Blunt Traumatic Rupture of the Aorta

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1 ORIGINAL ARTICLE Blunt traumatic aortic rupture Blunt Traumatic Rupture of the Aorta Shen-Feng Chao, Bee-Song Chang Department of Thoracic and Cardiovascular Surgery, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan ABSTRACT Objective: Aortic rupture is a potentially fatal complication in trauma. We report our surgical result in the treatment of traumatic aortic rupture in eastern Taiwan. Patients and Methods: From August 1996 to October 2000, six patients with traumatic aortic rupture had surgery at Tzu Chi General Hospital. Five had a widened mediastinum on chest X-ray examination. They were diagnosed using chest contrast-enhanced computed tomography (CT), transesophageal echography (TEE), magnetic resonance imaging (MRI), or aortogram. Results: All aortic ruptures were located at the aortic isthmus and were grafted via a left thoracotomy. A Gott's shunt was used in one patient and five patients received femorofemoral pump assistance. One patient with a liver laceration and internal bleeding underwent elective surgery 72 hours after injury. Laparotomy was successfully avoided. Five patients completely recovered after surgery. One patient with a rare case of traumatic aortic dissection died of acute renal failure with hyperkalemia after aorta repair. Conclusion: Traumatic aortic rupture should be treated as soon as possible. Computed tomography is the first choice in the emergency room. MRI can be used in relative stable patients. Aortography can be avoided. In selected case, aortic repair can be delayed to avoid laparotomy. Venous arterial femorofemoral pump assistance prevents paraplegia. (Tzu Chi Med J 2004; 16: ) Key words: blunt chest trauma, traumatic aorta rupture, aortic isthmus rupture INTRODUCTION High-speed deceleration injury, predominately caused by motor vehicle accidents, is the primary cause of blunt traumatic aortic injury [1-4]. Traumatic aortic rupture usually causes a widened mediastinum. When a widened mediastinum is seen on chest X-ray and the aortic knob shadow is not clearly seen, traumatic aortic rupture should be kept in mind [1-4]. This report discusses traumatic aortic rupture in six patients treated in eastern Taiwan. PATIENTS AND METHODS From August 1996 to October 2000, six patients with traumatic aortic rupture were surgically treated at the Tzu Chi General Hospital. All patients were men. Their ages ranged from 31 to 61 years old, with a mean age of 39.8 years. The mechanisms of injuries were falls in two patients and major traffic accidents in four. When chest X-ray revealed a widened mediastinum, disappearance of the aortic knob and a history of high-speed deceleration injury, aortic isthmus injury was suspected. Owing to the immediate availability of contrast-enhanced spiral computed tomography (CT) in the emergency room, five patients had this examination first. Owing to its increasing popularity, MRI was used in two patients. The examinations and mediastinum findings are summarized in Table 1. Received: May 27, 2003, Revised: June 13, 2003, Accepted: February 3, 2004 Address reprint requests and correspondence to: Dr Shen-Feng Chao, Department of Thoracic and Cardiovascular Surgery, Buddhist Tzu Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan Tzu Chi Med J No. 3! NPT

2 S. F. Chao, B. S. Chang Table 1. Examinations of the Mediastinum and Aortic Isthmus Case Chest X-ray Intimal flap and TEE Aortogram MRI mediastinum defmority on CT Aortic isthmus Aortic isthmus aortic isthmus 1 widen No intimal flap, Intimal flap - - mild deformity 2 + No intimal flap ntimal flap Deformity - Severe deformity 3 + Intimal flap, Mild deformity 4 + Intimal flap, - - Deformity No deformity Deformity 6 - Intimal flap, No deformity -: no examination Table 2. Treatment and Results Case Bypass method Operation Result Combined injuries Treatment of combined injuries 1 Gotts shunt' Graft Alive L-spine, tibia open fractures ORIF of spine, leg ext. fixation 2 Femorofemoral Bypass Graft Alive Brain contusion Hemothorax Conservative 3 Femorofemoral Bypass Graft Alive Liver laceration Conservative 4 Femorofemoral Bypass Graft Alive Forearm open fracture ORIF 5 Femorofemoral Bypass Graft Alive Tibia open fracture, femur ORIF fracture, bil. Hemothorax 6 Femorofemoral Bypass Graft Dead Internal bleeding bowel ischemia Bowel resection L-spine: lumbar spine; ORIF: open reduction and internal fixation All aorta ruptures were repaired with Dacron or Hemashield vascular graft interposition via a left thoracotomy. Five patients received femorofemoral pump assistance. One patient with a lumbar burst fracture, paraplegia, and open fracture of both legs received a heparin-bounded (Gott's) shunt from the ascending aorta to the femoral artery. The bypass method, operation, results, combined injuries, and treatment of combined injuries are summarized in Table 2. All of our aortic rupture patients had multiple organ injuries. Five patients had a widened mediastinum, which was diagnosed in the emergency room. One patient with an aortic dissection involving the aortic isthmus was found to have a normal mediastinum. Contrastenhanced CT examination revealed 4 of 5 patients had a deformity of the aorta or intimal flap inside the aorta. CT failed to reveal a deformity or intimal flap in the first patient, however follow-up TEE examination of this patient clearly found an intimal flap at the aortic isthmus. CT found that the second patient had a deformity of the aorta. However, we ordered a follow-up aortogram and TEE examinations. Deformities of aortic isthmus and intimal flap were seen clearly, but the aortogram was subsequently abandoned because it was too time-consuming and more invasive. In the third patient, CT scan clearly found an intimal flap and mild deformity of the aorta, whereas in the fourth (Fig. 1), it found only a small intimal flap (Fig. 2). To confirm this diagnosis, the fourth patient underwent a MRI examination (Fig. 3). The fifth patient (who transferred from another hospital 4 days after injury) was in stable condition upon arrival and underwent direct MRI examination. Aortic isthmus rupture was clearly found in both MRI examinations. The sixth patient presented with acute paraplegia from the T4 level and hypovolemic shock. His chest X-ray did not find a widened mediastinum, hemothorax, or spinal fracture. He received emergency laparotomy to repair a superior mesentery artery injury and bowel ischemia. He was alert but his blood pressure was not well controlled after the operation. Acute anuria and coldness of NPU! Tzu Chi Med J No. 3

Blunt traumatic aortic rupture Fig. 3. The same patient whose MRI clearly shows an aortic isthmus deformity. Fig. 1. Chest X-ray found widened mediastinum in patient four.

However, the general surgeon suggested conservative treatment at first.

Abdominal internal bleeding did not increase. Another abdominal computed tomography performed 3 days later.

3 Blunt traumatic aortic rupture Fig. 3. The same patient whose MRI clearly shows an aortic isthmus deformity. Fig. 1. Chest X-ray found widened mediastinum in patient four. ated Grade III liver laceration and internal bleeding. Laparotomy with liver resection or hepatorraphy is necessary when internal bleeding increases. However, the general surgeon suggested conservative treatment at first. To avoid active liver bleeding after full heparinization during aortic repair, the patients' blood pressure and heart rate were controlled with vasodilators and beta-blocker in the ICU. Abdominal internal bleeding did not increase. Another abdominal computed tomography performed 3 days later. The liver enhanced well without contrast leakage and there was no increase in internal bleeding. Aorta repair was performed with full heparinization. He recovered well and laparotomy was successfully avoided. RESULTS Fig. 2. The same patient whose contrast enhanced spiral computed tomography found periaotic hematoma with a small intimal flap in the aorta. No aorta deformity was found. both legs were found in the intensive care unit (ICU) 18 hours after the injury. Emergency contrast-enhanced chest CT found severe aortic dissection from aortic isthmus to abdominal aorta. This caused abdominal aorta occlusion and acute renal failure. The third patient with aortic rupture had an associ- Five of six patients underwent immediate thoracotomy after diagnosis to repair the aorta. All six patients with aortic isthmus rupture underwent vascular graft interposition via a left thoracotomy. Five of them had femorofemoral pump assistance. The first patient had a heparin-bonded (Gott's) shunt placed between his ascending aorta and femoral artery without heparinization. Lumbar spine internal fixation and external fixation of both lower legs were done after thoracotomy. He was discharged from the hospital after several operations on his legs and rehabilitation for his spinal cord injury. Five patients recovered well and were discharged from hospital without paraplegia. One patient with aortic dissection and lower body ischaemia died of postop- Tzu Chi Med J No. 3! NPV

4 S. F. Chao, B. S. Chang erative refractory hyperkalemia. DISCUSSION Many patients with great vessel injury are in shock on arrival in the emergency room. Usually, they have several kinds of associated injuries. When chest X-rays find a widened mediastinum in patients with major blunt chest trauma, aorta rupture should be highly suspected [1-4]. Sriussadaporn and Franchello recommended aortography in the diagnosis of widened mediastinum in blunt chest trauma patients [1,5]. Some authors recommend spiral computed tomography in traumatic aortic rupture [6-8], but others feel MRI is more accurate than aortography and CT [9-11]. Aortography is invasive and is not immediately available in our emergency room. On the other hand, chest contrast-enhanced spiral CT is available and convenient. CT was used to see the aortic deformity and intimal flap with periaortic hematoma [1-4]. If chest contrastenhanced spiral CT clearly finds deformity of the aortic isthmus or intimal flap with periaortic hematoma, no further study is necessary. If diagnosis is still not clear, aortogram, TEE or MRI can be done to confirm the diagnosis. In our experience, contrast-enhanced spiral CT is fast and convenient. It is the first choice among diagnostic tools in our emergency room. If the patient's condition is stable, the use of MRI can be considered for the first examination. MRI, with its multi-planar imaging capability, is now widely used [9-11]. The only limitation is difficulty in monitoring and accessing a trauma patient while the scan is being performed. Aortography should be avoided because it is more invasive. If the patient needs an immediate operation, TEE can be done in the operating room to confirm the diagnosis. Traumatic aortic dissection is rare [12]. A widened mediastinum need not occur. The chest X-ray of one of our patients did not show a widened mediastinum or hemothorax. Aortic dissection was found only after acute renal failure and ischemia of both legs developed. Partial femoral vein and femoral artery bypass is a good method to protect the spinal cord and lower body circulation [13]. Many doctors prefer the clamp and sew method with or without femorofemoral pump assistance [3,4]. The incidence of paraplegia does not significantly increase as a result. However, a short clamping time has a strong relation with the incidence of paraplegia. Nagy et al reviewed the reports on blunt aortic injury published between 1966 and 1997, and suggested prompt surgical repair using distal perfusion to minimize renal and spinal cord ischemia [14]. However, we preferred use of vascular grafting to repair the aortic rupture and to prevent tension at the anastomosis. This procedure requires more time and femorofemoral pump assistance to prevent spinal cord ischemia. Heparin-bonded shunts from the ascending aorta to the femoral artery can be used to avoid further wound bleeding during heparinization [15,16]. However, shunt tubes are not always available in the operating room. Emergency surgery for multiple injury patients is very important. Aortic isthmus rupture is often not the first priority [6]. Cardiac tamponade, brain hemorrhage with compression signs, and internal bleeding are higher priorities [17,18]. In rare cases, aorta repairs can be delayed to avoid additional surgery for repair of some associated injuries. Before the repair of the aorta proceeds, appropriate vasodilators and beta-blocker usage are very important to prevent aortic rupture. CONCLUSION Traumatic rupture of the aorta requires immediately treatment. The physician should consider the diagnosis of aortic isthmus injury when a widened mediastinum is seen on chest roengenography. Chest contrast-enhanced spiral CT is the first choice in the emergency room. MRI can be used in stable patients. TEE can be used in unstable patients in the operating room to confirm the diagnosis. Aortogram should be avoided. In rare case, aortic rupture repair can be delayed to avoid laparotomy. Venous arterial femorofemoral pump assistance prevents paraplegia. REFERENCES 1. Sriussadaporn S, Luengtaviboon K, Benjacholamas V, Singhatanadgige S: Significance of a widened mediastinum in blunt chest trauma patients. J Med Assoc Thai 2000; 83: Creasy JD, Chiles C, Routh WD, Dyer RB: Overview of traumatic injury of the thoracic aorta. Radiographics 1997; 17: Fishman JE: Imaging of blunt aortic and great vessel trauma. J Thorac Imaging 2000; 15: Fedriga E, Minoratic D, Pozzato C, Taglieri C, Castagnone D: Traumatic rupture of thoracic aorta: Review of a 10-year experience. Radiol Med 1996; 92: Franchello A, Olivero G, Di Summa M, Memore L, Scavarda B, Bertoldo U: Rupture of thoracic aorta resulting from blunt trauma. Int Surg 1997; 82: Pate JW, Gavant ML, Weiman DS, Fabian TC: Traumatic rupture of the aortic isthmus: Program of selective management. World J Surg 1999; 23: NQM! Tzu Chi Med J No. 3

