Rupture of the descending aorta just distal to the

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1 Rupture of the Ascending Aorta Caused by Blunt Trauma Peter J. Symbas, MD, W. Stewart Horsley, MD, and Panagiotis N. Symbas, MD Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia Background. Rupture of the ascending aorta caused by blunt trauma rarely has been diagnosed and treated. As a result, the clinical manifestations and management of this injury have not been clearly defined. Methods. We describe the clinical presentation, diagnosis, and management of 3 consecutive patients with ascending aortic rupture treated during the last 3 years. We also review the cases with this injury reported in the English-language literature until Results. The predominant clinical manifestations of all patients, including reviewed case reports, were those of other organ, and 5 had signs of aortic regurgitation and 1 of cardiac tamponade. The mediastinal silhouette was normal in 6 and widened in 14 patients, 1 of whom had also rupture of the subclavian artery. The aortic tears were managed with primary repair or with graft interposition and the valve injury with replacement or repair. Three of 20 patients died, for an overall mortality of 15%. Conclusions. Ascending aortic rupture should be considered in any patient with severe blunt trauma who has widened mediastinum or cardiac tamponade, as well as in patients with associated major thoracic. Absence of a widened mediastinal silhouette does not exclude the diagnosis. The repair is relatively straightforward, but survival depends primarily on the severity of associated. (Ann Thorac Surg 1998;66:113 7) 1998 by The Society of Thoracic Surgeons Rupture of the descending aorta just distal to the origin of the left subclavian artery from blunt trauma is a well-recognized injury. By contrast, treatment of patients who have traumatic rupture of the ascending aorta rarely has been reported. We report 3 consecutive patients treated for rupture of the ascending aorta after a motor vehicle accident (MVA) during the last 3 years. Case Reports Patient 1 A 40-year-old man was involved in a high-speed MVA. When he arrived in the emergency department, his physical examination was remarkable for a compound fracture of the right tibia and fibula and superficial facial lacerations. Chest x-ray films showed fracture of the left fourth rib and a widened mediastinum (Fig 1A). Aortography revealed rupture of the ascending aorta just above the aortic valve (Fig 1B). Immediate surgical exploration through a median sternotomy revealed a hematoma of the right anterolateral proximal aortic wall. The distal ascending aorta and right atrium were cannulated and cardiopulmonary bypass was initiated. After aortic crossclamping and cardioplegic arrest, a small aortotomy was made anteromedially, exposing a transverse rupture that extended from just above the orifice of the left coronary artery to just above the commissure between the noncoronary and right coronary cusps. The aortic valve Accepted for publication Feb 21, Address reprint request to Dr Symbas, Emory University School of Medicine, 69 Butler St SE, Atlanta, GA appeared normal. The aortotomy was extended into the rupture and around the remaining medial aortic wall, and the continuity of the aorta was restored with graft interposition. His postoperative course was uneventful, and he was discharged from the hospital on the 9th postinjury day. Patient 2 A 57-year-old, morbidly obese woman was involved in a high-speed MVA that resulted in a 60-cm intrusion on the driver s side. She arrived at the emergency service obtunded, with a blood pressure of 90/60 mm Hg, pulse rate of 138 beats/min, and respiration rate of 12 breaths/ min. Physical examination revealed crepitus on the left lateral chest wall, abrasions on the left shoulder, and decreased breath sounds on the left side. Peripheral pulses were normal. The patient was profoundly acidotic with a base deficit of negative 18.7 and a ph of A chest x-ray film showed bilateral hemopneumothoraces but no obvious abnormality of the mediastinal silhouette (Fig 2A). A pelvic x-ray film showed fracture of the right ramus and an x-ray film of the leg revealed tibia plateau fracture. Computed tomography of the abdomen and head demonstrated hematoma of the liver and left perinephric area and left frontal brain contusion, respectively. The patient was intubated in the emergency room and chest tubes were inserted into each pleural space. After infusions of blood and crystalloid and correction of the base deficit, she became hemodynamically stable and was transferred to the intensive care unit. A transesophageal echocardiogram showed aortic regurgitation, a tear of the proximal ascending aorta, and cardiac contusion by The Society of Thoracic Surgeons /98/$19.00 Published by Elsevier Science Inc PII S (98)

