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Ann Thorac Surg 2002;74:S1888-S1891
© 2002 The Society of Thoracic Surgeons
a Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
b Surgery/Trauma and Critical Care, Metro Health Medical Center, Cleveland, Ohio, USA
* Address reprint requests to Dr Gill, MD, FRCS(C), Department of Cardiothoracic Surgery, Cleveland Clinic Foundation, 2500 Metro Health Dr, 3rd Floor, Hamann Bldg, Cleveland OH, 44109, USA.
e-mail: gillis{at}ccf.org
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Outcomes may be improved by purposefully delaying surgical intervention of the traumatically ruptured descending thoracic aorta.
METHODS: 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.
RESULTS: 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).
CONCLUSIONS: 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.
Thoracic aortic injury occurs in 10% to 30% of fatally injured adult blunt trauma victims and is the second most common cause of death, after head injury, in this population [1]. Blunt aortic trauma from motor vehicle crashes is responsible for approximately 16,000 deaths per year in the United States [2]. As many as 85% of patients do not survive to reach the hospital [3]. The traditional management has emphasized emergent surgical repair regardless of other associated injuries. In selected patients a delay in operative intervention can decrease morbidity and mortality [4–6]. The purpose of this retrospective review is to report our experience with delayed surgical intervention of aortic injuries in a contemporary setting.
Patients and methods
Patients with the diagnosis of injury to the thoracic aorta (ICD-9 code 901.0) were identified through the Trauma Registry at the Metro Health Medical Center, the level 1 trauma center for the greater Cleveland area, between January 1993 and April 2002. Patient records from hospital charts were reviewed for demographic data, mechanism of injury, associated injuries, injury severity score (ISS), Glasgow coma scale score (GCS), revised trauma score (RTS), resuscitation volume, hypotension during resuscitation, radiographic studies, time/date of aortic repair, technique of repair, clamp and bypass times, presence of postoperative paraplegia or renal failure, and death. Renal failure was defined as creatinine persistently greater than 2 or the need for hemodialysis. The diagnosis of aortic rupture was confirmed by radiographic studies and autopsy reports. Telephone follow-up was performed for patients who had nonoperative intervention. The data were recorded and statistically analyzed using Microsoft Excel. Tests of significance included the Student’s t test and the 
2 or Fisher’s exact test where appropriate. A p value of 
0.05 was considered statistically significant.
Results
During the 9-year study period, 19,501 trauma admissions occurred and 57 (0.29%) patients with descending thoracic aortic rupture (DTAR) were identified. There were 32 male and 25 female patients, of whom 93% (53 of 57) were injured by motor vehicle crashes, 3 patients fell, and 1 patient was injured in a horse-drawn carriage roll-over.
Twenty patients (35%) died during resuscitation and workup, 12 in the trauma bay, 2 in the intensive care unit (ICU), and 2 in the angiography suite. The cause of death in 6 was a closed head injury, aortic injury in 5, head injury and aortic tear in 3, and unknown in 2. Four patients died in the operating room during positioning and preparation and attempted salvage. One had an open head injury and an exploratory laparotomy before his arrest on the table leading to an emergency thoracotomy and an attempted aortic cross clamp. He was pronounced dead before any repair. One patient had a closed head injury and an emergent left thoracotomy while arresting but developed fixed and dilated pupils and the procedure was abandoned. The other two also had emergent thoracotomies but arrested and died before aortic cross clamping. All four had autopsy confirmed aortic injuries and all occurred prior to 1999, before the institution of antiimpulse regimen.
Thirty-one patients had diagnostic imaging with angiography and computed tomography (CT), 3 had CT only, 2 had CT and transesophageal echocardiography (TEE), 2 had CT plus angiography and magnetic resonance imaging (MRI), and 1 had chest radiograph only. Eighteen patients could not receive imaging studies and expired soon after admission but had autopsy-proven diagnoses of aortic rupture. Seven of 18 were dead on arrival.
