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Ann Thorac Surg 2000;69:70-73
© 2000 The Society of Thoracic Surgeons

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Original Articles

Surgical outcome of traumatic rupture of the thoracic aorta

^a Service de Chirurgie Cardio-Vasculaire, Hôpital du Bocage, Dijon, France

Address reprint requests to Dr Tatou, Chirurgie Cardio-Vasculaire, Hôpital du Bocage, 2, Blvd de Lattre de Tassigny, BP 1542, 21034 Dijon Cedex, France

	Abstract

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Background. The aim of this study was to point out the results of different techniques of spinal cord protection in surgically-treated patients with traumatic thoracic aorta (TTA).

Methods. A multicentric study was carried out involving 182 patients with TTA. Four patients died before surgery. Two patients were operated on without any investigation and 2 had no aortic tear at thoracotomy. The remaining 174 patients had aortic isthmus disruption and were included in the study. The mean age was 32.3 ± 14.29 years with 126 men (72.4%) and 48 women (27.6%). Road accidents were causal in 163 patients (93.66%); polytraumatism was frequent. A standard chest roentgenogram led to a diagnosis which was confirmed with aortography in 94.8% of cases. Surgical repair of visceral lesions was performed in 52 patients (29.9%) for traumatic spleen, liver, diaphragm, mesentery, and gut. These operations were done before or after aortic operation in 21.3% and 8.6% of cases, respectively. Thirty-three patients (19%) died and 9 (5.2%) had paraplegia. Sixty-nine patients had clamp and sew technique (group 1). Ninety-three patients had different types of extracorporeal circulation (group 2), and 12 patients had Gott shunt (group 3). No difference appeared between the 3 groups according to mortality and paraplegia. But the sex ratio, age, visceral lesions, craniocerebral lesions, the type of aortic repair, and cross-clamp time were discriminative.

Results. The univariate analysis point out age, cross-clamp time, hemothorax, and anatomical type of aortic injury as the risk factors of death. This was confirmed by a multivariable test which retained age, cross-clamp time, and hemothorax as risk factors. When not diagnosed in time, TTA is serious and has a bad prognosis. In spite of a high mortality and morbidity, the surgical management has improved. Immediate operation and medullar protection are the stumbling block in this operation.

Conclusions. Operation can be delayed in some cases, but one must take care of hemodynamic instability. This calls for a repair of the serious associated lesions first, or of a quick performing of a thoracotomy for ruptured aorta. The question remains, is it better to protect the spinal cord with the lower aortic perfusion and avoid the simple cross-clamp? Clinical studies give few answers to this question, and the best answer has not yet been given, as we lack prospective studies in this field.

	Introduction

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The traumatic rupture of thoracic aorta remains a surgical challenge because its diagnosis is not easily carried out, its mortality is high, and its morbidity is tragic.

This mortality is in relation to the seriousness of the lesions, the polytraumatism, and the immediate operation. The morbidity is in relation to the difficult problem of spinal cord protection, which leads to paraplegia in young patients. Thus, the medical situation can easily become a medical-legal problem.

If in some cases emergency operation of aortic lesion can be delayed, the risk of postoperative paraplegia remains, and the question of this morbidity is emphasized by lawyers.

	Material and methods

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Data on 182 patients (traumatic thoracic aorta [TTA] victims) were collected from 10 cardiovascular surgical centers. The following data were collected: causal accidents, clinical signs, associated lesions, chest radiographic signs, aortography and scan signs, surgical access, anatomical aspect of the lesion, type of repair performed, surgical strategy, method of spinal cord protection used, morbidity, and mortality within the 30 postoperative days. Only the patients who had had an aortic isthmus lesion for less than 3 weeks were accepted in this study.

Among the 182 patients, 4 died before operation. Two had immediate thoracotomy without investigation and died. Two patients had no aortic tear at thoracotomy. These patients were excluded from the study. The remaining 174 patients were operated on, and the left posterolateral thoracotomy was the common access used.