2 114 SYMBAS ET AL Ann Thorac Surg RUPTURE OF ASCENDING AORTA 1998;66:113 7 Aortography was interpreted to show aortic regurgitation and possible intimal tear of the ascending aorta (Fig 2B). Because of the other organ and the medically manageable aortic valve regurgitation, we elected to delay the surgical repair and treat her first with -blockers. During the early hospitalization period she acquired Pseudomonas species and Acinetobacter calcoaceticus pneumonia, followed by right pleural empyema. Management included mechanical ventilation, eventually requiring tracheostomy, appropriate antibiotic therapy, and chest tube drainage. During this period, sequential chest radiographs showed no change of the mediastinal silhouette. After a prolonged, complicated course of maximal medical management, the infections cleared and the other healed, and on the 71st hospital day she was taken to the operating room. Through a median sternotomy, cardiopulmonary bypass was instituted using right atrial and distal ascending aortic cannulation. A small anteromedial aortotomy exposed a transverse tear of the aorta extending from just above the orifice of the left coronary artery around and above the noncoronary cusp to just above the orifice of the right coronary artery. The aortotomy was extended into the site of the tear. The aortic valve cusps were normal and the insufficiency appeared to be caused from prolapsing of the commissure between the noncoronary and right coronary cusps. This commissure was resuspended with horizontal mattress sutures pledgeted both inside and outside the aorta, and the aorta was closed with running suture. After a relatively uneventful postoperative course, she was discharged from the hospital on the 27th postoperative day Fig 1. (A) Chest radiograph showing abnormal mediastinal silhouette. (B) Digital subtraction aortography showing rupture of the ascending aorta. Fig 2. (A) Chest radiograph showing no appreciable abnormality of the mediastinal silhouette. (B) Aortogram showing possible intimal tear just above the aortic valve and aortic valve regurgitation.

3 Ann Thorac Surg SYMBAS ET AL 1998;66:113 7 RUPTURE OF ASCENDING AORTA 115 with no evidence of aortic valve regurgitation. She had remained in the hospital for this prolonged period postoperatively for rehabilitation from orthopedic. Patient 3 A 58-year-old man was injured in a high-speed head-on MVA. On arrival to the hospital he was hypotensive with a Glasgow coma scale of 15, nasal fractures, flail chest, a distended abdomen, a widened mediastinal silhouette, and fluid in the right pleural space. A right chest tube was inserted, which drained 500 ml of blood, and a diagnostic peritoneal lavage was positive. Emergent laparotomy showed a grade II liver injury managed with packing. Because of episodic unexplained hypotension and persistent hypothermia and acidosis, the abdomen was closed with towel clips. An intraoperative transesophageal echocardiogram by a trainee showed no aortic injury. Because the patient remained unstable, aortography was performed, showing a tear of the aorta 1 cm above the aortic valve with aortic valve regurgitation. Repeat transesophageal echocardiography by an experienced echocardiographer demonstrated the aortic tear as well as the aortic valve regurgitation. Despite aggressive resuscitative efforts his clinical condition failed to improve and a chest x-ray film demonstrated increased congestion of the lung. Six hours after the abdominal operation he was taken back to the operating room for mediastinal exploration. When the pericardium was opened an ecchymotic area on the right lateral wall of the ascending aorta just distal to the sinuses of Valsalva was encountered. Under total cardiopulmonary bypass, aortotomy was performed. This exposed a transverse tear of the aorta starting just above the commissure between left and noncoronary cusps and extending into the right coronary sinus. There was no injury to the aortic valve cusps, but there was a small intimal flap at the commissure between the noncoronary and right coronary cusps, resulting in aortic valve incompetence. Suspension of the commissures between the right coronary and noncoronary cusps and the left and noncoronary cusps failed to render the valve competent. Therefore the valve was replaced and the rupture was repaired with prosthetic graft interposition. The lungs appeared ecchymotic and edematous, prompting rubber dam closure of the sternotomy. After an initial stormy postoperative course, a delayed closure of the chest and abdomen was performed on the third postoperative day. He tolerated the closures well hemodynamically, but his gas exchange worsened, prompting reopening of the laparotomy incision. After some initial improvement in gas exchange, his oxygenation progressively worsened, and he died 4 days after his injury. Comment Ruptures of the ascending aorta from blunt trauma rarely have been treated, as compared with ruptures of the descending aorta. The reasons