Among the 37 survivors, 31 patients underwent surgical intervention and 6 were managed nonoperatively. Reasons for nonoperative management were refusal to have surgery (2), a "do-not-resuscitate" order (1), planned transfer to another institution (1), aborted surgery due to technical difficulty (1), and no recovery of cerebral function (1). On telephone follow-up, 4 of 6 (66%) are alive and well, including the patient with the severe head injury, 1 (17%) died of adult respiratory distress syndrome in the ICU at another institution 9 days after transfer, and 1 (17%) is lost to follow-up. Average follow-up time in the nonoperative group is 40 ± 23 months (range, 4 to 72).
Among survivors (n = 28) and nonsurvivors (n = 29) the mean age was 41 ± 18 years (range, 13 to 70) and 53 ± 23 years (range, 18 to 92), the mean ISS was 31 ± 13 (range, 17 to 75) and 40 ± 16 (range, 16 to 75, p = 0.04), the mean GCS was 11 ± 5 (range, 3 to 15) and 6 ± 5 (range, 3 to 15; p = 0.001), and the mean RTS was 10 ± 3 (range, 4 to 12) and 6 ± 5 (range, 0 to 12; p = 0.001), respectively. Associated injuries included orthopedic (26%), nonaortic thoracic (26%), abdomen (20.5%), head (11.5%), spine (9.6%) and face (5.8%). Overall operative mortality was 29% (9 of 31). Six had intraoperative cardiac arrest and 3 had uncontrollable hemorrhage.
Of the surgical group, 55% (17 of 31) of patients were repaired using partial left heart bypass and 45% (14 of 31) using the "clamp-and-sew" (clamp) technique (Table 1). One patient who had a simple plication of a small midthoracic aortic pseudoaneurysm was included in the clamp group but excluded from the clamp time calculation. The surgical group was also analyzed according to emergent (<24 hours after admission; range, 55 minutes to 23 hours) or delayed repair (>24 hours after admission; range, 25 hours to 16 months; Table 1).
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Motor vehicle crashes (MVC) account for more than 80% of aortic injuries, the majority (>80%) occurring at the isthmic level [7]. Immediate management of aortic injuries has been greatly influenced by Parmley’s series of 275 autopsy records in which 89.7% died within 6 hours of presentation and only 9% survived beyond 4 hours [3]. This is a retrospective autopsy study in which up to 50% of patients had other fatal injuries and only 40% of the patients were injured by MVCs. Only 36.7% had injuries of the isthmus but 63% of these patients survived. Also the denominator in this study is unknown and it was performed before the era of established trauma centers, advanced hemodynamic monitoring, and the widespread use of intravenous ß-blockers and vasodilators.
In the current series 93% of patients were injured in MVCs and the majority of aortic tears were at the isthmus, as reported in other series [8]. Risk factors for death in the current series of DTARs included higher ISS, lower GCS, lower RTS, higher age, and earlier surgical intervention. Survivors had mean ISS values of 31.2 versus 39.7 (p = 0.04) for nonsurvivors, and were younger, with a mean age of 41 versus 52 (p = 0.04). Survivors also tended to have surgical repair less emergently at a mean of 30 days after admission, whereas those who died were repaired earlier at a mean of 17 hours (p = 0.43).
Patients in the current series were repaired either using the clamp technique or with partial left heart bypass and the trend was toward better outcomes with the clamp technique. Although no prospective, randomized trial is available comparing the different techniques, proponents exist for both [4, 8–10]. Mattox reported 23 patients with an average clamp time of 37.5 minutes, and a paraplegia and death rate of 13% (3 of 23) and 22% (5 of 23). The present study also supports the clamp technique, with a 0% rate of paraplegia in the clamp group compared with the 12% rate of paraplegia in the bypass group. The mortality rate of 36% in the clamp group is consistent with other reports [9, 10]. The rationale for using a clamp-only technique is in its simplicity, the need for minimal dissection fairly high short-segment resection of healthy aortic tissue without sacrificing many intercostal arteries. There is a finite morbidity and mortality (1.3%) associated with the use of adjunctive measures such as the Gott shunt [11]. In support of adjunctive distal perfusion, the comprehensive meta-analysis by von Oppell [10] reports paraplegia and mortality rates as low as 8.4% and 7.4%, respectively. With the clamp technique alone outcomes are best at more experienced centers with shorter clamp times (<30 minutes) [8, 9, 12].
