Mid-Descending aortic traumatic aneurysms Israel Rabinsky, Gurmeet S. Sidhu and Robert B.

Wagner Ann Thorac Surg 1990;50:155-160 DOI: 10.1016/0003-4975(90)90115-M

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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association. Copyright 1990 by The Society of Thoracic Surgeons. Print ISSN: 0003-4975; eISSN: 1552-6259.

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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 11 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 2 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 2 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 1990;50:155-60)

n contrast to the massive literature that has developed 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 2 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.

minutes. The postoperative course was uneventful. The patient gradually regained consciousness and was discharged 2 months after admission.

Patient 2
A 21-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 100 beats/min, breathing spontaneously at 25/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 2A). 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 28). 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 2C). 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, 20 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.
0003-4975/90/$3.50

Case Reports Puatient 2

A 25-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 172/80 mm Hg. The chest roentgenogram on admission was interpreted as negative for widened mediastinum. A computed tomogram of the chest (Fig 1A) 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 1B). 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 20% 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 20852.

0 1990 by The Society o Thoracic Surgeons f

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Ann Thorac Surg 1990;50:155-60

below the region of the isthmus and above the level of the diaphragmatic aortic hiatus (T-7 to T-10).

Results
Of the 823 patients in the collected surgical series with aortic ruptures 96.7% had rupture located at the isthmus, 2.3% at the ascending aorta or arch, and only 1%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 27.2% had ruptures located at the ascending aorta through the arch and 15.7% in the descending aorta through the aortic hiatus. A total of 11 patients (including ours) were found in the literature with tears in the mid-descending aorta (defined as between T-7 and T-10).

Comment
The locations of aortic ruptures summarized from 28 surgical series of nonpenetrating aortic injury in Table 1 contrast dramatically with those derived from autopsy series (see Table 2). 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 91.5% of the clinical series [2, 371. Of particular interest is the 15.7% incidence of descending aortic injuries in the autopsy data as compared with a 1%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 1%). 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 v i z ~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 1 of the 11 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 [28, 34, 351. In Table 3 it can be seen that in 6 of the 11 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-

B
Fig 1 . (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 1 and compared with a compilation of eight autopsy series (Table 2). 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

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REVIEW RABINSKY ET AL MID-DESCENDING AORTIC RUPTURES

157

Fig 2 . ( 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.

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Table 1. Site of Aortic Rupture in Surgical Series

Author

Year
1972 1975 1976 1977 1977 1978 1978 1979 1979 1980 1980 1980 1980 1981 1981 1984 1984 1984 1984 1985 1985 1985 1985 1986 1987 1988 1988

Isthmus
16 65 17 39 35 50 11 14 10 42 30 32 17 21 34 58 40 19 14 58 31 16 20 41 15 16 22

ASCD

Arch

DESC

DIAPH

Branches
3 5

Comments
2 innominate, 1 subclavian

Keen [l] Thevenet [2] Appelbaum et a1 [3] Bodily et a1 [4] Ayella et a1 [6]
Kirsh et a1 [7] Pezzela et a1 [8]

...

...
1

... ...

1 1

... ...

...
...
1

... ... ... ...

... ... ...

Acute tears only

3 multiple; also reference [5] 1 multiple 2 innominate, 3 subclavian

... ...
1
1

... ...
...

...
5

... ...
...
... ... ...
2

Plume and DeWeese [9] Avery et a1 [lo] Akins et a1 [ l l ] Williams et a1 [12] Motin et a1 [13] Ketonen et a1 [14] Skotnicki et a1 [15] Soyer et a1 [16] Grande et a1 [17] Schmidt and Jacobson [18] Oliver et a1 [19] Tegner et a1 [20] Pate [21] Mattox et a1 [22] Stiles et al (231 Verdant et a1 [24] Marvasti et a1 [25] Langlois et a1 [26] Hartford et a1 [27] Tribble and Crosby [28] PGHC (present report) Subtotals Total aorta (n = 823) Percent
a

...
...
1

2 1

... ...
1

... ...
... ...

Associated aortic root injury

... ...

...
2

...
1

...
1

...
... ... ... ...

2 innominate

...
1 1

... ... ...

... ... ... ...

1

...
...

... ... ... ...

1

... ... ...

1 1

... ...

...
...
1 12

...
... ... ...
7 19 2.3%

... ... ... ... ... ... ... ... ... ... ... ... ... ...
1

... ... ...

1

... ...
...

...
...
...

...
...

... ...

1 innominate

...
...
2

...
... ... ...

...
...
3

2 innominate

...
2

3 innominate, 1 subclavian

... ...
2 23

(From reference [28] plus personal communication,

1989) 2 subclavian

1990

12 796 796 96.7%

2 6

...
2

8b
l%b

Ascending aorta

+ arch.

Descending aorta

+ diaphragmatic level.
DESC = descending aorta; DIAPH = at diaphragmaticlevel; PGHC = Prince

ASCD = ascending aorta; Georges Hospital Center.

