Surgical outcome of traumatic rupture of the thoracic aorta

BACKGROUND: The aim of this study was to point out the results of different techniques of spinal cord protection in surgically-treated patients with traumatic thoracic aorta (TTA). METHODS: A multicentric study was carried out involving 182 patients with TTA. Four patients died before surgery. Two patients were operated on without any investigation and 2 had no aortic tear at thoracotomy. The remaining 174 patients had aortic isthmus disruption and were included in the study. The mean age was 32.3+/-14.29 years with 126 men (72.4%) and 48 women (27.6%). Road accidents were causal in 163 patients (93.66%); polytraumatism was frequent. A standard chest roentgenogram led to a diagnosis which was confirmed with aortography in 94.8% of cases. Surgical repair of visceral lesions was performed in 52 patients (29.9%) for traumatic spleen, liver, diaphragm, mesentery, and gut. These operations were done before or after aortic operation in 21.3% and 8.6% of cases, respectively. Thirty-three patients (19%) died and 9 (5.2%) had paraplegia. Sixty-nine patients had clamp and sew technique (group 1). Ninety-three patients had different types of extracorporeal circulation (group 2), and 12 patients had Gott shunt (group 3). No difference appeared between the 3 groups according to mortality and paraplegia. But the sex ratio, age, visceral lesions, craniocerebral lesions, the type of aortic repair, and cross-clamp time were discriminative. RESULTS: The univariate analysis point out age, cross-clamp time, hemothorax, and anatomical type of aortic injury as the risk factors of death. This was confirmed by a multivariable test which retained age, cross-clamp time, and hemothorax as risk factors. When not diagnosed in time, TTA is serious and has a bad prognosis. In spite of a high mortality and morbidity, the surgical management has improved. Immediate operation and medullar protection are the stumbling block in this operation. CONCLUSIONS: Operation can be delayed in some cases, but one must take care of hemodynamic instability. This calls for a repair of the serious associated lesions first, or of a quick performing of a thoracotomy for ruptured aorta. The question remains, is it better to protect the spinal cord with the lower aortic perfusion and avoid the simple cross-clamp? Clinical studies give few answers to this question, and the best answer has not yet been given, as we lack prospective studies in this field.     

Endovascular treatment of traumatic rupture of the thoracic aorta

BACKGROUND: Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the 'gold standard', but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative. METHODS: A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up. RESULTS: A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1.5 per cent. Some 6.7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14.4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias. CONCLUSION: Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.     

Blunt force rupture of the thoracic aorta and diaphragm: an unusual association]

The aim of this study was to report two cases of rupture of the right hemidiaphragm with intra-thoracic liver hernia, associated with a traumatic aortic disruption. These two lesions followed traffic accidents, and were both treated separately. Both patients had a long-term favourable progression. Association of these two lesions is particularly rare: fewer than 50 cases have been previously described in an extensive review of the literature. CT-scan seems to be particularly efficient in diagnosis, even if less efficient than other more specific explorations. The order of surgical management is guided by the physical examination, and especially by abdominal emergency.     

Surgical experience with traumatic rupture of the thoracic aorta

Nine cases of traumatic thoracic aortic rupture (TAR), operated on at St. Marianna University Hospital between July 1980 and December 1988, were reviewed in order to evaluate the role of contrast-enhanced CT in the early diagnosis of TAR. The absence of mediastinal hematoma on CT eliminated the need for aortography in 30 (38.5%) of the 78 patients suspected of having TAR on the basis of chest roentgenograms. The presence of mediastinal hematoma necessitated aortography in 48 patients. However, operative treatment was carried out without aortography in 3 patients who had specific signs of rupture on CT. CT proved to be a reliable indicator for the selection of the patients who need aortography. As a rule, emergency operations were performed in these patients. Simple aortic crossclamping was employed in 4 patients, and heparinless left heart bypass with the BioPump was performed for spinal cord protection in 2 recent patients without complication of embolization. Use of the BioPump as an adjunct in the repair of TAR appears to be promising.     

