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J Thorac Cardiovasc Surg 1994;107:638-0640
© 1994 Mosby, Inc.

Letters to the Editor

Transesophageal echocardiography for the diagnosis of traumatic injury of the thoracic aorta

P. Hengster, MD, W. Furtwängler, MD, H. Pernthaler, MD

Departments of Surgery and Anesthesiology
University Hospital Innsbruck
Innsbruck, Austria

To the Editor:

Blunt injury of the thoracic aorta occurs as a result of massive chest trauma. Only 10% to 30% of affected patients reach the hospital alive, generally when rupture is only incomplete or occurs later as secondary rupture.Go 1 We report here the case of a patient with posttraumatic secondary aortic rupture. Diagnosis was confirmed by transesophageal echocardiography (TEE).

A 32-year-old worker fell from a height of about 10 meters and was brought to the emergency department by helicopter. At arrival, the patient was awake and alert, in shock with a blood pressure of 80/50 mm Hg and pulse rate of 100 to 130 beats/ min, but breathing spontaneously. Physical exploration disclosed multiple lacerations, decreased breath sounds over the right side of the chest, dyspnea, and macrohematuria. All peripheral pulses were palpable without any differences between the upper and lower extremities. The chest radiograph revealed multiple rib fractures, a right-sided pneumothorax, and rupture of the left hemidiaphragm with displacement of the spleen, colon, stomach, and omentum majus into the thoracic cavity (Fig. 1). The mediastinum was shifted to the right side and slightly broadened, but a thoracic hematoma was not expected at this time (Fig. 1). Because of respiratory problems remaining after drainage of the right hemithorax, the patient was immediately brought to the operating room for exploration of the abdominal cavity and repair of the diaphragmatic rupture. An upper abdominal midline incision was made, the herniated organs were repositioned into the abdomen, and the diaphragmatic rupture, which extended across the pars membranacea and included both crura of the diaphragm, was closed. Exploration did not reveal any organ damage; even the spleen was completely intact. Pulsations of the aorta were found to be normal, and the thoracic cavity was found to be free of blood and was closed.



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  		Fig. 1. Chest radiograph at admission shows multiple fractures of ribs, a right pneumothorax, and rupture of left diaphragm with displacement of abdominal organs into thoracic cavity. Mediastinum is shifted to right side.

 
Suddenly, about 6 hours after the accident, within 20 minutes, 1500 ml blood emptied through the left thoracic drainage and the patient's blood pressure fell to 40 mm Hg. At this time, broadening of the mediastinum was manifest and rupture of a big thoracic vessel was assumed. A dissection of the thoracic aorta was clearly seen by TEE (Fig. 2), confirming the diagnosis of aortic injury. A left thoracotomy was performed immediately and the ascending aorta was clamped for about 1 minute until the blood could be removed and the structures were seen. The aorta now was clamped between the left common carotid artery and the left subclavian artery, which itself was closed with a second clamp. The aorta was torn nearly completely around the circumference at the typical side below the left subclavian artery, held together only by a small bridge of 2 to 3 mm at the posterior wall. The distal aorta had some backflow and was also clamped. Because of severe lacerations, it was not possible to anastomose ends directly; a 40 mm long, 20 mm in diameter, woven Dacron prosthesis was therefore interposed by means of 4-0 continuous polytetrafluoroethylene stitches.* Crossclamp time was 26 minutes. The operation was performed without any shunt or temporary bypass. During the operation, a cardiac arrest occurred and resuscitation by open-chest heart massage was performed successfully for 3 minutes. During the operation, about 50 U blood, including packed erythrocytes obtained with a Cell Saver device (Haemonetics Corp., Braintree, Mass.) was transfused.



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  		Fig. 2. TEE shows dissection in descending thoracic aorta.

 
In the postoperative course, the patient was in the intensive care unit for 42 days. After the fifth day after admission, multiorgan failure developed, with sepsis caused by Staphylococcus aureus, reduced renal clearance, acute respiratory distress syndrome, and liver failure with coagulopathy, which made hemofiltration necessary for 9 days. An electrocardiogram 2 weeks after the accident presented diffuse repolarization disturbance and sinus tachycardia. Neurologically, on the day of admission a bulbar cerebral syndrome of grade I to II was diagnosed. After the operation, the pupils were wide and rigid bilaterally, which may have been partially caused by the medications. The next day, the patient was surprisingly awake and alert and moved his toes slightly; an incomplete paraplegia was estimated at the level of D10-11. Two days later, evoked potentials revealed normal sensory but no motor functions. One month later, the patient was already able to stand. He was transferred to a rehabilitation center for further physical exercise and training.

