Surgical management of penetrating mediastinal arterial trauma

Fifty-two patients with penetrating injury to the arteries caudal to the thoracic inlet and cephalad to the heart came under the care of the Durban Metropolitan Vascular Service, South Africa, over a 13-year period. The innominate artery was the commonest vessel injured (n = 23). Five patients (11%) had multiple vessel injuries, four of which involved the aortic arch, and 18 (34%) had arteriovenous fistulae. Mortality was greatest with injuries involving the aortic arch (n = 17) and ascending aorta (n = 4) in which intra-operative exsanguination was the leading cause of death (five patients). Injuries involving the inferior and posterior walls of the aortic arch and those located between the innominate and left common carotid origins were the most difficult to control. Seven patients with aortic injuries presented with cardiac tamponade, three of whom had associated injuries involving the atria. Seven of 21 (33%) patients with aortic injuries died compared to 2 of 31 (6%) with aortic arch branch injury (p < 0.05, chi-square) for an overall mortality of 17%.