent an open repair of the iliac and femoral aneurysms, followed by thoracic endovascular aneurysm repair in a staged manner without complications. Ten months later, he presented with hypotension, and permanent paraplegia developed.     

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.     

Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.     

Acute traumatic rupture of the thoracic aorta. Role of delayed surgical treatment

Acute traumatic rupture of the thoracic aorta (ATRTA) is considered to be an emergency which requires immediate surgery. However surgical mortality is high with an average of 20% in the literature. Twenty-seven patients were observed from 1973 to 1986. Three patients were not operated on (Group I). Twenty patients had immediate surgery (group II) with 60% deaths, 4 patients underwent delayed surgery (Group III) with 25% deaths. Analysis of causes of deaths shows that mortality is mainly due to the severity of associated lesions. Associated lesions were present in 72% of patients who did not survive and in only 37% of the survivors. Associated lesions may be lethal initially (E.G. Brain trauma) or they may be aggravated by the thoracic procedure. Complications from associated lesions may also compromise the outcome of the thoracic procedure. It is well known that the majority of deaths from ATRTA are observed within 24 hours. Immediate repair of the aortic lesion should remain the rule when aortic rupture is isolated or associated with moderate injuries. However, in some cases with severe and multiple associated lesions who survive the initial aortic injury, delayed repair of ATRTA could be considered.     

Traumatic disruption of the thoracic aorta in children.

HYPOTHESIS: This study was undertaken to identify mechanisms of injury, diagnostic modalities, surgical management, and outcome in children with traumatic aortic disruptions. DESIGN: Retrospective study. SETTING: University-affiliated private hospital. PATIENTS: All patients younger than 17 years listed in the trauma registry. INTERVENTION: Operative repair of thoracic aortic injuries. MAIN OUTCOME MEASURES: There were 8 boys and 3 girls ranging in age from 12 to 17 years (mean, 14.8 years). Seven children were motor vehicle passengers; 3 were pedestrians struck by vehicles; and 1 was thrown from a bull. Aortic injuries were suspected on the basis of the mechanism of injury and abnormal chest x-ray films (mediastinal widening). Aortic injuries were confirmed in 9 patients by arch aortography and in 2 patients by computed tomography. The injuries involved the isthmus of the aorta in 9 patients (complete transections) and the aortic arch in 2 patients (avulsions of the great vessels). Isthmus injuries were repaired by means of left heart bypass with direct cannulation of the distal thoracic aorta in 8 patients and femoral venous to femoral arterial bypass in 1 patient. Arch injuries were repaired during hypothermic circulatory arrest. The injured aortic segments were replaced with interposition grafts. There were no direct complications of anticoagulation. Ten patients (91%) survived. The only death was caused by a severe closed head injury. There were no instances of paraplegia related to aortic repairs. CONCLUSION: Good outcomes resulted from early diagnosis based on mechanism of injury, prompt aortography, and computed tomography and operative management that included distal aortic perfusion with left heart bypass.     

Intraoperative aortic dissection.

Intraoperative aortic dissection is a rare but potentially fatal complication of open heart operations. If the dissection is promptly recognized and repaired, however, the outcome may be significantly better. In this study, we reviewed the hospital records of patients with dissection of the aortic arch occurring as a complication of a cardiac operation at Massachusetts General Hospital and Mt. Auburn Hospital from January 1980 through June 1990. During this period, 14,877 surgical procedures with the use of cardiopulmonary bypass and aortic cannulation were performed, and 24 patients (0.16%) with iatrogenic aortic dissection were identified. Dissection was discovered intraoperatively in 20 patients and postoperatively after complications developed in 4. Of the 20 patients whose injuries were discovered intraoperatively and repaired, 4 (20%) died. Of the 4 whose injuries were discovered after operation, 2 (50%) died. The primary cause of death was ventricular dysfunction resulting from myocardial ischemia. Dissections originated at the aortic cannulation site in 10 patients, at the cross-clamp site in 8, at the site of the partial-occlusion clamp in 7, at the proximal anastomosis in 1 patient, and as a result of direct injury in 1. Three of these patients had simultaneous injuries at the aortic cannulation site and at the heel of the partial-occlusion clamp. Two techniques of repair were used: primary repair and patch or tube graft insertion. There were two deaths in the patients who underwent primary repair and four deaths in patients requiring graft replacement. Although it is uncommon, intraoperative aortic dissection can be a lethal complication of cardiac operations.(ABSTRACT TRUNCATED AT 250 WORDS)