5 Blunt traumatic aortic rupture 7. Wicky S, Capasso P, Meuli R, Fischer A, von Segesser L, Schnyder P: Spiral CT aortography: An efficient technique for the diagnosis of traumatic injury. Eur Radiol 1998; 8: Mengozzi E, Burzi M, Miceli M, Lipparini M, Sartoni Galloni S: Application of spiral computerized tomography in the study of traumatic lesions of the thoracic aorta. Radiol Med 2000; 100: Fattori R, Celletti F, Bertaccini P, et al: Delayed surgery of traumatic aortic rupture. Role of magnetic resonance imaging. Circulation 1996; 94: Hughes JP, Ruttley MS, Musumeci F: Case report: Traumatic aortic rupture: Demonstration by magnetic resonance imaging. Br J Radiol 1994; 67: Cohn SM, Pollak JS, McCarthy S, Degutis LC: Detection of aortic tear in the acute trauma patient using MRI. Magn Reson Imaging 1994; 12: Goverde P, Van Schil P, Delrue F, d'archambeau O, Vanmaele R, Eyskens E: Traumatic type B aortic dissection. Acta Chir Belg 1996; 96: Bouchart F, Bessou JP, Tabley A, et al: Acute traumatic rupture of the thoracic aorta and its branches. Results of surgical management. Ann Chir 2001; 126: Nagy K, Fabian T, Rodman G, Fulda G, Rodriguez A, Mirvis S: Guidelines for the diagnosis and management of blunt aortic injury: An EAST practice Management Guidelines Work Grout. J Trauma 2000; 48: Tatou E, Steinmetz E, Jazayeri S, Benhamiche B, Brenot R, David M: Surgical outcome of traumatic rupture of the thoracic aorta. Ann Thorac Surg 2000; 69: Razzouk AJ, Gundry SR, Wang N, del Rio MJ, Varnell P, Bailey LL: Repair of traumatic aortic rupture: A 25- year experience. Arch Surg 2000; 135; Klena JW, Shweiki E, Woods EL, Indeck M: Purposeful delay in the repair of a traumatic rupture of the aorta with coexistent liver injury. Ann Thorac Surg 1998; 66: Pate JW, Fabian TC, Walker W: Traumatic rupture of the aortic isthmus: An emergency? World J Surg 1995; 19: Tzu Chi Med J No. 3! NQN

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account for 10% to 15% of all traffic fatalities majority fatal at the scene 50% who survive the initial injury die in the first 24 hours 90% die

account for 10% to 15% of all traffic fatalities majority fatal at the scene 50% who survive the initial injury die in the first 24 hours 90% die within the first month if aorta not repaired 30-90% overall