for this are twofold. First, rupture at the ascending aorta occurs less frequently, and second, a greater percentage of patients with isthmic rupture survive the initial impact. In two large autopsy series of blunt to the aorta, rupture at the aortic isthmus was found in 50% of 272 cases [1], and in 54% of 142 cases [2]. In these same series ascending aortic rupture occurred in 16% and 8%, respectively. The remaining occurred at various other sites along the aorta. In two other studies of patients who arrived alive in the emergency service, rupture of the ascending aorta was found in none of 116 patients with aortic rupture [3] and in 3.5% of 1,126 patients with aortic and brachycephalic tears [4]. We reviewed the cases with rupture of the ascending aorta reported in the English-language literature until When the reports did not describe the clinical manifestations, methods of diagnosis, treatment, and outcome, these cases were excluded. Within these constraints we found 17 patients with ascending aortic rupture described (Table 1) [5 17]. The predominant clinical manifestations of all patients including ours were those of other organ ; 5 patients also had signs of aortic regurgitation, and 1, cardiac tamponade (Table 1). The aortic valve incompetence in patients with ascending aortic rupture from blunt trauma may be caused by injury of the cusps or loss of commissural suspension. In both of our patients the regurgitation was caused by the latter, whereas in the other 3 reported cases the valve incompetency was caused by tear of the cusps in 2 and tear of a cusp and commissural dissection in 1 patient. Although in the vast majority of patients with isthmic rupture the chest roentgenograms have an abnormal mediastinal silhouette, in 6 of the 20 patients with tear of the ascending aorta the mediastinal silhouette was not widened. Also in 2 patients the radiographic findings were not reported, and 1 of the patients who had an abnormal mediastinum also had rupture of the left subclavian artery. There are two plausible reasons for the absence of widening of the mediastinum in some patients with ascending aortic rupture. First, the hematoma of the ascending aortic wall, which is not covered with parietal pleura, usually is small. Second, an aortic hematoma that is intrapericardial may be obscured. The radiologic findings of our patients and of those reported in the literature indicate that ascending aortic rupture from blunt trauma may be present even in the absence of a widened mediastinal silhouette on chest roentgenogram. These patients may instead present with signs or symptoms of aortic valve regurgitation or cardiac tamponade. Occasionally, patients may have associated thoracic indicative of severe trauma as the only indication for arteriography, transesophageal echocardiography, or other diagnostic studies. A high level of suspicion, despite a normal mediastinal shadow on chest x-ray film, is necessary to avoid missing ascending aortic. Transesophageal echocardiography was performed in only 1 of the other reported cases and in 2 of our patients. The aortic tear was seen in all 3. This experience and the

4 Table 1. Summary of Case Reports of Ascending Aorta Rupture From the Literature Authors Type of Symptoms and Signs X-Ray Findings Diagnosis Site of Aortic Aortic Valve Marzelle et al [5] Fall Other WMS AOG Distal ascending aorta Parnsihgha et al [6] MVA Other WMS AOG Distal ascending aorta Charles et al [7] MVA AOR and other NMS AOG Above AOV Tear of cusp intimal flap Kirsch et al [8] MVA AOR and other Cannulation Sites Type of Repair Outcome None FA GI S None ND PR D WMS AOG Above AOV Tear of cusp FA PR and S MVA Other WMS AOG Above AOV None ND PR S O Connor et al [9] MVA AOR and other NMS AOG Above AOV Tear of cusp FA PR and S Violon et al [10] MVA Other WMS AOG Above AOV None ND PR S Fleckenstine et al [4] MVA Other WMS AOG Above AOV None ND PR S Lundell et al [11] MVA Other WMS AOG 4 cm above AOV None ND PR S MVA Other WMS AOG Above AOV None ND PR S MVA Other WMS AOG Above AOV None ND PR S Sadow et al [12] MVA Other NMS AOG 4 cm above AOV None FA PR S Catoire et al [13] MVA Other ND Echo Above AOV None NS D Dunn and William [14] MVA Other NMS AOG Above AOV None FA PR S Daniels and MVA Cardiac NMS AOG Ascending AO None ND PR S Maddison [15] tamponade Fall Pain, coldness ND AOG Ascending AO None ND GI S right leg Lewis et al [16] MVA Chest pain WMS AOG Ascending AO None ND GI S Symbas et al Patient 1 MVA Other WMS AOG Above AOV None AO GI S Patient 2 MVA AOR and other WMS AOG and Echo Above AOV Commissural prolapse AO GI D Patient 3 MVA AOR and other NMS AOG and Echo Above AOV Commissural prolapse ND GI and AO PR S AO aorta; AOG aortography; AOR aortic valve regurgitation; AOV aortic valve; aortic valve replacement; D died; Echo echocardiography; FA femoral artery; GI graft interposition; MVA motor vehicle accident; ND not determined; NMS normal mediastinal silhouette; PR primary repair; S survived; WMS widened mediastinal silhouette. S 116 SYMBAS ET AL Ann Thorac Surg RUPTURE OF ASCENDING AORTA 1998;66:113 7

