I pertaining to traumatic aneurysms of the aorta at the

Transcription

1 COLLECTIVE REVIEW Mid-Descending Aortic Traumatic Aneurysms Israel Rabinsky, MD, Gurmeet S. Sidhu, MD, and Robert B. Wagner, MD Departments of Surgery and Radiology, Prince Georges Hospital Center, Cheverly, and Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland Two patients with traumatic rupture of the middescending aorta successfully repaired are presented. Most clinical series of aortic tears do not include this entity. A review of the world literature reveals only 9 previous cases. In 6 of the patients the diagnosis was either missed or delayed. In 4 patients the diagnosis was delayed or missed because of the absence of a superior mediastinal hematoma, and in patients the diagnosis was delayed because of inadequate (single-plane) aortography. Suspicion may be lacking because of absence of the upper mediastinal hematoma considered to be the sine qua non for the diagnosis of aortic rupture. Al- though deceleration is considered to be the mechanism of injury in tears at the isthmus, severe hyperextension (often associated with fracture dislocation of the underlying thoracic vertebra) is considered to be the causative factor in descending aortic tears. Experience with the patients presented here demonstrates that a high index of suspicion and complete two-plane aortography is required to avoid the potential for catastrophic outcome subsequent to overlooking a tear of the mid-descending aorta. (Ann Thorac Surg 990;50:55-60) n contrast to the massive literature that has developed I pertaining to traumatic aneurysms of the aorta at the level of the isthmus, little has been written concerning traumatic aneurysms of the mid-descending thoracic aorta. Encounters with such patients within 4 days prompted us to review this rare entity. The purpose of this communication is to report the unique features in diagnosis, mechanism of injury, and frequency of aortic trauma at the level of the mid-descending aorta. Case Reports Puatient A 5-year-old driver of a high-speed motor vehicle accident was admitted to the shock-trauma unit with an open depressed skull fracture, multiple lacerations, fractured ribs, and extremity fractures. Vital signs were stable and the blood pressure was 7/80 mm Hg. The chest roentgenogram on admission was interpreted as negative for widened mediastinum. A computed tomogram of the chest (Fig A) was obtained, and the patient was taken to the operating room for repair of his skull fracture. The following morning the thoracic computed tomogram was reviewed and interpreted as demonstrating a mediastinal hematoma at the level of the arch. An aortogram was then performed, which revealed a false aneurysm at the level of T-8 (Fig B). At thoracotomy a hematoma was found that began at the arch and extended down the descending aorta to T-9. The entire hematoma was explored with the finding of a 0% transverse tear posteromedially at T7-8. For adequate visualization of the tear, the aorta was transected anteriorly, then the edges were debrided and reapproximated with a cross-clamp time of less than 30 Address reprint requests to Dr Wagner, 50 W Edmonston Dr, Rockville, MD 085. minutes. The postoperative course was uneventful. The patient gradually regained consciousness and was discharged months after admission. Patient A -year-old victim of a high-speed automobile accident arrived in the emergency room with a blood pressure of 90/50 mm Hg and pulse of 00 beats/min, breathing spontaneously at 5/min. Positive physical findings included multiple lacerations, decreased breath sounds at the right base, and tenderness over the right clavicle. A chest roentgenogram revealed a right hemopneumothorax, pulmonary contusion, and a right clavicular fracture. The mediastinum was believed to be suspicious for hematoma (Fig A). A computed tomogram of the abdomen revealed a nonfunctioning left kidney. Digital subtraction angiography (used in place of standard aortography to reduce contrast load because of the renal injury) was performed, which confirmed the thrombosis of the left renal artery. The angiogram was carried up to the level of the arch and was initially thought to be negative (Fig 8). Upon review a suspicious double density at the level of the mid-descending aorta was identified. The following morning, a conventional aortogram with a cross-table lateral view was performed, which revealed a tear at the level of T7-8 (Fig C). At thoracotomy a hematoma was located at the region of T-7 to T-8. The laceration, which was found to be a transverse tear of 40% of the aortic circumference on the posteromedial aspect of the aorta, was repaired with direct suture with the aorta crossclamped above and below (cross-clamp time, 0 minutes). The renal artery was not explored. The postoperative course was complicated by pulmonary insufficiency, but the patient gradually recovered and was discharged on the 30th day by The Society of Thoracic Surgeons /90/$3.50

