Delayed operative intervention in the management of traumatic descending thoracic aortic rupture

Outcomes may be improved by purposefully delaying surgical intervention of the traumatically ruptured descending thoracic aorta.

Fifty-seven patient records identified through the Trauma Registry of a level 1 trauma center between January 1993 and April 2002 were retrospectively analyzed between groups who underwent "clamp-and-sew" versus partial left heart bypass repair techniques and between emergent versus delayed repair.

Thirty-two (56%) of 57 patients were male. The mean age among survivors and nonsurvivors was 41 +/- 18 (range 13 to 70) and 52 +/- 23 (range 18 to 92; p = 0.04) years, and Injury Severity Score was 31 +/- 13 (range 17 to 75) and 40 +/- 16 (range 16 to 75; p = 0.04) points, respectively. Thirty-one (54%) underwent surgical intervention, 20 (35%) died during their initial resuscitation, and 6 (11%) were managed nonoperatively. Seventeen (55%) were repaired using partial left heart bypass and 14 (45%) using the clamp technique. Twenty-one (68%) had emergent repair and 10 (32%) had delayed repair. The rates of paraplegia, renal failure, and mortality were 12% (2 of 17), 0%, and 24% (4 of 17) in the bypass group, 0% (p = 0.29), 0%, and 36% (5 of 14, p = 0.36) in the clamp group, 9.5% (2 of 21), 0%, and 38% (8 of 21) in the emergent group (<24 hours after admission), and 0% (p = 0.45), 0%, and 10% (1 of 10, p = 0.12) in the delayed group (>24 hours after admission), respectively. Mean clamp times for the bypass and clamp groups were 44 +/- 18 (21 to 90) and 30 +/- 10 (14 to 52) minutes, respectively (p = 0.02). Overall operative mortality was 29% (9 of 31).

Purposefully delaying surgical intervention in selected cases of descending thoracic aortic rupture and using the clamp technique does not increase mortality or morbidity over immediate operation and use of partial left hear bypass.