Branches = brachiocephalicarteries;

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 2 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 [41, 421. 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 451. Unsuspected mediastinal hematomas sensitivity [44, 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

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Ann Thorac Surg 1990;SO: 155-60

REVIEW RABINSKY ET AL MID-DESCENDING AORTIC RUPTURES

159

Table 2. Levels of Aortic Transection in Autopsy Series

Author Strassman [29] Parmley et el [30] Zeldenrust and Aartes [31] Jensen [32] Greendyke [33] Sevitt [34] Gotzen et a1 [35] Arajarvi et a1 [36] Total (n = 740) Percentc
a

Year Total Isthmus ASCD Arch DESC DIAPH ABDOM MULT 61 11 1958 171 104 1962 88 1964 68 1966 1977 1980 34 37 26 1947 38 2 95 29 63 35 22 25 21 26 25 381 50.4%

Comments Multiple ruptures With associated heart injury

8 6 17 47 11
15

...

...
16 6

12 3 27 6 18

... ...
... ... 5

. . . Ruptures in one site

11 5 12

...
11 2

. . . . . . . . . . . . . . . . . . 1 ...
36 24 198 27.2%

...
7 5 1

..
4

. . . Ascending and arch lesions

combined
8

1 7 3

...

...
2 7 13 Associated with heart rupture in 5 patients Unbelted Belted

1989 140

lob
19b 113b 15.7%b 20 2.8%

58 7.8%

Ascending aorta + arch. Descending aorta + diaphragmatic level. Total percentage greater than 100% because Parmley series calculated multiple injuries as separate patients, whereas Strassman and Arajarvi counted as major injury. ASCD = ascending aorta; DESC
=

ABDOM = abdominal aorta; aortic injuries.

descending aorta;

DIAPH = at diaphragmatic level;

MULT

multiple

Table 3. Traumatic Rupture of the Mid-Descending Aorta

Author Kirsh et a1 [37] Kirsh et a1 [7] Plume and DeWeese (91 Motin et a1 [I31 Fisher et a1 [38] Year 1976 1978 1979 1980 1981 1985 1987 1988 1990 Patients 1/43 1/58 1/15 1/36 2/54 Comment Descending mid-thoracic aorta-associated with fracture dislocation of thoracic spine. Descending aorta just above diaphragm-negative mediastinum or loss of aortic knob. Mid-descending aorta; associated right atrial appendage rupture.

David et a1 [39] Stothert et a1 [40] Tribble and Crosby [28] Present series

1 1
1/25 2/17

T9-10. Minimal mediastinal changes on admission chest roentgenogram. Missed diagnosis. T7-8. Initial mediastinal hematoma obscured by cardiac silhouette. T7-8. Delayed diagnosis due to one-plane aortogram. Hyperextension postulated. T9-10 (estimated from published aortogram). Described as just above aortic hiatus. One of two aortic tears in patient, the other at isthmus. (From reference [28], also personal communication [1989] 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 t o avoid missing this potentially fatal lesion.

References
1. Keen G. Closed injuries of the thoracic aorta. Ann R Coll Surg Engl 1972;51:137-56. 2. Thevenet A. Traumatic ruptures of the thoracic aorta and their surgical management. Ann Chir Thorac Cardiovasc 1975;14:69-79. 3. Appelbaum A, Karp RB, Kirklin JW. Surgical treatment for

closed aortic injuries. J Thorac Cardiovasc Surg 1976; 71:458-60. 4. 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 1977; 17:754-60. 5. DeMeules JE, Cramer G, Perry JF Jr. Rupture of aorta and great vessels due to blunt thoracic trauma. J Thorac Cardiovasc Surg 1971;61:438-42. 6 . Ayella RJ, Hankins JR, Turney SZ, Cowley RA. Ruptured thoracic aorta due to blunt trauma. J Trauma 1977;17199-205. 7. Kirsh MM, Orringer MB, Behrendt DM, Mills LJ, Tashian J,

