Chapter
Surgical Treatment of an
Acute Isthmus Traumatic Rupture
32
Thierry Langanay, Bertrand De Latour,
Alain Leguerrier
Contents
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32.1
Introduction
32.2
Clinical
32.2.1
32.2.2
32.2.3
32.2.4
32.3
Technique of Surgical Repair . . . . . . . . . . . . . 322
32.4
Special
32.4.1
32.4.2
32.4.3
32.4.4
32.4.5
Features . . . . . .
Patients . . . . . .
Diagnosis . . . . .
Surgical Treatment
Results . . . . . . .
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Situations and Controversies
Update in Natural History .
Associated Lesions . . . . . .
Postoperative Paraplegia . .
Endovascular Therapy . . . .
Medical Treatment . . . . . .
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319
319
320
321
322
325
325
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325
326
326
32.5
Current Therapeutic Strategy . . . . . . . . . . . . . 326
32.6
Proposal for a Timing Reappraisal of Aortic Repair 327
32.7
Conclusion . . . . . . . . . . . . . . . . . . . . . . . 328
32.1 Introduction
Acute ruptures of the aortic isthmus account for about
85% of aortic injuries due to blunt trauma. They are
generally related to a violent crash involving a sudden
deceleration. Polytraumatisms and other life-threatening
injuries are often associated with cardiovascular lesions.
It is generally admitted that about 80% of casualties die
at the accident scene and that among the survivors only
20% would survive without emergent surgical repair of
the aortic injury.
After surgery, however, the hospital mortality rate remains high, and stands around 20% in most reports in
the literature [1, 2]. This high mortality rate seems to
be mostly linked to lesions associated with aortic rupture. On the other hand, paraplegia is the most feared
complication after surgery requiring aortic cross-clamping. The use of cardiopulmonary bypass (CPB), which
provides distal perfusion during the duration of aortic
cross-clamping, appears to dramatically reduce the risk
and the actual rate of postoperative spinal cord injury
[2]. But the necessity of full systemic heparinization
during CPB entails the risk of inducing or severely worsening bleeding in a coexisting internal wound and particularly brain or pulmonary contusion, leading to fatal
hemorrhage in many cases. This raises the difficult
question of surgical priority and/or of delaying the aortic repair until the associated life-threatening lesions
are sufficiently healed or under control [3±5].
32.2 Clinical Features
32.2.1 Patients
From October 1976 to October 2004, 62 patients (52 men
and ten women) were operated on for an acute rupture of
the thoracic aorta in our institution. The age ranged between 14 and 72 years with a mean of 28 Ô 10.5 years. Forty
patients (63%) were less than 30 years old (Fig. 32.1).
The patients' files were analyzed retrospectively from
the data collected at the time of hospitalization. Those
data together with the data collected during the followup were entered into the database of our center, and
were treated statistically with a Hewlett-Packard 9000
computer using Statview statistical software.
All patients had been victims of a violent accident
involving a mechanism of sudden deceleration. Fifty-six
patients (90%) experienced a traffic accident: car crash
in 41 cases (66%), motorcycle crash in 13 cases (21%),
and pedestrian knock over in two cases (3%). Six patients (10%) had been the victim of fall (8±10 m).
On admission, 26 patients (42%) showed evidence of
hypovolemic shock with unstable hemodynamics. Ten
patients (16%) presented with acute respiratory distress,
in connectionwith a flail chest in six patients (10%).
Five patients (8%) suffered from a pseudocoarctation
syndrome with complete abolition of the femoral
pulses. In two of those (3%) there was evidence of ischemia of the lower limbs in relation to a complete
thrombosis of the distal aorta.
320
VII. Aortic Injury
Fig. 32.1. Repartition of patients according to age
Fig. 32.3. Aortic rupture on the computed tomography scan
One patient (1.5%) had paraplegia due to a coexisting spine fracture and spinal cord lesion, one patient
(1.5%) had paraparesis and one patient (1.5%) suffered
from neurological deficit of the right upper limb.
