[Traumatic rupture of the aortic isthmus. Our experience with 23 cases]

Traumatic rupture of the aortic isthmus is a highly lethal lesion. Controversy currently exists regarding the best management of the lower body circulation system during repair of an acute aortic transsection. The aim of this study was to evaluate our results using different methods of distal aorta perfusion in order to prevent ischemia of the spinal cord.

Between October 1987 and October 1999, 23 patients (20 males, 3 females, mean age 28 years) with rupture of the thoracic aorta underwent surgical repair; 18 of these were acute ruptures and 5 post-traumatic pseudoaneurysms.

All cases of rupture were associated with violent, sudden deceleration and in all but one subject it was due to a traffic accident. Twenty patients had severe associated lesions involving the cranium, abdomen, thorax or leg fractures. The operation was performed with a left postero-lateral thoracotomy in all but one case which underwent sternotomy (the patient with an associated lesion of the distal part of the arch). In 1 patient repair was accomplished using simple aortic cross-clamping, in another with total cardiopulmonary bypass, deep hypothermia and cardiac arrest and in 4 cases with partial cardiopulmonary bypass (1 left atrium-femoral artery and 3 femoro-femoral bypass). Seventeen patients were treated using the centrifugal pump (Bio-Medicus) for left atrium-femoral artery bypass. The perioperative mortality was 8.6%, including 2 patients operated in cardiogenic shock. In the 21 surviving patients the postoperative period was free from any cardiovascular complications, with no cases of paraplegia. There were no late deaths (mean follow-up 4 years) and all patients are in good clinical conditions.

These results indicate that the outcome mainly depends on preoperative clinical conditions, associated lesions and the timing of the operation. We conclude that the Bio-Medicus centrifugal pump is a simple and safe means of perfusing the lower body, kidney, and spinal cord without heparinization in a patient with multiple injuries.