‘Peeling paint’ dermatitis as a presenting sign of cystic fibrosis

Presentation of cystic fibrosis with a rash is rare, with only 19 previously reported cases. This unusual presentation is associated with false negative sweat tests, delays in diagnosis and considerable mortality. Multiple nutritional deficiencies, the aberrant production of prostaglandins and free-radical mediated damage have been implicated in the pathogenesis of this kwashiorkor-like dermatitis. In spite of the rarity of this presentation, recognition of the rash is important, not only to expedite the diagnosis, but also to gain insight into the disease. We present a further case to highlight this unusual presentation and discuss potential pathophysiological mechanisms.     

The epidemiology of traumatic rupture of the thoracic aorta in children: a 13-year review

Traumatic rupture of the thoracic aorta (TRA) is a rare but highly lethal injury in children that occurs as a result of car versus pedestrian accidents and motor vehicle accidents. TRA is often associated with life-threatening injuries to other organ systems. Therefore children with TRA like adults sustaining TRA must be treated urgently but systematically. The rarity of this injury makes it all the more important for physicians treating pediatric trauma victims to be cognizant of the importance of the injury and the clinical and radiographic signs. Even when TRA is promptly recognized in children it is associated with a high in-hospital mortality. The proper use of child restraint systems and adherence to the 55 M.P.H. speed limit may be important factors in reducing the mortality of TRA in children after MVA.     

Endovascular repair for acute traumatic rupture of the thoracic aorta

BACKGROUND: We report endovascular treatment of acute traumatic rupture of the thoracic aorta as a potential alternative to open surgery for high-risk patients. METHODS: Between January 2001 and July 2002, 9 patients with acute traumatic rupture of the thoracic aorta were treated with a stent-graft. In all cases the endovascular management was selected because of age, associated polytrauma, or comorbidities. Preoperative workup included chest computed tomography scan, transoesophageal echography, and angiography. The devices used were the Excluder and the Talent stent-grafts. RESULTS: Eight patients underwent immediate repair and 1 patient was treated within 5 days of the accident because of delayed diagnosis of aortic rupture after surgical management of spleen rupture. The stent-graft was successfully expanded in all patients through the common femoral artery (n = 7) or the common iliac artery (n = 2). There was no perioperative death, renal failure, or neurologic complication (paraplegia or stroke). In 1 patient the computed tomography scan at 7 days postoperatively showed proximal endoleak requiring placement of a second stent-graft. Follow-up ranged from 4 to 20 months. All spiral computed tomography scans performed during follow-up revealed no evidence of endoleak, migration, or alteration of the stent-graft. CONCLUSIONS: Endovascular repair in the acute phase of traumatic rupture of the thoracic aorta is technically feasible and safe, and may represent an alternative to open surgery for high-risk patients.     

Surgical treatment of traumatic thoracic aorta rupture: a 7-year experience.

OBJECTIVES: Traumatic aortic rupture is highly lethal and an ongoing therapeutic challenge. We review our 7-year experience with traumatic aortic disruption. METHODS: We treated 12 cases of traumatic rupture of the thoracic aorta (TRTA) from December 1994 to June 2001 at our institution. Of these, 9 were male, and the average age 26 years. Injuries were caused by traffic accidents in 9 cases and falls in 3. Contrast-enhanced helical computed tomography was used to diagnose10 cases and digital subtraction angiography to diagnose 2 at other hospitals. Six of 12 (50%) disruptions were located in the aortic isthms. All surgery was conducted under cardiopulmonary bypass. A percutaneous cardiopulmonary support system (heparin-bonded artificial lung and centrifugal pump) was used in 6 cases since 1998. RESULTS: Among the 12 patients, 6 had early surgical repair within 2 days after the accident, and all survived free of neurological problems. Six other had repair delayed more than 2 days and all were doing well. CONCLUSION: Immediate repair of aortic lesions should be the rule because the majority of deaths from TRTA occur within 24 hours. We believe, however, that immediate surgery may not be necessary for some patients with severe, multiple associated lesions who survive initial traumatic aortic disruption of the aorta.     

Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis

BACKGROUND: Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear. METHODS: A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group. RESULTS: One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 +/- 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 +/- 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 +/- 22 versus 36 +/- 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 +/- 9 versus 32 +/- 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms. CONCLUSIONS: Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.     