2 56 REVIEW RABINSKY ET AL Ann Thorac Surg 990;50: below the region of the isthmus and above the level of the diaphragmatic aortic hiatus (T-7 to T-0). A Results Of the 83 patients in the collected surgical series with aortic ruptures 96.7% had rupture located at the isthmus,.3% at the ascending aorta or arch, and only % at the descending aorta or diaphragmatic aorta. Of the 740 collected patients in the autopsy group only 50.4% had ruptures at the isthmus, whereas 7.% had ruptures located at the ascending aorta through the arch and 5.7% in the descending aorta through the aortic hiatus. A total of patients (including ours) were found in the literature with tears in the mid-descending aorta (defined as between T-7 and T-0). B Fig. (A) Computed tomogram of chest (mediastinal zuindow). A slight thickening of the periaortic soft tissues is seen (arrow). Af operation, this was a hematoma that extended downzuard from the aortic arch to T-9. (B) Thoracic aortogram reveals laceration in the pusteriomedial wall of the mid-descending thoracic aorta with a false aneurysm. Material and Methods Twenty-eight surgical series of aortic rupture are summarized in Table and compared with a compilation of eight autopsy series (Table ). All totals and percentages are given in reference to aortic tears only. Tears of the brachiocephalic vessels are not included. To compare the surgical series with the autopsy series the lacerations of the ascending aorta and aortic arch are combined, and lacerations of the mid-descending aorta and diaphragmatic aorta are combined in the total figures. In Table 3 we define mid-thoracic descending aorta as that segment Comment The locations of aortic ruptures summarized from 8 surgical series of nonpenetrating aortic injury in Table contrast dramatically with those derived from autopsy series (see Table ). The incidence of isthmus lesions is much more frequent (96.7%) in the clinical series than that (50.4%) compiled from the autopsy series. When tears of the brachiocephalic vessels are included, lesions of the isthmus comprise 89% to 9.5% of the clinical series [, 37. Of particular interest is the 5.7% incidence of descending aortic injuries in the autopsy data as compared with a % incidence in the surgical series. This raises the obvious question as to whether this lesion is frequently overlooked. The autopsy series as reported do not specify whether the autopsies were performed strictly on patients seen dead on arrival or on some victims with delayed rupture. As would be expected, the incidence of multiple ruptures is much higher in the autopsy series as compared with the surgical series (7.8% versus %). A clue as to the disparity in incidence of the middescending aortic ruptures between the autopsied patients and surgical patients may be attributed to the mechanism of injury. It is generally agreed that the mechanism Of injury in ruptures Of the mid-descending aorta direct trauma to the viz~ extreme hyperextension Of the spine (with the Vine pressing forward and shearing the aorta) or injury secbndaryto fracture dislocation of the adjacent spine [34]. These mechanisms are said to account for the fact that all lacerations of the mid-descending aorta are transverse [34]. We note, however, that in only of the clinical patients with this lesion was there an associated dislocation of the spine. In contradistinction to the apparently more direct trauma required for this injury, the trauma required to tear the aorta at the isthmus is thought to be indirect from acute deceleration phenomena [8, 34, 35. In Table 3 it can be seen that in 6 of the accumulated patients with mid-descending aortic tears the diagnosis was initially missed. In 4 of these cases the mediastinum was believed to be negative on routine chest roentgeno-

3 Ann Thorac Surg 990;50: REVIEW RABINSKY ET AL 57 A C B Fig. (A) Admission chest roentgenogram reveals mediastinal widening. The aortic knob is obscured. (B) A digital substraction aortogram reveals a minimally suspicious double density in the mid-descending thoracic aorta (arrow, lower right). No aortic isthmus lesion is seen. (C) A repeat convential aortogram in cross-table lateral projection reveals a laceration in the posterior wall of the mid-descending aorta with a false aneurysm.