According to the surgical strategy, this population was divided into 3 groups: group 1, 69 patients had a clamp and sew technique after 50 UI/kg of heparin therapy; group 2, 93 patients had extracorporeal circulation (ECC). Different types of ECC were used: femoro-femoral partial bypass with the interposition of oxygenator (60 patients), pulmonary-femoral artery bypass (13 patients), total bypass (9 patients), in the situation of complex aortic tear involving the aortic arch, in which 3 circulatory arrests were necessary, left atria-femoral artery circulatory assistance with centrifugal pump (9 patients); group 3, 12 patients had a Gott shunt inserted between the ascending and the thoracic descending aorta.

The decision of surgical strategy was based on surgeon preference. The repair of the aortic injury was either the end-to-end sew or the interposition of vascular prosthesis. When visceral lesions were present, they were repaired either before or after the aortic operation, according to the hemodynamic status.

Operative neurological injury was defined as a lower extremity sensosimotor deficit that was not present preoperatively.

BMDP application software (BMDP, University of California, Berkley, CA) was used for statistical analysis. After the descriptive analysis of the whole population, the first step was the univariate comparative study of different data between the 3 groups and the analysis of the survival outcome. Student’s t test or ² test were used to compare the different groups. The difference was considered significant if p was less than 0.05. The second step was multivariate analysis using the forward stepwise logistic regression, to outline the risk factors of mortality according to the significant data pointed out by the univariate analysis.

	Results

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Concerning the whole population of 174 patients operated on, the mean age was 32.3 ± 14.29 years with 126 men (72.4%) and 48 women (27.6%). The type and the rate of causal accident was car crash in 163 patients (93.6%), fall in 7 patients (4%), crushing in 3 patients (1.7%), and plane crash in 1 patient.

Polytraumatism was frequent: the associated lesions were bone fracture in 134 patients (77%), visceral lesions in 62 patients (35.6%), craniocerebral lesions in 68 patients (39%), and hemothorax and pulmonary contusion in 85 patients (48.9%). Standard chest roentgenogram revealed the following: hemothorax (85, 48.9%), enlarged mediastinum (141, 81%), blurred aortic knob (66, 37.9%), tracheal removal (36, 20.6%), left bronchus lowering (17, 9.7%), and nasogastric tube deviation (9, 5%).

The diagnosis was confirmed with aortography in 165 patients (94.8%), aortography and scan in 24 patients (13.7%), scan only in 2 patients, magnetic nuclear resonance in 6 patients, and transesophageal echography in 1 patient. Surgical repair of the visceral lesions was performed in 52 patients (29.9%) for traumatic spleen, liver, diaphragm, mesentery, and gut. These operations were done before or after aortic operation in 21.3% and 8.6% of cases, respectively. The anatomical aspect of the aortic tear was total rupture in 87 patients (50%), partial rupture in 78 patients (44.8%), and rupture enlarged to the transverse aorta in 9 patients (5.2%).

Thirty-three patients (19%) died within days 30 postoperatively: 9 from craniocerebral lesions with coma, 11 from pulmonary contusions, and 9 from other causes, including multivisceral failure. Morbidity was caused by paraplegia (9 cases, 5.2%), recurrent nerve paralysis (2 cases), high blood pressure (2 cases), and respiratory failure (7 cases).

Comparing the surgical strategy of the 3 groups, there was no significant difference according to the type of accident, bone lesions, hemothorax, anatomical type of lesions, paraplegia, and survival outcome after operation. As summarized in Table 1, there was a significant difference between the 3 groups concerning sex ratio, age, craniocerebral and visceral lesions, type of aortic repair, and aortic cross-clamp time.

When multivariable analysis was used to check the risk factors of mortality in this series, three variables were of high risk: age (p < 0.0001), cross-clamp time (p < 0.04) and hemothorax (p < 0.004).

	Comment

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The first description of TTA was made by Vesalius in 1557 [1]. From 1942 to 1985, many autopsic studies were done, and the rate of TTA became higher with the increase of better picking of patients and energetic resuscitation at the scene. As described by Von Oppel and colleagues [2] from 1972 to 1992, the English literature described only 1742 TTA patients reaching the hospital alive. Thus, there is a separation between clinical and autopsic rates of TTA: many patients died at the scene or on their way to hospital; in autopsic studies, the diagnosis of TTA was not made prior to autopsy; transection involved all layers of aortic wall in nearly 93% of the patients; the aortic injury was not only limited to the isthmus; and significant cardiac contusion was associated in more than 50% of cases. Most of the patients in this period who died beyond 12 hours in the autopsic series, would be diagnosed and operated on nowadays because of the improvement in diagnosis.