Acute traumatic rupture of the thoracic aorta: place of delayed surgical repair

Acute traumatic rupture of the thoracic aorta (ATRTA) is considered as 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 upon (Group I), twenty patients had immediate surgery (Group II) with 60% mortality, four patients underwent delayed surgery (Group III) with 25% mortality. Analysis of cause of death show that associated lesions were present in 72% of pts who did not survive and in only 37% among 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. It is well known that the majority of deaths from ATRTA occur within 24 hours. Immediate repair of the aortic lesion should be the rule when aortic rupture is isolated or associated with moderate injuries. It may be however that in some cases with severe and multiple associated lesions who survive the initial aortic injury, delayed repair of ATRTA could be considered.     

Management of traumatic rupture of the thoracic aorta in pediatric patients

BACKGROUND: Traumatic rupture of the thoracic aorta (TRA) in the pediatric population is uncommon. Management of TRA in general has evolved to include selective nonoperative and endovascular stent graft approaches, although operative repair remains the standard. METHODS: We conducted a retrospective chart review of patients younger than 16 years of age admitted to a single institution between March 1985 and February 2002. RESULTS: Of 160 patients admitted with TRA, 11 were younger than 16 (11.9 +/- 3.5) years of age. Concomitant injuries included closed head injury (5 patients) and acute lung injury (6 patients). All were started on beta-blockers when the diagnosis was suspected. Laparotomy was required in 3 patients and orthopedic procedures in 5 patients. Six underwent operative repair (two primary repairs), with no mortality. Cross-clamp time was 30.4 +/- 2.6 minutes. One patient (operated on without bypass) was partially paralyzed. Two patients were managed nonoperatively, 1 with an intimal arch injury, who on subsequent follow-up has demonstrated healing, and 1 who died of head injury. Three patients were managed by endovascular stent grafts, 2 who died of closed head injury and 1 who at 1-year follow-up has fully recovered. The endovascular stent grafts were placed through the femoral artery in 2 patients and through an iliac conduit in 1 patient. No patient died of rupture. CONCLUSIONS: The approach to pediatric TRA should be identical to the adult, with early institution of beta-blockers. Depending on the clinical setting, a spectrum of options should be considered, including operation, non-operation, and endovascular stent graft, although the choice of the latter must be tempered by the lack of long-term follow-up data.     

Surgical treatment of acute traumatic rupture of the thoracic aorta a timing reappraisal?

OBJECTIVE: To report our experience with surgery of thoracic aortic rupture due to blunt trauma. METHODS: Between October 1976 and October 1999, 50 patients suffering from acute rupture of the thoracic aorta due to blunt trauma were operated on. On admission, 22 patients (44%) presented with hypovolemic shock and all but five (90%) sustained major associated injuries. Thirty-one patients (62%) underwent immediate operation for aortic repair, whereas the procedure was delayed from 6 to 60 days in ten patients because of late diagnosis or coexisting life-threatening lesions thought to largely worsen the operative risk. In 48 patients, the aortic repair was carried out with the aid of cardiopulmonary bypass (CPB) in order to maintain the distal perfusion and to prevent spinal cord injury. An inert 'Gott' shunt and the 'clamp-and-sew' technique were used in one patient each. RESULTS: The hospital mortality amounts to 18% (nine patients). Four patients (8%) died intraoperatively and five patients (10%) died in the postoperative course. In five patients (10%) death was caused by cerebral or pulmonary hemorrhage, possibly worsened by systemic heparinization during CPB. One case of postoperative paraplegia (2%) was observed in a patient operated on with the aid of CPB. There was neither aortic rupture nor sudden death in the group of patients in whom the surgical procedure was delayed. CONCLUSIONS: The immediate outcome of patients suffering from acute traumatic aortic rupture strongly depends on the associated injuries. In some cases, the emergency aortic repair must be favorably delayed because of the necessity of life-sustaining measures and management of major coexisting injuries, which could be worsened by the use of CPB. Conversely, the risk of paraplegia is significantly reduced by the use of CPB and distal perfusion during the time of aortic cross-clamping.     

‘Raccoon Eyes’ (periorbital haematoma) as a sign of skull base fracture

This is a study of the relationship between skull base fracture and the raccoon eyes sign in a prospective study in cadavers. Fifty cadavers were analysed with cranio encephalic trauma and skull base fracture or the raccoon eyes sign. Both conditions were present in 24 (48.0%) cases. The association was significantly higher in cases with a frontal basal fracture and epidural haematoma. The raccoon eyes sign is easily recognised and can be associated with basal fractures.