32.2.2 Diagnosis
The possibility of an aortic rupture was suggested by
several signs associated in various manners. Widening
of the upper mediastinum was present on plain chest
film in 51 patients (82%) (Fig. 32.2). In 23 patients
(37%) the aortic rupture was suspected because of the
loss of parallelism of the aortic walls or the widening
of the aortic isthmus on routine computed tomography
(CT) scans performed to check the thoracic lesions of
the polytraumatism (Fig. 32.3).
Fig. 32.4. Aortogram showing the loss of parallelism of the aortic walls
Table 32.1. Lesions associated with aortic rupture
Patients
Fig. 32.2. Widening of the upper mediastinum on the standard
chest X-ray
Thoracic lesions
Rib fracture
Flail chest
Sternal fracture
Head injury
Skull fracture
Brain contusion and coma
Orthopedic injury
Lower limb fracture
Upper limb fracture
Pelvic fracture
Rachis fracture
Maxillo-facial fracture
Clavicule fracture
Abdominal lesions
Ruptured spleen
Kidney contusion
Liver wound or contusion
Ruptured diaphragm
Other
37
25
47
21
N
46
12
7
2
13
27
15
19
4
8
3
10
7
7
2
2
Percentage
60
74
19
11
40
3
21
76
43
24
30
6
13
5
34
16
11
11
3
3
T. Langanay et al.
Chapter 32 Surgical Treatment of an Acute Isthmus Traumatic Rupture
Fig. 32.5. Delay between the accident and the
aortic repair
Fig. 32.6. Techniques of aortic repair and spinal cord protection
In one patient (1.6%) the occurrence of a systolic
murmur 11 days after the accident led to the diagnosis,
which was confirmed by a transesophageal echocardiogram (TEE) and a subsequent aortogram.
Forty-four patients (71%) underwent an aortogram
(Fig. 32.4). For the remaining 18 patients (29%), an aortogram was not obtained either because the CT scan
convincingly demonstrated the presence of the aortic lesion (16 cases, 26%) or because the clinical condition
was too unstable to allow any further delay to surgery.
For those two patients, the diagnosis was confirmed at
emergency thoracotomy. If an aortogram was the rule
in the early years of this series, it has now been replaced by CT scan and for the last twelve patients no
aortogram was obtained.
The aortic lesion was isolated in only five patients
(8%). All other patients (57±92%) sustained major associated injuries, reflecting the magnitude of the violence
of the accident. The associated injuries are summarized
in Table 32.1. They were responsible for coma in 13
cases (21%), and an emergency laparotomy was performed prior to the aortic repair in 17 cases (28%).
32.2.3 Surgical Treatment
Thirty-seven patients (60%) underwent aortic repair
within 24 h of the accident (Fig. 32.5). Conversely, 25
patients (40%) were treated after a delay extending over
1 month, 23 patients were operated on and two patients
were treated with an endoprosthesis. This delay was
either due to a late diagnosis, the aortic rupture being
obscured by major coexisting lesions in 12 patients, or
was made on purpose for 13 patients because of the
presence of severe associated injuries (four polytraumas
with multiple and severe orthopedic lesions, two ruptured spleens, one liver wound, one coma grade III and
several pulmonary contusions) thought to make the
emergency aortic repair riskier than continued intensive medical therapy.
Sixty patients were operated on by conventional surgery and two were treated with an endoprosthesis (Fig.
32.6).
During surgery, the patients were intubated with a
double-lumen tube in order to allow separate ventilation of the lungs. The isthmic aorta was approached
through a left posterior thoracotomy in the fourth intercostal space in 58 patients (96%). In the remaining two
patients, a sternotomy was carried out for resuscitation
321
322
VII. Aortic Injury
purposes. Spinal cord protection and perfusion of distal
organs were achieved by the use of a conventional CPB
whenever possible. This was the case for 57 patients
(95%), the remaining three patients being operated on
either with a Gott shunt (one patient) or with the
clamp-and-sew technique (two patients). The CPB was
established in various manners. The aortic clamping
time ranged from 21 to 110 min (mean, 58 min). There
was no difference in clamping time depending on the
presence or the absence of CPB.
