Diagnosis and early surgical management of traumatic thoracic aortic disruption

Traumatic rupture of the thoracic aorta is a major cause of death. Survival greatly depends on early diagnosis, degree of injuries to other districts and timing of repair. To address the controversial aspects of this condition, we retrospectively reviewed our experience.

Between April 1984 and December 1998, 39 patients (31 males, 79%), with a mean age of 33 +/- 7 (range, 17 to 59 years), underwent surgical repair at our institution. Final diagnosis of aortic disruption was achieved in 33 patients (85%) by aortogram, and in 6 (15%) by transesophageal echocardiography (TEE) alone. Four patients (8%) had a false negative chest X-ray on admission. Twenty-four patients (61.5%) had additional major injuries to other districts (n = 4, cranial trauma; n = 13, cranial trauma + pelvic fracture; n = 5, lesions to abdominal viscera; n = 2, lesions to abdominal viscera + pelvic fracture). Surgical techniques included simple aortic cross-clamping in 7 patients (18%), partial femoral-femoral bypass in 17 (44%), and partial left heart bypass in 15 (38%). Two patients underwent direct aortic suture (5%), whereas 37 (95%) had interposition of a vascular graft.

Three patients (8%) died after major hemorrhaging during the early phases of our experience. Paraplegia occurred in 1 patient (2.5%) in the single aortic cross-clamping group. There was no morbidity directly attributable to the administration of heparin for cardiopulmonary bypass.

Although aortography is still the gold standard to achieve diagnosis, the use of TEE as a method of detecting traumatic injury to the thoracic aorta appears feasible in critical patients, advantageously saving time. With a meticulous surgical approach and the use of an effective method for distal aortic perfusion during repair, it is possible to achieve good outcomes.