4 58 REVIEW RABINSKY ET AL Ann Thorac Surg 990;50:55-60 Table. Site of Aortic Rupture in Surgical Series Author Year Isthmus ASCD Arch DESC DIAPH Branches Comments Keen [l] Thevenet [] Appelbaum et a [3] Bodily et a [4] Ayella et a [6] Kirsh et a [7] Pezzela et a [8] Plume and DeWeese [9] Avery et a [lo] Akins et a [ll] Williams et a [] Motin et a [3] Ketonen et a [4] Skotnicki et a [5] Soyer et a [6] Grande et a [7] Schmidt and Jacobson [8] Oliver et a [9] Tegner et a [0] Pate [] Mattox et a [] Stiles et al (3 Verdant et a [4] Marvasti et a [5] Langlois et a [6] Hartford et a [7] Tribble and Crosby [8] PGHC (present report) Subtotals Total aorta (n = 83) Percent %.3% 6 8b l%b innominate, subclavian Acute tears only 3 multiple; also reference [5] multiple innominate, 3 subclavian Associated aortic root injury innominate innominate innominate 3 innominate, subclavian (From reference [8] plus personal communication, 989) subclavian a Ascending aorta + arch. Descending aorta + diaphragmatic level. ASCD = ascending aorta; Branches = brachiocephalic arteries; DESC = descending aorta; DIAPH = at diaphragmatic level; PGHC = Prince Georges Hospital Center. gram. The actual aortic hematoma effected by the lesion may be obscured by the heart on routine chest roentgenograms. Our first case was a serendipitous aortographic finding resulting from the computed tomographic demonstration of an unsuspected mediastinal hematoma. In patients the diagnosis was nearly missed because of inadequate (one-plane) aortography. These difficulties in diagnosis lead one to suspect that some tears may go undiagnosed and spontaneously heal as suggested by Stiles and Bryant [4, 4. This postulate would account for some of the disparity between the autopsy and clinical series. Indications for aortography in high-speed decelerating injuries should be liberal. In addition to the standard chest roentgenographic findings that suggest the need for obtaining aortography, viz, widened mediastinum, apical cap, depressed left main bronchus [43], the finding of a thoracic vertebral fracture should prompt aortography to confirm the diagnosis and to determine the site or sites of rupture. Although the role of computed tomographic scan in thoracic trauma remains controversial, we have for the past 7 years used thoracic computed tomographic scans in major thoracic trauma because of the improved diagnostic sensitivity [44, 45. Unsuspected mediastinal hematomas diagnosed by computed tomography, as demonstrated in our initial patient, warrant aortography. Because of the relative difficulty in diagnosing traumatic tears of the mid-descending aorta, the clinician must maintain a high

5 Ann Thorac Surg 990;SO: REVIEW RABINSKY ET AL 59 Table. Levels of Aortic Transection in Autopsy Series Author Year Total Isthmus ASCD Arch DESC DIAPH ABDOM MULT Comments Strassman [9] Parmley et el [30] Zeldenrust and Aartes [3] Jensen [3] Greendyke [33] Sevitt [34] Gotzen et a [35] Arajarvi et a [36] Total (n = 740) Percentc % lob 4 9b 98 3b 7.