In two cases (3%) the aortic repair had to be carried
out during circulatory arrest at deep hypothermia because of the proximal extension of the aortic tear to the
transverse arch.
The aortic rupture was circumferential in 39 patients
(65%), partial in 20 (33%) and bifocal in one (2%). The
aortic repair could be achieved through direct suture in
26 patients (43%) but required a Dacron prosthesis interposition in the remaining 34 patients (57%).
For the last two cases, because of coexisting lesions
(polytraumatism and lung contusion) and an unstable
aortic lesion, an endoprosthesis was implanted on the
second day after the accident. The immediate outcome
was uneventful.
32.2.4 Results
The overall hospital mortality amounts to 16% (ten patients). Four patients died in the operating theater. Six
patients died during the postoperative course. The time,
circumstances and causes of death are summarized in
Table 32.2.
Several nonfatal complications were observed during
the postoperative course. One patient experienced paraplegia (T-3 level), which appeared 72 h after the surgical procedure and was totally regressive within
3 months (2%). This patient had been operated on with
the aid of CPB with a cross±clamping time of 59 min, a
mean distal arterial pressure of 80 mmHg during CPB
and a total blood loss of 450 ml for the first postoperative 24 h. The only deleterious element could have been
the intraoperative suppression of two pairs of intercostal arteries. However, this delayed spinal cord injury
might have been the result of some reperfusion syndrome with spinal cord edema. This could then explain
the total regression of the neurological deficit in a
rather short time.
Eleven survivors (22%) showed evidence of arterial
hypertension. The mean age of this subgroup of patients was 22.7 Ô 6.4 years and all but two ruptures were
treated by a Dacron tube interposition. No particular
reason could be found; the arterial hypertension was
controlled by medical therapy.
32.3 Technique of Surgical Repair
The patient is placed in the right lateral decubitus position and then the hips are rolled back toward a more
supine position so that the left femoral vessels are accessible (Fig. 32.7) [6, 7].
During surgery, the patient is intubated with a double-lumen tube in order to allow separate ventilation of
the lungs. A catheter is inserted in the patient's right radial artery and another one in the right pedious artery,
opposite to the femoral arterial cannulation, to continuously monitor blood pressure and the distal perfusion.
One or two large-bore needles are positioned securely
in a peripheral vein after placement of a central vein
catheter. A Swan±Ganz catheter might be useful depending on the general condition of the patient (advanced age, cardiac or renal insufficiency). Vesical and
gastric tubes are also inserted.
The isthmic aorta is approached through a wide left
posterior thoracotomy in the fourth intercostal space.
This provides excellent viewing on the aortic isthmus
but allows also access to the aortic arch, the pulmonary
artery, the descending aorta and the left side of the
heart. The arterial cannulation is realized before the
thoracotomy because it allows rapid and massive retransfusion in the case of an aortic rupture occurring
during the thoracotomy, especially when the lung compression on the aortic adventitia is released during dis-
Table 32.2. Circumstances, dates and causes of hospital deaths
Surgery/accident
Associated lesions
Death/surgery
Causes
5th day
11th day
Emergency
Emergency
Emergency
Emergency
2nd day
Emergency
Emergency
2nd day endoprothesis
Brain contusion
Lung contusion
Resuscitation
Lung contusion
Brain contusion
Distal malperfusion
Distal malperfusion
Preoperative inhalation
Bronchial rupture + lung contusion
Brain lung contusion
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Intracerebral bleeding
Pulmonary bleeding
Multiorgan failure + hemorrhage
Pulmonary bleeding
Intracerebral bleeding
Multiorgan failure
Multiorgan failure
ARDS
Septicemia
ARDS
ARDS acute respiratory distress syndrome
0
0
0
0
1
1
2
2
10
31
T. Langanay et al.
Fig. 32.7. The patient is positioned in the right lateral decubitus
position
section. A cell-saver device is used to suck the blood
out of the thorax so that it permits an autotransfusion
either by the CPB or by the peripheral veins.