5 Ann Thorac Surg SYMBAS ET AL 1998;66:113 7 RUPTURE OF ASCENDING AORTA 117 proven diagnostic accuracy of the transesophageal echocardiography for other lesions of the ascending aorta suggest that this test may prove to be of great diagnostic value for this injury. However, its reliability is clearly operator-dependent. The tear of the aorta in all 3 of our patients was just above the aortic valve; it involved the right lateral aortic wall and extended at various lengths around the aorta. The site of rupture in other reported cases was just above the aortic valve in 10 patients, 4 cm above the valve in 2, in the distal ascending aorta in 2, and in 3 patients the exact site of the tear was not described (Table 1). These findings suggest that the arterial cannulation can be done in the majority of patients with ascending aortic rupture at the distal ascending aorta or proximal arch rather than the femoral artery. Two of our patients were operated on shortly after admission. Because of the other organ and subsequent pulmonary and pleural infections, which were thought to add inordinant risk to early surgical treatment, the third patient was operated on 71 days after her injury with good results. This observation suggests that, as in isthmic aortic ruptures [17], the time of the repair of the ascending aortic tear may be individualized. Patients with evidence of cardiac tamponade or uncontrollable aortic valve regurgitation, or patients with no other organ, which add unacceptable risk to the surgical treatment, should be operated on as soon as possible. The remaining patients, such as those with massive pulmonary injury, major central nervous injury, or retroperitoneal bleeding, may be treated medically, with vasodilators or -blockers to maintain the systemic blood pressure less than 140 mm Hg and to control the aortic wall tension, until the other or complications cease to add unacceptable risk to the surgical treatment. In addition they should be closely observed for progression or appearance of widening of the mediastinal silhouette or worsening of the aortic valve regurgitation. In summary, ascending aortic rupture from blunt trauma is a rare, often lethal injury requiring a high level of suspicion for timely diagnosis and treatment. The diagnosis should be considered in any patient with severe blunt trauma who has widened mediastinal silhouette or signs of aortic regurgitation or cardiac tamponade, as well as in patients with associated major thoracic. Absence of a widened mediastinal silhouette does not exclude the diagnosis. Repair using cardiopulmonary bypass is relatively straightforward, but survival depends primarily on the severity of associated. References 1. Parmley LF, Mattingly TW, Marion WC, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958; 17: Feczko JD, Lynch L, Pless JE, et al. An autopsy case review of 142 penetrating (blunt) of the aorta. J Trauma 1992; 33: Kodali S, Jamieson WRE, Leiai-Stephens M, et al. Traumatic rupture of the thoracic aorta. A 20-year review Circulation 1991;84(Suppl 3): Fleckenstine JL, Schultz SM, Miller RH. Serial aortography assesses stability of atypical aortic arch ruptures. Cardiovasc Intervent Radiol 1987;10: Marzelle J, Nottin R, Dartevelle P, et al. Combined ascending aorta rupture and left main bronchus disruption from blunt chest trauma. Ann Thorac Surg 1989;47: Parnsingha T, Sakiyalak P, Phodnipleux P. Rupture of ascending aorta due to blunt trauma. J Med Assoc Thailand 1974;57: Charles KP, Davidson KG, Miller H, et al. Traumatic rupture of the ascending aorta and aortic valve following blunt chest trauma. J Thorac Cardiovasc Surg 1977;73: Kirsh MM, Orringer MB, Behrendt DM, et al. Management of unusual traumatic ruptures of the aorta. Surg Gynecol Obstet 1978;146: O Connor JB, Davis CC. Traumatic rupture of the ascending aorta and aortic valve. 1980;912: Violon D, Steppe R, Welch W, et al. Traumatic rupture of the ascending aorta: a case report. Angiology 1982;33: Lundell CJ, Quinn MF, Finck EJ. Traumatic laceration of the ascending aorta: angiographic assessment. AJR Am J Roentgenol 1985;145: Sadow SH, Murray CA III, Wilson RF, et al. Traumatic rupture of ascending aorta and left main bronchus. Ann Thorac Surg 1988;45: Catoire P, Bonnet F, Delaunay L, et al. Traumatic laceration of the ascending aorta detected by transesophageal echocardiography. Ann Emerg Med 1994;23: Dunn JA, William MG. Occult ascending aortic rupture in the presence of an air bag. Ann Thorac Surg 1996;62: Daniels DL, Maddison FE. Ascending aortic injury: an angiographic diagnosis. AJR Am J Roentgenol 1981;136: Lewis JV, Dunn JA, Compton RP. Injuries of the ascending aorta. S Tenn Med Assoc 1993;86: Pate JW, Fabian TC, Walker W. Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995;19: