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Ann Thorac Surg 1998;66:774-778
© 1998 The Society of Thoracic Surgeons

Original articles: Cardiovascular

Operation for chronic traumatic aortic aneurysm: when and how?

Takahiro Katsumata, MD, PhDa, Amihay Shinfeld, MDa, Stephen Westaby, FRCSa

a Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford, England, United Kingdom

Accepted for publication April 3, 1998.

Address reprint requests to Dr Katsumata, Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. There are few guidelines for surgical intervention late after unoperated traumatic aortic rupture. We reviewed our experience and the literature to determine when and how to operate.

Methods. Between 1987 and 1997, we treated 9 patients aged 22 to 82 years with chronic traumatic aneurysm. Seven patients underwent aneurysm resection. Two patients have not been operated on. The injury-to-operation interval ranged from 8 weeks to 18 years (mean, 4.1 years). One patient underwent median sternotomy and patch repair during hypothermic circulatory arrest. Six patients underwent left thoracotomy: 2 were operated on with left atrio–femoral bypass, and 4 with hypothermic circulatory arrest and ascending aortic cannulation.

Results. There was no surgical mortality or morbidity. The 2 patients who were not operated on remained asymptomatic without radiologic change in the aneurysm after follow-up of 2 and 9 years.

Conclusions. From this limited experience and literature review, we make the following subjective observations: (1) all patients with new symptoms should be operated on promptly, and (2) asymptomatic densely calcified aneurysms detected more than 2 years after the accident can be observed by repeated tomography unless new symptoms arise.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
There are few guidelines for surgical intervention late after unoperated traumatic aortic rupture. The simplest strategy is to recommend operation on all patients at presentation. However, surgical intervention for calcified aneurysms of the distal aortic arch extending into the descending thoracic aorta carries the potential for substantial morbidity including paraplegia [1]. Some densely calcified aneurysms remain stable indefinitely and established size criteria are inapplicable for false aneurysms. We therefore reviewed our experience of chronic traumatic aortic rupture and searched the literature to determine when and how to operate for this problem.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Our collective experience comprises 9 patients in 10 years (1987 to 1997). Five were men and 4 women, with ages ranging from 22 to 82 years. The interval between the time of injury and surgical intervention (7 patients) ranged from 8 weeks to 18 years (mean, 4.1 years). Two patients were not operated on and remain under observation.

The mode of clinical presentation is shown in Table 1. Each patient had experienced deceleration trauma and was hypertensive or receiving treatment for hypertension. Four patients (patients 1, 2, 6, and 7) did not recall the traumatic incident without detailed questioning. One patient (patient 2) suffered sudden hemoptysis from an aortobronchial fistula (Fig 1). This was the only life-threatening presentation. In 6 patients, late presentation was with chronic symptoms and chest radiographic findings that suggested a distal arch aneurysm. In each case the diagnosis was confirmed by computed tomographic (CT) scan.


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  		Table 1. Patients With Chronic Traumatic Aortic Aneurysm

 


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  		Fig 1. (Patient 2.) Computed tomographic scan with contrast medium in the bronchi adjacent to the aortobronchial fistula.

 
Indications for operation
In all but patient 5, the chronic traumatic aneurysm was an unexpected finding. Aortic laceration was the only significant injury in patient 5 and in the absence of hemodynamic deterioration her decision to decline surgical intervention was accepted. Blood pressure control with ß-blockers resulted in a satisfactory recovery. She was followed up by CT at 6-month intervals, and remains well 2 years later. The second patient who was not operated on had no symptoms and elected for 6-month follow-up and treatment with propranolol. There has been no change in the size of the aneurysm, no symptoms, and no other indication to operate during the subsequent 9 years (patient 8, Fig 2). Patient 1 was referred for surgical intervention after prolonged intensive care for multiple injuries. A suspected aortic laceration was confirmed by angiography. Patient 2 presented acutely with hemoptysis, and a chest radiograph showed an aneurysm in the superior mediastinum. Computed tomography scan showed some calcification in the wall of the false aneurysm and blood in the bronchial tree (Fig 1). Aortobronchial fistula was diagnosed and the operation was carried out as an emergency. Patient 6 suffered hypertension and a hoarse voice after a deceleration road traffic accident. The densely calcified false aneurysm was identified during assessment for a legal claim (Fig 3). After independent conflicting opinions from three cardiac surgeons this man elected for surgical repair.



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  		Fig 2. (Patient 8.) Computed tomographic scan 17 years after injury showing the calcified false aneurysm. There was no change in size during the 9-year follow-up period.