Clinical evidence of injury to the thoracic aorta is usually not immediately obvious in thoracic trauma, but the suspicion should always be kept in mind. Most traumatic ruptures of the aorta occur at the level of the isthmus aortae, just distal to the left subclavian vein.Go 1 Only rarely does rupture of the descending or even ascending thoracic aorta result. Symptoms such as pain, hoarseness, dyspnea, bruit in the chest or neck, or murmur of aortic regurgitation, as well as persistent shock with cardiac arrest, are not necessarily significant but are severe signs.Go 1 Further clinical findings may include hypertension of the upper extremity or even left-right differences.Go 1 For the diagnosis of traumatic injuries of the thoracic aorta, the first examination is routinely performed chest radiography, which normally reveals a broadening of the mediastinum as a sign for a hematoma or obliteration of the aortic knob or even a fluidohematopneumothorax but may also be without any pathologic findings.Go 1 In the literature, a normal roentgenogram is found in as many as 27.8% at admission.Go 1 Computed tomographic scan and also magnetic resonance imaging, alone or in combination with arteriography or also digital substraction angiography, will give more exact information about aneurysms or lacerations of the thoracic aorta.Go Go 2-4 Magnetic resonance imaging may be superior for the differentiation of specific tissues, such as a thrombus or streaming blood, but has not excelled the computed tomographic scan significantly until recently.Go 4 Arteriography is certainly the proven superior method to verify in the massively traumatized patient the extent of a presumed vascular injury in continuous bleeding lesions. Venous digital subtraction angiography was not conclusive in every case, but arterial digital subtraction angiography proved highly specific and sensitive.Go 2 However, all examinations can be misleading.Go Go 2-4 When a diagnosis is made, a high index of speculation is still included. These diagnostic procedures are connected with movement of the patient to the diagnostic equipment and can be performed only when the patient is in relatively stable cardiovascular condition. They may also be much too time-consuming.

In our case, TEE was used to confirm the diagnosis. TEE is frequently performed in intensive care units for the critical judgment of cardiac function in relation to filling grade or the status of the cardiac muscle. It is a highly specific and sensitive method for the diagnosis of aortic dissection and for cardiac contusion but has never been reported to be used after accident in a traumatized patient.Go Go 5-8 The method could easily be performed at the bedside several times. Changes in the lacerated aorta can be detected earlier; treatment commenced earlier is more successful. For the diagnosis of aortic injury, TEE is highly sensitive and specific if there is a dissecting process (Fig. 2). In the case of a hematoma, which may also be the result of rib fractures, there may be difficulties in discriminating the aorta from surrounding structures. Results are therefore not conclusive in this case.

In conclusion, TEE is a helpful method, avoiding invasive and time-consuming investigations. It allows close observation in addition to electrocardiograms, blood gas monitoring, and repeated roentgenograms.

References

  1. Mitchell RL, Enright LP. The surgical management of acute and chronic injuries of the thoracic aorta. Surg Gynecol Obstet 1983;157:1-4.[Medline]
  2. Crone-Münzebrock W, Jend HH. Ergebnisse und Erfahrungen mit der digitalen Subtraktionsangiographie (DSA) bei traumatischen Gefässläsionen der thorakalen Aorta und der supraaortalen Äste. Roentgen B1 1987;40:137-9.
  3. Egan TJ, Neimann HL, Herman RJ, Malave SR, Sanders JH. Computed tomography in the diagnosis of aortic aneurysm dissection or traumatic injury. Radiology 1980;136:141-6.[Abstract/Free Full Text]
  4. Theissen P, Gross-Fengels W, Sechtem U. Differenzierung zwischen Dissektion und Aneurysma verum der Aorta descendens thorakalis mit Magnetresonanztomographie. Roentgen B1 1989;42:246-56.
  5. Börner N, Erbel R, Braun B, Henkel B, Meyer J, Rumpelt J. Diagnosis of aortic dissection by transesophageal echocardiography. Am J Cardiol 1984;54:1157-8.[Medline]
  6. Erbel R, Börner N, Steller D, et al. Detection of aortic dissection by transoesophageal echocardiography. Br Heart J 1987;58:45-51.[Abstract/Free Full Text]
  7. Erbel R, Rennollet H, Engberding R, Visser C, Daniel W, Roclandt J. Complementary role of echocardiography in the diagnosis of aortic dissection including transesophageal echocardiography. Lancet 1989;1:457-61.[Medline]
  8. Taams MA, Gussenhoven WJ, Schippers LA, et al. The value of transesophageal echocardiography for diagnosis of thoracic aorta pathology. Eur Heart J 1988;29:1308-16.



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