The prime causal accident in this series was motor vehicle crashes and the rate of polytraumatism was high. The clinical picture of polytraumatism can conceal TTA, thus, one must think about TTA when violent traumatism occurs. This leads to a careful and critical examination of the chest roentgenogram which is often done in bad conditions. As described by Woodring and King [3], in the majority of cases, the chest radiograph will show evidence of mediastinal abnormalities leading to aortography for the diagnosis confirmation. However, a few cases of false negative results in patients remained in which the liberal use of aortography resulted in the detection of minor degrees of aortic injury. The recent use of transesophageal echography in the detection of aortic injury with a high sensitivity [4] allows the examination of these patients with blunt chest trauma story, and normal or subnormal chest radiograph. Thus, a careful examination of chest radiograph and combination with aortography, or transesophageal echography can help screen these patients more accurately.

Polytraumatism rules out the problems of surgical management. In this study, 21.3% of patients underwent visceral operation before aortic operation because of hemodynamic instability; immediate aortic operation becomes relative. Maggisano and associates [5] examined the hypothesis that TTA can be managed by selective delayed operative repair. Only 4.5% of patients died as a result of a ruptured aorta, within 72 hours of admission, without being operated on. It became obvious that immediate aortic operative repair is not required in all cases, and hemodynamic with neurological conditions are the discriminative factors in this decision. However, the risk of secondary rupture inclines us to be cautions with stable patients as described by Fabian and coworkers [6]. So, we agree with Gammie and colleagues [7], that the use of agressive medical treatment with beta-blockers and vasodilatators in the interval before the operation is an essential aspect of management. The central point of discussion surrounding the treatment of acute aortic disruption is the method used to protect against spinal cord ischemia. The mortality impact of those methods is another aspect of the debate. Many animal studies have shown reduction of paraplegia with distal aortic perfusion. But most clinical series have failed to demonstrate a clear benefit. Even when the aim was well defined, the statistical power of the study was weak. Despite the large number of patients in this series, we had only 9 cases of paraplegia: 4 in group 1 (5.7%), 4 in group 2 (4.3%), and 1 in group 3 (8.3%), and the difference of cross-clamp time was not a discriminative variable. Whatever the surgical technique, it seems that one cannot avoid paraplegia. More studies are needed to find the best method in order to reduce this complication to the minimum. Thus, a cross-clamp time limit of 30 minutes is only the first step in this direction. In each technique proposed, many technical variations can occur with possible incidence on paraplegia. A significant decrease of paraplegia was described when the inert shunt was inserted in the ascending aorta versus the apex of the left ventricle [2]. Active increase of distal perfusion decreases the rate of paraplegia [8], and the biomedicus pump used as the left-to-left heparinless circulatory assistance is the best technique according to many authors [9, 10].

The high mortality of this operation is another point of discussion. Nowadays, the results are the summation of many clinical improvements. In the past, the majority of patients died at the scene. Today, those who reach the hospital alive have multiple lesions, which may be the origin of postsurgical complications and death. In this study, there was no difference of mortality between the 3 groups of surgical strategy, but when the study was focused on overall mortality with multivariable analysis of the risk factors, age, cross-clamp time, and hemothorax were the influencing factors. Increased age associated with atherosclerosis can modify the type of anatomical aorta ruture and complicate the repair, as described by Nicolosi and colleagues [11]. Total disruption and complex tears extending to the aortic arch are more difficult to repair, sometimes including the interposition of prostheses and a longer cross-clamp time. Hemothorax is often associated with pulmonary contusions leading to hypoxemia, longer tracheal intubation, and pulmonary infections. The best surgical management must take care of the associated lesions if we want to ensure survival outcome.