A median sternotomy can be preferred in the case of
an unstable hemodynamic state because of the easiest
and fastest realization. It allows the installation of a
CPB and an aortic cross-clamping.
Great care must be taken during the dissection not
to provoke a hemorrhage by disturbing the mediastinal
hematoma, which usually holds back the tear and prevents active bleeding in the pleural space. If this does
occur, the use of the cell-saver and cardiotomy suction
will allow immediate and massive autotransfusion via
the femoral arterial cannula and maintenance of a
Chapter 32 Surgical Treatment of an Acute Isthmus Traumatic Rupture
stable hemodynamic condition during the control of
the aorta. To avoid such a situation, the lung is cautiously retracted and the aorta controlled proximally
and distally before entering the hematoma. Most of the
time, this requires separate control of the distal arch
and the left subclavian artery.
The mediastinal pleura is opened beyond the hematoma over the distal transverse arch, the left subclavian
artery and the upper descending aorta. The dissection
is carried around the vessels, and once the circumferential control has been obtained three tapes are placed, so
that a cross-clamp can be placed immediately in case a
rupture occurs during the dissection of the hematoma
which is conducted step by step toward the tear. The
hematoma is largely removed; the distal clamp is then
moved proximally as far as possible to avoid keeping intercostal arteries in the excluded part of the aorta by
the clamping which would provoke retrograde bleeding
and to allow retrograde flow to go into the intercostal
arteries. The dissection is conducted toward the transection, staying in the periaortic tissue plane. Usually
there is some bleeding into the field from the intercostal arteries between the clamps. They should not be ligated nor oversewn if possible in order to preserve
spinal cord vascularization and the aorta is tailored to
preserve their origins in the repair. The dissection is often more difficult in the case of delayed repair, compared with fresh rupture, because of fibrosis of the hematoma that already exists. In all cases, identification of
the recurrent nerve is difficult, so it might be injured
by the surgical act as well as by the accident itself (a
postoperative recurrent paralysis is not so rare in our
experience) (Fig. 32.8).
A transversal aortotomy is realized in front of the lesion, which is then analyzed; the tear might be circumferential, incomplete with a preserved posterior wall or
more complex with a spiroid tear. Aortic continuity is
reestablished either by a direct end-to-end suture or by
a graft interposition. Whenever possible, we prefer to
realize a direct reconstruction, with a continuous running suture with 4-0 (3-0) polypropylene as it permits
us to obtain an ad integrum restitution of the aorta
without any sequelae. To avoid inadequate tractions on
the suture, it might be necessary to mobilize the two
extremities of the aorta by means of a larger dissection.
A direct repair is usually possible when the rupture is
incomplete because the intact part of the aortic wall
prevents the retraction of the two extremities. It might
be more difficult in the case of a spiroid tear concerning a lack of tissue or in the case of delayed surgery. In
such situations, a graft interposition with a pretreated
collagen-woven Dacron tube will be realized (Fig. 32.9).
One must remember that cross-clamping the distal
aortic arch rather than the aorta beyond the left subclavian artery induces a greater increase in left ventricular
afterload and decreases the collateral flow to the lower
part of the body and the spinal cord through the left
323
324
VII. Aortic Injury
Fig. 32.8. Operative view of the aortic rupture
Fig. 32.9. The aorta is repaired by a direct end-to-end anastomosis or a graft
interposition
T. Langanay et al.
Chapter 32 Surgical Treatment of an Acute Isthmus Traumatic Rupture
1. The coexisting lesion can be life-threatening in itself
(e.g., spleen rupture, liver contusion and brain trauma).
2. The number and gravity of the coexisting lesions
may induce an intractable condition of hypovolemic
shock and multiorgan failure.
3. The full systemic heparinization required by the
CPB may adversely affect a brain or pulmonary contusion, leading to fatal hemorrhage.
4. Some lesions (open fractures, voluminous limb hematomas) may become septic.
subclavian artery. So if this can be done, the clamp
should be moved beyond the left subclavian artery.
32.4 Special Situations and Controversies
32.4.1 Update in Natural History
Parmley et al. [8] reported, in their classic autopsy study,
that 89.7% of patients who sustain a traumatic rupture of
the thoracic aorta will die within 6 h following the accident and that only 9% will survive beyond 24 h. Since
1958, therefore, traumatic aortic rupture has been considered as an absolute surgical emergency and the fear
of ªimpending ruptureº has led the surgical community
to rush for aortic repair. It appeared with time and
through increasing reported experiences that this surgical attitude could be debated, as it could be, in some instances, more harmful than useful. Many reports, indeed,
have demonstrated that the aortic lesion is seldom isolated [9, 10]. In a study by Pate et al. [9], only two out
of 59 patients had an isolated rupture of the thoracic aorta. The authors questioned the conclusions of the report
of Parmley et al. emphasizing the fact that it was a retrospective necropsic study implying many selections biases.
Similarly, Williams et al. [11] consider that Parmley et al.
overestimated the risk of delayed rupture of the aorta and
that many patients could undergo laparotomy or orthopedic surgery prior to the aortic repair with very little risk
of sudden rupture of the aortic false aneurysm. In a study
concerning 33 cases of isthmic aortic rupture, Cernaianu
et al. [12] demonstrated a close relationship between the
patients' survival rates and the delay separating the accident and the hospital referral. Conversely, they were unable to establish any relationship between the survival
rate and the delay separating the hospitalization from
the diagnosis, on the one hand, and the diagnosis from
the aortic repair, on the other hand.
Recent literature [12±14] reports mortality rates ranging
from 5 to 35% and is in accordance with the figures reported by Von Oppell et al. [2] in their meta-analysis.
32.4.3 Postoperative Paraplegia
Paraplegia may complicate the surgical repair in 3±33%
of cases according to the literature [2, 14±16]. In a wellknown meta-analysis, carried out from 87 reports and
including 1,492 patients operated on for acute traumatic
rupture of the aorta, Von Oppell et al. [2] compared the
rates of hospital mortality and paraplegia according to
the surgical technique used during the aortic repair
(Table 32.4). When a distal perfusion system was used,
the risk of paraplegia decreased significantly compared
with that for the simple aortic cross-clamping technique
(6.1 vs 19.2%, p < 0.0001). The difference between ªactiveº and ªpassiveº perfusion systems also appeared significant (2.3 vs 11.1% paraplegias).
Similar data have been reported by several groups.
From a review of the literature including 749 patients,
Zeiger et al. [17] observed 2.9% paraplegias with the
use of CPB vs 20.4% with simple cross-clamping. Kodali
et al. [13] reported a difference of 3.2 vs 28.5% and Pate
et al. a difference of 3.8 vs 26.7% [10].
In contrast, the use of CPB, either total or partial,
requiring full heparinization of the patient, has been
held responsible for an increase in mortality and morbidity. In particular this technique can induce fatal
hemorrhage of brain and pulmonary contusions. This
possibly explains the high mortality observed in the
group of patients operated on with total heparinization
(18.2%) compared with that of those operated on without heparin (11.9%, p < 0.01) in the meta-analysis of
32.4.2 Associated Lesions
The literature emphasizes that aortic rupture is seldom
isolated and that associated lesions are responsible for
hospital mortality in the majority of cases (Table 32.3).
