Abstract
Surgical strategy and long-term outcomes of patients with rupture of the ascending aorta, aortic arch and supra-aortic vessels following blunt thoracic trauma have been rarely reported. We reviewed our institutional experience between 1995 and 2016. We identified 2 patients with an innominate artery ruptures, 2 with an aortic arch ruptures and 1 with an ascending aorta rupture; all were induced by the posterior displacement of the anterior chest wall. All patients underwent open surgical repair. Cardiopulmonary bypass with antegrade cerebral perfusion was required in 2 cases. All patients were alive at the end of the follow-up (median 18 months; from 3 to 180 months) including 1 patient with cortical blindness.
INTRODUCTION
Rupture of the ascending aorta, aortic arch or supra-aortic vessels is rarely seen in cases of blunt thoracic trauma [1–3]. Compared with isthmus ruptures [4], more proximal ruptures most often require open repair and must avoid secondary injury to the brain, especially in the setting of polytrauma with pre-existing damage.
There have been few reports describing open repair of proximal aortic trauma and its outcomes.
We report our experience, as tertiary centre, on 5 consecutive cases referred for open repair between 1995 and 2016, including clinical presentation, surgical strategies and long-term outcomes.
DEMOGRAPHICS, PRESENTATION AND DIAGNOSTIC MODALITIES
The 5 patients presented with a common mechanism of the posterior displacement of the anterior chest wall (Table 1). Vessel ruptures were either contained by the adventitia or complete. After diagnosis, the patients were immediately transferred to the operating room for open repair.
Clinical presentations, surgical strategies and outcomes
| Demographics (age/sex) | Presentation | Diagnosis modalities | Surgical techniques | Outcomes |
|---|---|---|---|---|
| Case 1 (30 years/male) |
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| Case 2 (41 years/male) |
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| Case 3 (18 years/male) |
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| Case 4 (26 years/male) |
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| Case 5 (23 years/male) |
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| Demographics (age/sex) | Presentation | Diagnosis modalities | Surgical techniques | Outcomes |
|---|---|---|---|---|
| Case 1 (30 years/male) |
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| Case 2 (41 years/male) |
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| Case 3 (18 years/male) |
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| Case 4 (26 years/male) |
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| Case 5 (23 years/male) |
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ARDS: acute respiratory distress syndrome; CPB: cardiopulmonary bypass; CT: computed tomography; DHCA: deep hypothermic circulatory arrest; IA: innominate artery; ICU: intensive care unit; MRI: magnetic resonance imaging; PTA: percutaneous transluminal angioplasty.
Clinical presentations, surgical strategies and outcomes
| Demographics (age/sex) | Presentation | Diagnosis modalities | Surgical techniques | Outcomes |
|---|---|---|---|---|
| Case 1 (30 years/male) |
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| Case 2 (41 years/male) |
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| Case 3 (18 years/male) |
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| Case 4 (26 years/male) |
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| Case 5 (23 years/male) |
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| Demographics (age/sex) | Presentation | Diagnosis modalities | Surgical techniques | Outcomes |
|---|---|---|---|---|
| Case 1 (30 years/male) |
|
|
|
|
| Case 2 (41 years/male) |
|
|
|
|
| Case 3 (18 years/male) |
|
|
|
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| Case 4 (26 years/male) |
|
|
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| Case 5 (23 years/male) |
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ARDS: acute respiratory distress syndrome; CPB: cardiopulmonary bypass; CT: computed tomography; DHCA: deep hypothermic circulatory arrest; IA: innominate artery; ICU: intensive care unit; MRI: magnetic resonance imaging; PTA: percutaneous transluminal angioplasty.
SURGICAL TECHNIQUES AND RESULTS
The surgical techniques and outcomes are reported in Table 1. Circulatory arrest with isolated antegrade cerebral perfusion was performed at the time of sternotomy in 1 case (Case 4, Fig. 1).
Case 4. (A) Mechanism of the aortic arch rupture in the setting of blunt trauma. (B) A computed tomography scan showing a sagittal reconstruction of the manubrium fracture associated with the aortic arch rupture. (C) Surgical repair of the aortic arch with a patch and supra-aortic vessel reperfusion.
DISCUSSION
We report long-term outcomes after open repair of 5 patients with ascending aorta, aortic arch or innominate artery blunt ruptures. Long-term results were good when compared with the severity at the presentation. The main determinants of our strategy were immediate repair after diagnosis, optimal cerebral protection and the use of cardiopulmonary bypass.
Limitations
Limitations are due to the limited number of patients and long period of experience. However, interpretation of the literature is limited by the rarity of the disease. Herein, we reported our consecutive experience with long-term follow-up.
CONCLUSION
In conclusion, strategies including open repair with cardiopulmonary bypass and aggressive cerebral protection lead to good long-term results.
Conflict of interest: none declared.