 


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  		Fig 3. (Patient 6.) Computed tomographic scan showing a densely calcified false aneurysm 3 years after injury.

 
The remaining patients were investigated for new onset of pain, hypertension, or a hoarse voice (patients 3, 4, 7, and 9). They elected for surgical repair when the false aneurysm was detected.

Surgical approach
There were dense inflammatory adhesions between the aneurysm and the lung in all patients. Patient 1 in the subacute phase had a dense fibrous reaction around the area of injury, which gave the impression that rupture was improbable. Similarly patient 6 had an extremely hard calcified aneurysm wall, which was considered very unlikely to change with time. In contrast, the aneurysm in patient 2 had eroded the left upper lobe bronchus and ruptured. Although the remaining aneurysms had areas of calcification in the wall, this was not uniform and there were thin areas of fibrous false aneurysm between. Under these circumstances future aneurysm rupture could not be ruled out.

One patient underwent median sternotomy and deep hypothermic circulatory arrest (20°C of pharyngeal temperature) using ascending aortic cannulation and a two-stage venous cannula in the right atrium (patient 9) (Fig 4). The aneurysm was excised with Dacron patch repair of the resulting defect. The remaining 6 surgical patients underwent left thoracotomy through the fourth intercostal space. Left atrio–femoral bypass and aortic cross-clamping were used in 2 patients. In the remaining 4 patients, distal arch patch repair (n = 1) or replacement (n = 3) was performed using hypothermic cardiopulmonary bypass with venous return from the main pulmonary artery and arterial return to the ascending aorta. Cooling was undertaken to protect the abdominal viscera and, with the pump turned off briefly, a clamp was applied between the left common carotid and left subclavian arteries. Low-flow cardiopulmonary bypass (300 to 400 mL/min) was then reestablished to perfuse the coronary and carotid arteries. In 2 patients who had distal arch replacement the left subclavian artery was reimplanted end-to-side into the graft. In the third patient (patient 4) both the left common carotid and left subclavian arteries were reimplanted (Fig 5).



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  		Fig 4. (Patient 9.) Three-dimensional reconstructed image of a computed tomographic scan showing a saccular aneurysm above the isthmus. The aneurysm was approached through a median sternotomy.

 


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  		Fig 5. (A) (Patient 4.) Aortogram 1.5 years after injury shows a huge false aneurysm separating the origins of the two distal brachiocephalic vessels. (B) The central cannulation technique was employed for distal arch resection through an extended left thoracotomy in patients 2, 4, 6, and 7.

 

   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
There was no surgical mortality or morbidity. All patients made an uneventful recovery without stroke, paraplegia, or new onset of recurrent laryngeal nerve palsy. None required postoperative inotropic support. The left upper lobe was conserved in patient 2. Patient 4 had a renal transplant with impaired function but this did not deteriorate further after the procedure. Hypertension invariably persisted after surgical repair. The mean duration of postoperative hospital stay was 8 days (range, 5 to 14 days). All the patients who were operated on are alive and well after a mean follow-up period of 3.2 years (range, 0.2 to 6.6 years). The 2 patients who were not operated on remain without symptoms or radiologic change in the aneurysm after follow-up of 2 and 9 years.

The outcomes of various surgical modalities for descending thoracic aortic replacement in chronic traumatic aneurysm are summarized in Table 2 [2–19].


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  		Table 2. Results of Descending Thoracic Aortic Replacement for Chronic Traumatic Aortic Aneurysm

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Most patients with traumatic aortic rupture die at the site of injury, but 18% to 20% of those without associated cardiac injury will live for more than 1 hour [20, 21]. Even if a patient survives acute injury, the periaortic hematoma is unstable, and rupture followed by exanguination is probable within the next few weeks without surgical intervention [2]. In 275 cases of traumatic aortic rupture reported by Parmley and colleagues [20], 239 (88%) died during the first hour, 28 (10%) within 2 weeks, and others after 22, 50, and 76 days. Only 5 patients (2%) survived long enough to have development of a chronic traumatic aneurysm.

In a comprehensive review (1982), Finkelmeier and colleagues [15] identified 413 reported cases of chronic traumatic thoracic aneurysm. Eighty-five percent of the patients underwent surgical repair and the remaining 15% were followed up without surgical intervention. They showed a 93% probability of survival 5 years after injury for surgical patients versus 71% for patients who were not operated on. Corresponding figures 10 years after injury were 85% and 66%. One third (20 of 60) of the patients who were not operated on died because of aortic rupture during the follow-up period. Those with only intimal disruption (adventitial integrity was preserved) survived without surgical interventions [22, 23].