This stems from four main reasons:
Table 32.3. Role of associated lesions in hospital mortality (from the literature)
Katz et al. [15]
Mattox et al. [14]
Pate et al. [19]
Langanay et al. [5]
Ruptures (N)
Deaths (N)
Number of deaths related
to associated lesions
Percentage of deaths related
to associated lesions
35
32
59
57
5
6
6
9
4
6
2
5
80
100
33
55
325
326
VII. Aortic Injury
Table 32.4. Comparison of mortality and paraplegia rates according to the method of spinal cord protection. (From Von
Oppell [2])
Clamp and sew
Total distal perfusion
Passive
Active
1,492
patients
Mortality
(%)
Paraplegia
(%)
443
985
424
561
16
15
12.3
17.1
19.2
6.1
11.1
2.3
Von Oppell et al. [2]. In 1984, Mattox et al. [14] recommended the technique of simple aortic cross-clamping
without any adjunct for intraoperative management of
the traumatic injury of the descending aorta. In their
series, the rate of paraplegia was not significantly different whether CPB was used or not (4.5 vs 8.3%, respectively). This led many surgeons to believe that they
could avoid using CPB and to consider that the clampand-sew technique was as safe as the distal perfusion
technique. However, Katz et al. [15] have demonstrated
that beyond 30 min of cross-clamping without distal
perfusion, the risk of spinal cord injury dramatically increases. Therefore, considering the very significant differences in the rate of paraplegia highlighted by many
authors, there is presently an obvious trend within the
surgical community to clearly advocate the use of active
distal perfusion systems during the time of aortic repair
for acute traumatic isthmic rupture [18, 19].
To reduce the conflict between the necessary use of
distal perfusion and the increased risk linked to heparinization, it has been recommended to use heparinless
bypass systems with a centrifugal pump [2]. Heparincoated circuits could also represent a tempting alternative as they make theoretically possible the reduction or
the suppression of total heparinization. But those systems are still being evaluated and the possible risk of
thrombosis entailed by the circuits limits their indications and makes their use still controversial.
32.4.4 Endovascular Therapy
The endovascular implantation of a prosthesis has been
proposed, for around 10 years now, for the elective but
also emergent treatment of thoracic aortic rupture. It is
a less invasive technique which necessitates only a surgical or percutaneous femoral artery access, with only
light systemic heparinization (or even not in case of
contraindication). Hospital mortality appears low, from
0 to 6% [20±26]. In addition, procedure-related morbidity is lower than under conventional surgery. No paraplegia and no renal insufficiency have been reported.
But this new technique is not free of problems, i.e., access failure because of small and calcified iliac arteries,
iliac dissection and primary endovascular leaks. This
means that patients have to fulfill certain anatomic prerequisites.
In view of literature data, emergency endovascular
treatment of acute lesions appears safe and efficient,
showing encouraging early and midterm results. It is
particularity indicated in complex multitrauma patients
avoiding CPB and allowing for prompt treatment of associated lesions. But questions regarding long-term
complications and durability of stent grafts remain unanswered and long-term follow-up will therefore be necessary and allow for a definitive conclusion. So today
conventional surgical treatment remains our first choice
and endovascular treatment is proposed only for highrisk patients.
32.4.5 Medical Treatment
The concept of pharmacological treatment and medical
support of acute aortic dissection introduced by Wheat
et al. [27] in 1984 was first proposed by Aronstam et al.
[28] for the treatment of traumatic rupture of the aorta.