No single radiographic sign, or combination of signs, has demonstrated sufficient sensitivity to enable the identification of all cases of traumatic aortic rupture. But the combination of chest radiograph, aortography, and tranesophageal echography can help screen these patients more accurately. Visceral lesions can be cured before aortic repair, which has to be delayed with some precautions, particularly according to the hemodynamic status.

Surgical strategy, including cross-clamp sew and different types of distal perfusion, is not discriminative according to mortality and paraplegia. Prospective studies are necessary in this field.

Operative repair of TTA still has a relatively high mortality rate. Preoperative factors, particularly age, hemothorax, and anatomical type of aortic injury, are important determinants of operative mortality.

	Footnotes

 
^* With the participation of the Cardiovascular Departments from the Institutions of Amiens, Angers, Bordeaux, Caen, Les Plessis-Robinson, Marseille, Strasbourg, Toulouse, and Tours. See the Appendix.

	Appendix

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Participating Cardiovascular Departments

Amiens: Jacques Pietri, MD, Joël Gamain, MD, Centre Hospitalier Universitaire

Angers: Jean Louis Debrux, MD, Bernard Enon, MD, Jean Pillet, MD, Chirurgie Cardio-Vasculaire et Thoracique, Centre Hospitalier Universitaire

Bordeaux: Xavier Roques, MD, Hôpital Cardiologique du Haut Levêque

Caen: Dominique Maiza, MD, Centre Hospitalier Universitaire de la Côte de Nacre

Plessis-Robinson: Alain Chapelier, MD, Centre Chirurgical Marie Lannelongue

Marseille: Patrice Bergeron, MD, Hôpital Saint Joseph

Strasbourg: Bernard Eisenman, MD, Service de Chirurgie Cardio-Vasculaire

Toulouse: Alain Carene, MD, Philippe Soula, MD, Centre Hospitalier Universitaire de Rangueil

Tours: Lucien Castellani, MD, Michel Marchand, MD, Hôpital Trousseau

	References

Top Abstract Introduction Material and methods Results Comment Appendix References

 

1. Vesalius AN, Benetus T, ed. Sepulchretum sive anatomia pratica [Practicing anatomy on dead bodies]. Geneva 1700:290.
2. Von Oppell U., Dunne T.T., De Groot M.K., Zilla P. Traumatic aortic rupture. Ann Thorac Surg 1994;58:585-593.[Abstract]
3. Woodring J.H., King J.G. The potential effects of radiographic criteria to exclude aortography in patients with blunt chest trauma. J Thorac Cardiovasc Surg 1989;97:456-460.[Abstract]
4. Saletta S., Lederman E., Fein S., Singh A., Kuehler D.H., Fortune J.B. Transesophageal echocardiography for initial evaluation of the widened mediastinum in trauma patients. J Trauma 1995;39:137-141.[Medline]
5. Maggisano R., Nathens A., Alexandrova N.A., et al. Traumatic rupture of the thoracic aorta. Ann Vasc Surg 1995;9:44-52.[Medline]
6. Fabian T.C., Richardson J.D., Croce M.A., et al. Prospective study of blunt aortic injury. J Trauma 1997;42:374-383.[Medline]
7. Gammie J.S., Shah A.S., Hattler B.G., et al. Traumatic aortic rupture. Ann Thorac Surg 1998;66:1295-1300.[Abstract/Free Full Text]
8. Pate J.W., Fabian T.C., Walker W.A. Acute traumatic rupture of the aortic isthmus. Ann Thorac Surg 1995;59:90-99.[Abstract/Free Full Text]
9. Forbes A.D., Ashbaugh D.G. Mechanical circulatory support during repair of thoracic aortic injuries improves morbidity and prevents spinal cord injury. Arch Surg 1994;129:494-498.[Abstract]
10. Read R.A., Moore E.E., Moore F.A., Haenel J.B. Partial left heart bypass for thoracic aorta repair. Survival without paraplegia. Arch Surg 1993;128:746-752.[Abstract]
11. Nicolosi A.C., Almassi G.H., Bousamra M., II, Haasler G.B., Olinger G.N. Mortality and neurologic morbidity after repair of traumatic aortic disruption. Ann Thorac Surg 1996;61:875-878.[Abstract/Free Full Text]

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