% 5.7%b % Ruptures in one site Multiple ruptures 5 With associated heart injury Ascending and arch lesions combined 8 Associated with heart rupture in 5 patients 7 Unbelted 3 Belted a Ascending aorta + arch. Descending aorta + diaphragmatic level. Total percentage greater than 00% because Parmley series calculated multiple injuries as separate patients, whereas Strassman and Arajarvi counted as major injury. ABDOM = abdominal aorta; ASCD = ascending aorta; DESC = descending aorta; DIAPH = at diaphragmatic level; MULT = multiple aortic injuries % Table 3. Traumatic Rupture of the Mid-Descending Aorta Author Year Patients Comment Kirsh et a [37] 976 /43 Descending mid-thoracic aorta-associated with fracture dislocation of thoracic spine. Kirsh et a [7] 978 /58 Descending aorta just above diaphragm-negative mediastinum or loss of aortic knob. Plume and DeWeese (9 Motin et a [I /5 /36 Mid-descending aorta; associated right atrial appendage rupture. Fisher et a [38] 98 /54 T9-0. Minimal mediastinal changes on admission chest roentgenogram. Missed diagnosis. David et a [39] Stothert et a [40] Tribble and Crosby [8] Present series /5 /7 T7-8. Initial mediastinal hematoma obscured by cardiac silhouette. T7-8. Delayed diagnosis due to one-plane aortogram. Hyperextension postulated. T9-0 (estimated from published aortogram). Described as just above aortic hiatus. One of two aortic tears in patient, the other at isthmus. (From reference [8], also personal communication [989] as to exact site.) Delayed diagnosis. No widening of mediastinum on plain roentgenogram. (See text.) Delayed diagnosis. Lesion missed on one-plane aortography. (See text.) index of suspicion and obtain adequate two-plane aortography of the entire aorta to avoid missing this potentially fatal lesion. References. Keen G. Closed injuries of the thoracic aorta. Ann R Coll Surg Engl 97;5: Thevenet A. Traumatic ruptures of the thoracic aorta and their surgical management. Ann Chir Thorac Cardiovasc 975;4: Appelbaum A, Karp RB, Kirklin JW. Surgical treatment for closed aortic injuries. J Thorac Cardiovasc Surg 976; 7: Bodily K, Perry JF Jr, Strate RG, Fischer RP. The salvageability of patients with post-traumatic rupture of the descending thoracic aorta in a primary trauma center. J Trauma 977; 7: DeMeules JE, Cramer G, Perry JF Jr. Rupture of aorta and great vessels due to blunt thoracic trauma. J Thorac Cardiovasc Surg 97;6: Ayella RJ, Hankins JR, Turney SZ, Cowley RA. Ruptured thoracic aorta due to blunt trauma. J Trauma 977; Kirsh MM, Orringer MB, Behrendt DM, Mills LJ, Tashian J,

6 60 REVIEW RABINSKY ET AL Ann Thorac Surg YY0;50: 5560 Sloan H. Management of unusual traumatic ruptures of the aorta. Surg Gynecol Obstet 978;46: Pezzella AT, Todd E, Dillon ML, Utley JR, Griffin WO. Early diagnosis and individualized treatment of blunt thoracic aortic trauma. Am Surg 978;44: Plume S, DeWeese JA. Traumatic rupture of the thoracic aorta. Arch Surg 979;4:4&3. 0. Avery JE, Hall DP, Adams JE, Headrick JR, Nipp RE. Traumatic rupture of the thoracic aorta. South Med J 979; 7: Akins CW, Buckley MJ, Daggett W, McIlduff JB, Austen WG. Acute traumatic disruption of the thoracic aorta. Ann Thorac Surg 98;3: Williams TE Jr, Vasko JS, Kakos GS, Cattaneo SM, Meckstroth CV, Kilman JW. Treatment of acute and chronic traumatic rupture of the descending thoracic aorta. World J Surg 980;4: Motin J, Latajet J, Cognet JB, et al. The diagnosis of traumatic rupture of the aorta. Nouv Presse Med 980; 9:8&7. 4. Ketonen P, Jarvinen A, Luosto R, Ketonen L. Traumatic rupture of the thoracic aorta. Scand J Thorac Cardiovasc Surg 980;4:3&9. 5. Skotnicki SH, Vincent J, Buskens FGM, van der Meer JJ, Kuijpers PJ, Lacquet LK. Traumatic rupture of the thoracic aorta. Acta Chir Belg 98;5: Soyer R, Brunet A, Piwnica A, et al. Traumatic rupture of the thoracic aorta with reference to 34 operated cases. J Cardiovasc Surg (Torino) 98;: Grande AM, Eren EE, Hallman GL, Cooley DA. Rupture of the thoracic aorta: emergency treatment and management of chronic aneurysms. Tex Heart Inst J 984;:4&9. 