This attitude was confirmed by several groups in the
ensuing years [29, 30]. Walker et al. [31] in an extensive
review of the literature found 64 patients medically
treated waiting for aortic surgery. Stulz et al. [35] in
1991 did not observe any death among patients treated
in a conservative manner. Those good results associated
with the higher mortality due to the coexisting lesions
have led many surgeons to question the dogma of ªnodelayº emergency aortic repair in any case and to redefine the therapeutic priorities. Therefore, new strategies
have recently been reported for the medical and surgical management of traumatic rupture of the aorta [3, 4,
19, 32±35]. Even if most of these authors have reported
no death while waiting for the aortic repair, one cannot
consider that there is no risk as Maggisano et al. [35]
reported two deaths as a result of aortic rupture within
72 h of admission to an intensive care unit [35]. Fortunately, this seems to be very rare because except in
cases of complete rupture the adventitia and surrounding mediastinal structures may form a solid fibrous
wall, reducing the risk of delayed rupture [31, 33, 34].
32.5 Current Therapeutic Strategy
The prevalence and the gravity of the lesions associated
with the aortic rupture (Table 32.1) in our series are in
accordance with data recently published. It is to be
noted that no patient died from hemorrhage. Six deaths
out of ten (60%) were directly related to an associated
lesion, five being possibly worsened by full heparinization during CPB: two cases of intracerebral hematoma
following a major head injury and three cases of respi-
T. Langanay et al.
Chapter 32 Surgical Treatment of an Acute Isthmus Traumatic Rupture
Fig. 32.10. The two periods of our therapeutic
strategy
Fig. 32.11. Hospital mortality according to our
new strategy
ratory distress syndrome after lung contusion. The
fourth case of respiratory disease complicated the outcome of an endoprosthesis.
Considering our experience and literature data, we
decided in 1995 to modify our therapeutic strategy. Between 1976 and 1994, 43 patients (group A) were
treated according to the golden rule of ªimmediate aortic repairº and since 1995, 19 patients (group B) have
been managed taking into account associated lesions
(Fig. 32.10). Though it is always very difficult to compare different patients operated at different periods, operative mortality appears much lower, 10 vs 18.6% in
group B (Fig. 32.11). It is also to be noted that no patient died from aortic rupture in the case of delayed
aortic repair.
32.6 Proposal for a Timing Reappraisal
of Aortic Repair
In view of literature and our recent results, we are now
convinced that the best chance for patients is based on
first treating surgically the most life-threatening lesion.
This policy is summarized in Fig. 32.12. The aortic repair should be undertaken immediately if the aortic
rupture is isolated or associated with a non-life-threatening lesion. In the case of a severe life-threatening associated lesion with a stable aortic lesion, the aortic repair should be performed in a second stage after treatment or healing of the coexisting lesion. In this case,
the patient should be maintained in a surgical intensive
care unit, the aortic evolution being closely monitored
by CT scan or TEE under strict control of blood pressure and aortic wall stress through the use of betablocking therapy. In the case of unstable aortic lesion
(e.g., recurring left hemothorax or pseudocoarctation
syndrome), requiring an emergency repair despite the
presence of severe associated lesions, endovascular repair represents the technique of choice today. If it does
not meet the required conditions the aortic repair
should be carried out with the use of heparinless systems such as centrifugal pumps and not by using the
clamp-and-sew technique.
327
328
VII. Aortic Injury
Fig. 32.12. Algorithm representing our proposition for a modern therapeutic strategy. CPB cardiopulmonary bypass
32.7 Conclusion
Acute traumatic rupture of the thoracic aorta is, indeed,
a life-threatening lesion which deserves surgical repair.
It is, however, generally associated with other severe
life-threatening lesions and may be hidden among
those. It, therefore, justifies early, active, exhaustive diagnostic procedures in the case of polytraumatism.
Should the patient show evidence of impending rupture
or major distal malperfusion, emergency surgical repair
is mandatory. But in some instances, surgical treatment
of the aortic rupture must be delayed under strict monitoring. This attitude allows management of other severe life-threatening lesions which, otherwise, would
deeply increase the risk of the aortic repair, and which
are responsible for the major contributor to hospital
mortality in those patients. Whatever the circumstances
of surgery, distal perfusion downstream from the aortic
cross-clamping must be maintained, using either CPB
or a heparinless centrifugal pump.
References
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