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Sloan H. Management of unusual traumatic ruptures of the aorta. Surg Gynecol Obstet 1978;146:365-70. 8. Pezzella AT, Todd E, Dillon ML, Utley JR, Griffin WO. Early diagnosis and individualized treatment of blunt thoracic aortic trauma. Am Surg 1978;44:699-703. 9. Plume S, DeWeese JA. Traumatic rupture of the thoracic aorta. Arch Surg 1979;114:24&3. 10. Avery JE, Hall DP, Adams JE, Headrick JR, Nipp RE. Traumatic rupture of the thoracic aorta. South Med J 1979; 72: 123840. 11. Akins CW, Buckley MJ, Daggett W, McIlduff JB, Austen WG. Acute traumatic disruption of the thoracic aorta. Ann Thorac Surg 1981;31:305-9. 12. 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 1980;4:545-52. 13. Motin J, Latajet J, Cognet JB, et al. The diagnosis of traumatic rupture of the aorta. Nouv Presse Med 1980; 9:282&7. 14. Ketonen P, Jarvinen A, Luosto R, Ketonen L. Traumatic rupture of the thoracic aorta. Scand J Thorac Cardiovasc Surg 1980;14:23&9. 15. Skotnicki SH, Vincent J, Buskens FGM, van der Meer JJ, Kuijpers PJ, Lacquet LK. Traumatic rupture of the thoracic aorta. Acta Chir Belg 1982;5:485-91. 16. Soyer R, Brunet A, Piwnica A, et al. Traumatic rupture of the thoracic aorta with reference to 34 operated cases. J Cardiovasc Surg (Torino) 1981;22:103-8. 17. Grande AM, Eren EE, Hallman GL, Cooley DA. Rupture of the thoracic aorta: emergency treatment and management of chronic aneurysms. Tex Heart Inst J 1984;11:24&9. 18. Schmidt CA, Jacobson JG. Thoracic aortic injury. Arch Surg 1984;119:12444. 19. 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 1984;38:586-91. 20. Tegner Y, Bergdahl L, Ekestrom S. Traumatic disruption of the thoracic aorta. Acta Chir Scand 1984;150:635-8. 21. Pate JW. Traumatic rupture of the aorta: emergency operation. Ann Thorac Surg 1985;39:531-7. 22. 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 1985;40:456-63. 23. Stiles QR, Cohlmia GS, Smith JH, Dunn JT, Yellin AE. Management of injuries of the thoracic and abdominal aorta. Am J Surg 1985;150:132-40. 24. Verdant A, Cossette R, Dontigny L, et al. Acute and chronic traumatic aneurysms of the descending thoracic aorta: a

10-year experience with a single method of aortic shunting. J Trauma 1985;25:601-7. 25. Marvasti MA, Meyer JA, Ford BE, Parker FB Jr. Spinal cord ischemia following operation for traumatic aortic transection. Ann Thorac Surg 1986;42:4258. 26. Langlois J, DeBrux JL, Binet JP, Khoury W. Traumatic aortic rupture. In: Grillo H, Eschapasse H, eds. International trends in general thoracic surgery; vol 2. Philadelphia: WB Saunders, 1987:273-84. 27. Hartford JM, Fayer RL, Shaver TE, et al. Transection of the thoracic aorta: assessment of a trauma system. Am J Surg 1966;1513224-9. 28. Tribble CG, Crosby IK. Traumatic rupture of the thoracic aorta. South Med J 1988;81:963-8. 29. Strassmann G. Traumatic rupture of the aorta. Am Heart J 1947;33:508-15. 30. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr. Non-penetrating traumatic injury of the aorta. Circulation 1958;1 71086-101. 31. Zeldenrust J, Aartes JH. Traumatic rupture of the aorta in traffic accidents. Ned Tijdschr Geneeskd 1962;106:46&8. 32. Jensen OM. Traumatic rupture of the aorta. Nord Med 1964;71:33741. 33. Greendyke RM. Traumatic rupture of the aorta. Special references to automobile accidents. JAMA 1966;195:527-30. 34. Sevitt 5. The mechanisms of traumatic rupture of the thoracic aorta. Br J Surg 1977;64:166-73. 35. Gotzen L, Flory RJ, Otte D. Biomechanics of aortic rupture at classical location in traffic accidents. Thorac Cardiovasc Surg 1980;28:64-8. 36. Arajarvi E, Santavirta S, Tolonen J. Aortic rupture in seat belt wearers. J Thorac Cardiovasc Surg 1989;98:355-61. 37. Kirsh MM, Behrendt DM, Orringer MB, et al. The treatment of acute traumatic rupture of the aorta: a 10-year experience. Ann Surg 1976;184:30%16. 38. Fisher RG, Hanlock F, Ben-Menachem Y. Laceration of the thoracic aorta and brachiocephalic arteries by blunt trauma. Radiol Clin N Am 1981;19:91-101. 39. David M, Sala JJ, Padet JM, Raoux MH, Brenot R. Traumatic rupture of the descending aorta D7-D8. Lyon Chirug 1985; 81:33&1. 40. Stothert JC Jr, McBride L, Tidik S, Lewis L, Codd JE. Multiple aortic tears treated by primary suture repair. J Trauma 1987;27955-6. 41. Stiles QR. Discussion of [23]. 42. 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 1987;22:187-96. 44. Wagner RB, Crawford WO Jr, Schimpf PP. Classification of parenchymal injuries of the lung. Radiol 1988;167:77-82. 45. Wagner RB, Jamieson PM. Pulmonary contusion: evaluation and classification by computed tomography. Surg Clin N Am 1989;69:3140.

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Mid-Descending aortic traumatic aneurysms Israel Rabinsky, Gurmeet S. Sidhu and Robert B. Wagner Ann Thorac Surg 1990;50:155-160 DOI: 10.1016/0003-4975(90)90115-M
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