Historically, management strategies have involved emergent repair of the aortic injury. Purposeful delay in the surgical management of DTAR is a concept that has been reported in the literature [4–6, 12, 13]. Galli and associates [4] reported mortality rates of 14.3% and 0% in the acute and delayed treatment groups. Pierangeli [13] showed a mortality rate of 19%, paraplegia rate of 14%, and renal failure rate of 5% in the emergent group versus zero mortality or complications in the delayed group. In our series, mortality rates of 38% (8 of 21) versus 10% (1 of 10) in the emergent and delayed groups, respectively, supports this concept.
Improved outcomes also may be attributable to a shift in management paradigm in 1999, with greater emphasis on strict antiimpulse therapy combined with purposeful delay and shorter clamp times (Table 2) Clamp times were improved after 1999, with a mean of 46.4 minutes versus 26.3 minutes before and after 1999 (p = 0.0003).
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Our current management strategy involves early institution of antiimpulse therapy once DTAR is suspected from the initial chest radiograph or computed tomography, correction of other life-threatening injuries before aortic repair, and the use of the clamp technique. All patients since 1999 except 2 had associated injuries. These were isolated aortic intimal tears that were followed up on serial CT scans and elective intervention was planned after expansion of the pseudo aneurysm was noted at 28 days and 18 months, respectively.
The present study is limited by its small sample size, retrospective design, and a change in treatment paradigm after 1999. Delayed operative intervention and the use of the clamp technique in selected cases of DTAR may be preferable to immediate operation and the use of partial left heart bypass.
References
This article has been cited by other articles:
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  P. H Lin, T. T Huynh, P. Kougias, M. J Wall Jr, J. S Coselli, and K. L Mattox Endovascular Repair of Traumatic Thoracic Aortic Injuries: a Critical Appraisal Asian Cardiovasc Thorac Ann, August 1, 2008; 16(4): 337 - 345. [Abstract] [Full Text] [PDF]
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 T. G. Gleason and J. E. Bavaria Trauma to the Great Vessels Card. Surg. Adult, January 1, 2008; 3(2008): 1333 - 1354. [Full Text]
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H. Hirose Blood Pressure Control for the Patients with Blunt Aortic Trauma Asian Cardiovasc Thorac Ann, June 1, 2005; 13(2): 200 - 200. [Full Text] [PDF]
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 M. Uzieblo, L. A. Sanchez, B. G. Rubin, E. T. Choi, P. J. Geraghty, M. W. Flye, J. A. Curci, M. R. Moon, and G. A. Sicard Endovascular Repair of Traumatic Descending Thoracic Aortic Disruptions: Should Endovascular Therapy Become the Gold Standard? Vascular and Endovascular Surgery, July 1, 2004; 38(4): 331 - 337. [Abstract] [PDF]
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 G. Iannelli, F. Piscione, L. Di Tommaso, M. Monaco, M. Chiariello, and N. Spampinato Thoracic aortic emergencies: impact of endovascular surgery Ann. Thorac. Surg., February 1, 2004; 77(2): 591 - 596. [Abstract] [Full Text] [PDF]
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M. Doss, J. Balzer, S. Martens, J. P. Wood, G. Wimmer-Greinecker, H.-G. Fieguth, and A. Moritz Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience Ann. Thorac. Surg., November 1, 2003; 76(5): 1465 - 1470. [Abstract] [Full Text] [PDF]
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 N. R. Tai and K. D Boffard Thoracic trauma: principles of early management Trauma, April 1, 2003; 5(2): 123 - 136. [Abstract] [PDF]
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