In our collective series, only 3 of 9 patients were admitted to the hospital after their accident, and aortic injury was recognized in one. The remaining 6 patients were eventually diagnosed after investigation for hypertension, a hoarse voice, or back pain. Because others must avoid detection, there is no clear impression as to how many patients remain stable indefinitely. In patient 8 (Fig 2) the aneurysm was an incidental finding during investigation of hypertension. Because it was 8 years after the injury, we elected to continue conservative treatment. This decision has been vindicated by a total follow-up of 17 years with no change in symptoms or radiologic appearance. Our surgical experience with patient 1 (operated on at 8 weeks) and patient 6 (operated on at 3 years) gave the impression that rupture of these aneurysms was extremely unlikely. In contrast, the aneurysm in patient 2 was thin-walled and ruptured through inflammatory adhesions to cause an aortobronchial fistula. Patients 3, 4, 7, and 9 also had relatively thin-walled false aneurysms with symptoms from expansion.

Our findings suggest that densely calcified and pain-free aneurysms detected years after the initial event have a stable course and may not need surgical intervention (patient 6 had a hoarse voice immediately after his accident). Others with late onset pain or hoarseness are not stable and should be operated on. We have a low threshold for operating in the event of radiographic change, irrespective of symptoms. An increase in aortic diameter of 1.0 cm during 12 months is an indication for prompt surgical intervention.

Follow-up in patients who are not operated on should include imaging (CT, magnetic resonance imaging or transesophageal echo) at 6-month intervals and oral ß-blocker agents to reduce the maximal rate of increase of left ventricular pressure.

The indications for surgical intervention late after aortic injury do not equate with those for other types of descending thoracic aneurysm in which pain or a maximum diameter greater than or equal to 7 cm is a strong predictor of rupture [24]. Conventionally, all saccular or false aneurysms should be operated on irrespective of size because of implied wall weakness. However, an extremely thick and uniform layer of calcium implies increased wall strength with little propensity to rupture. This, together with a significant risk of paraplegia, supports the policy of continued observation in selected patients as specified [24, 25].

A wide variety of surgical techniques have been advocated for both acute and chronic traumatic aortic aneurysms. The operation requires cross-clamping of the aortic arch proximal to the left subclavian artery with the risk of paraplegia. Consequently left atrio–femoral bypass, femoro–femoral perfusion with a pump oxygenator, or temporary aorto–aortic (or subclavian–femoral) shunt bypass have been used to avoid this complication.

Most false aneurysms eventually undergo extensive calcification. The lesion may involve arch vessels and higher intercostal arteries, especially in elderly patients with underlying hypertension. We have standardized our operative strategy for these patients and others with combined arch and descending thoracic aorta disease [26]. Through an extended left thoracotomy (with sternal transection if necessary) we cannulate the ascending aorta for arterial return and the right ventricle through the main pulmonary artery for venous return. This provides full cardiopulmonary bypass with systemic cooling to protect the spinal cord, kidneys, and abdominal viscera. The method allows total circulatory arrest (if required) during mobilization of the distal arch, but at 20°C a clamp is applied between the left common carotid and subclavian arteries so that coronary and cerebral perfusion can be continued while the distal arch is repaired. Although Von Oppell and colleagues’ comprehensive review of operation for acute transection [27] suggests a spinal cord protective effect from normothermic left atrio–femoral or nonpump shunt bypass, paraplegia still occurs with these methods. An important incidence of paraplegia is also evident from the collective review of 225 surgical cases of chronic traumatic aortic aneurysm from the English-language literature (see Table 2). We consider that deep hypothermia, together with continued cerebral perfusion with heparinized blood, is more likely to protect the spinal cord through the anterior spinal artery, and we have not experienced stroke or paraplegia with this method [26], even after total thoracic aortic resection. From this limited experience of 9 patients and review of the literature, we make the following observations: (1) All patients with new symptoms related to the aneurysm should be operated on promptly. Patients presenting within 2 years should be operated on unless they are at increased risk through comorbid conditions. However, asymptomatic patients with densely calcified aneurysms and an interval of greater than 2 years after the accident can be observed by careful follow-up pending symptomatic or radiologic change. Published guidelines for surgical intervention in true aneurysms do not necessarily apply to chronic traumatic false aneurysm. (2) We have developed a method using hypothermia to provide spinal cord and visceral protection, with continuous proximal perfusion to the cerebral and coronary vessels. This allows replacement of the distal transverse arch without time constraints. Although our initial experience with this technique is encouraging, further evaluation is required to assess its potential advantages over other established techniques.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
We thank Miss Katherine L. Ely, BSc, for editorial assistance.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

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