Traumatic Aortic Rupture

Aortic transection or other forms of traumatic aortic injury usually occur from a deceleration type of blunt trauma and usually occurs when a patient smashes his chest against the steering wheel in a motor vehicle accident. The tear usually occurs at the region of the ligamentum arteriosum just distal to the left subclavian artery. In this case, a left thoracotomy is performed and if there is a small hematoma without proximal extension, one can clamp the aorta proximal to the left subclavian, separately clamp the left subclavian, clamp the distal aorta and then do the repair with interposition graft if the cross-clamp time can be kept to less than 30 minutes. Cross-clamp time greater than 30 minutes results in an increased chance of paraplegia. If there is a large hematoma with proximal extension into the transverse or ascending aorta, femoral-femoral bypass is established, the patient is cooled, circulatory arrest established, the aorta opened and the repair done. This is achieved via a left thoracotomy. For ascending aortic traumatic injuries, a median sternotomy is performed and right atrial-femoral bypass is established. If one can get a cross-clamp proximal to the innominate, then one can perform the procedure with the aortic cannula in the distal ascending aorta or in the transverse arch. If one cannot get a cross-clamp on proximal to the innominate, then right atrial-femoral artery bypass is established, the patient cooled and hypothermic circulatory arrest established to perform the repair. Aortic transection is fur-

ther discussed in chapter 18 "Thoracic Trauma". Suggested Reading

Crawford ES, Crawford JL. Diseases of the aorta including an atlas of angiographic pathology and surgical technique. Baltimore: Williams & Wilkins, 1984. Cabrol C, Pavic A, Mesnildrey P, Gondjvakhch I, Langhlin L, Bors V, Carcos T, Grondin P. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986; 91:17-25. Kouchoukos NT, Marshall WG Jr, Wedge-Stecher TA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986; 92:691-705.

Crawford ES, Saleh SA. Transverse aortic arch aneurysm: improved results of treatment employing new modifications of aortic reconstruction and hypothermic cerebral circulatory arrest. Ann Surg 1981; 194:180-188. Crawford ES, Snyder DM. Treatment of aneurysms of the aortic arch. J Thorac Cardiovasc Surg 1983; 85:237-246.

Griepp RB, Stinson EB, Hollingsworth JF et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975; 70:1051-1063. DeBakey ME, McCollum CH, Crawford ES, Morris GC Jr, Howell JF, Noon GP, Lowrie GM. Dissection and dissecting aneurysms of the aorta: twenty year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982; 92:1118-1134.

Crawford ES, Crawford JL, Safi HJ, Coselli JS, Hess KR, Brooks B, Norton HJ, Glaeser DH. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 1986; 3:389-404.

Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Variables predictive of outcome in 832 patients undergoing Repairs of the descending thoracic aorta. Chest 1993; 104:1248-53.

Borst HG, Jurmann MJ, Bukner B, Laas J. Risk of replacement of descending aorta with a standardized left heart bypass technique. J Thorac Cardiovasc Surg 1994, 107:126-33.

Lawrie GM, Erale N, DeBakey ME. Long-term fate of aortic root and valve after ascending aneurysm surgery. Am Surg 1993; 217:711

Lass J, Jurmann MJ, Heinemann M, Borst HG. Advances in aortic arch surgery. 1992; 53:227-32

Crawford ES, Kirklin JW, Naftel DC et al. Surgery for acute ascending aortic dissection: Should the arch be included? J Thorac Cardiovasc Surg 1992; 104:46-59.

Coselli JS, Büket S, Djakanovic B. Aortci arch surgery: Current treatment and results. Ann Thorac Surg 1995; 59:19-27.

Najafi H. 1993 update: Descending aortic aneurysmectomy without adjuncts to avoid ischemia. Ann Thorac Surg 1993; 55:1042-5.

Yun KL, Glower DD, Miller DC et al. Aortci dissection resulting from tear of transverse arch: Is concomitant arch repair warranted? J Thorac Cardiovasc Surg 1991; 102:355.

Svensson LG, Crawford ES. Aortic dissection and aortic aneurysm surgery: Clinical observations, experimental investigations, and statistical analyses. Part II. Curr

Probl Surg 1992; 29:913.

18. Kato M, Ohnishi K, Kaneko M et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996; 94[Suppl 2]:188-93.

19. Dake MD, Miller DC, Semba CP et al. Transluminal placement of endovascular stent grafts for the treatment of decending thoracic aortic aneurysms. N Engl J Med 1994; 331:1729-34.

20. Fann JI, Dake MD, Semba CP et al. Endovascular stent-grafting after arch aneurysm repair using the "elephant trunk". Ann Thorac Surg 1995; 60:1102-5.

21. Yano H, Ishimaru S, Kawaguchi S. Endovascular stent-grafting of the descending thoracic aorta after arch repair in acute type A dissection. Ann Thorac Surg 2002; 73:288-91.

22. Passage J, Jalali H, Tam RKW et al. Bioglue surgical adhesive—an appraisal of its indications in cardiac surgery. Ann Thorac Surg 2002; 74:432-7.

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