8. Schmidt CA, Jacobson JG. Thoracic aortic injury. Arch Surg 984; 9: Olivier HF Jr, Maher TD, Liebler GA, Park SB, Burkholder JA, Magovern GJ. Use of the BioMedicus centrifugal pump in traumatic tears of the thoracic aorta. Ann Thorac Surg 984;38: Tegner Y, Bergdahl L, Ekestrom S. Traumatic disruption of the thoracic aorta. Acta Chir Scand 984;50: Pate JW. Traumatic rupture of the aorta: emergency operation. Ann Thorac Surg 985;39: Mattox KL, Holzman M, Pickard LR, Beall AC Jr, DeBakey ME. Clamphepair: a safe technique for treatment of blunt injury to the descending thoracic aorta. Ann Thorac Surg 985;40: Stiles QR, Cohlmia GS, Smith JH, Dunn JT, Yellin AE. Management of injuries of the thoracic and abdominal aorta. Am J Surg 985;50: Verdant A, Cossette R, Dontigny L, et al. Acute and chronic traumatic aneurysms of the descending thoracic aorta: a 0-year experience with a single method of aortic shunting. J Trauma 985;5: Marvasti MA, Meyer JA, Ford BE, Parker FB Jr. Spinal cord ischemia following operation for traumatic aortic transection. Ann Thorac Surg 986;4: Langlois J, DeBrux JL, Binet JP, Khoury W. Traumatic aortic rupture. In: Grillo H, Eschapasse H, eds. International trends in general thoracic surgery; vol. Philadelphia: WB Saunders, 987: Hartford JM, Fayer RL, Shaver TE, et al. Transection of the thoracic aorta: assessment of a trauma system. Am J Surg 966; Tribble CG, Crosby IK. Traumatic rupture of the thoracic aorta. South Med J 988;8: Strassmann G. Traumatic rupture of the aorta. Am Heart J 947;33: Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr. Non-penetrating traumatic injury of the aorta. Circulation 958; Zeldenrust J, Aartes JH. Traumatic rupture of the aorta in traffic accidents. Ned Tijdschr Geneeskd 96;06:46&8. 3. Jensen OM. Traumatic rupture of the aorta. Nord Med 964; 7 : Greendyke RM. Traumatic rupture of the aorta. Special references to automobile accidents. JAMA 966;95: Sevitt 5. The mechanisms of traumatic rupture of the thoracic aorta. Br J Surg 977;64: Gotzen L, Flory RJ, Otte D. Biomechanics of aortic rupture at classical location in traffic accidents. Thorac Cardiovasc Surg 980;8: Arajarvi E, Santavirta S, Tolonen J. Aortic rupture in seat belt wearers. J Thorac Cardiovasc Surg 989;98: Kirsh MM, Behrendt DM, Orringer MB, et al. The treatment of acute traumatic rupture of the aorta: a 0-year experience. Ann Surg 976;84:30% Fisher RG, Hanlock F, Ben-Menachem Y. Laceration of the thoracic aorta and brachiocephalic arteries by blunt trauma. Radiol Clin N Am 98;9: David M, Sala JJ, Padet JM, Raoux MH, Brenot R. Traumatic rupture of the descending aorta D7-D8. Lyon Chirug 985; 8:33&. 40. Stothert JC Jr, McBride L, Tidik S, Lewis L, Codd JE. Multiple aortic tears treated by primary suture repair. J Trauma 987; Stiles QR. Discussion of [3]. 4. Bryant LR. Discussion of [37]. 43. Mirvis SE, Bidwell JK, Buddemeyer EU, Diaconis JN, Pais SO, Whitley JE. Imaging diagnosis of traumatic aortic rupture: a review and experience at a major trauma center. Invest Radiol 987;: Wagner RB, Crawford WO Jr, Schimpf PP. Classification of parenchymal injuries of the lung. Radiol 988;67: Wagner RB, Jamieson PM. Pulmonary contusion: evaluation and classification by computed tomography. Surg Clin N Am 989;69:340.