J Thorac Cardiovasc Surg 1994;107:962-963
© 1994 Mosby, Inc.
Indications for median sternotomy for acute traumatic rupture of the descending thoracic aorta
Rémi Nottin, MD,
Daniel Roux, MD,
Alain Serraf, MD,
Jean-Pierre Duffet, MD,
Jean-Pierre Daniel, MD,
Yves D'Udekem, MD,
Jean-Paul Binet, MD
Centre Chirurgical Marie Lannelongue
Université Paris Sud
Le Plessis Robinson, France
To the Editor:
The standard approach for traumatic rupture of the descending thoracic aorta is through a leftthoracotomy In some instances, however, because of the severity of the associated lesions or thecomplexity of the aortic injury, this approach may be inadequate.
Between 1980 and 1990, we treated 22 ruptures of the descending thoracic aorta. In three cases,we had to perform aortic repair through a midsternotomy instead of the usual left thoracotomy. Thisapproach necessitates cardiopulmonary bypass (Fig. 1) to gain access to the descending aorta. Normothermic perfusion is started in the ascending aorta. The left lung must be perfectly deflatedand ventilation must be stopped. The rupture is controlled by proximal crossclamping of the aortabetween the left carotid and left subclavian arteries, the latter being clamped separately. The leftpleura is then opened and blood is emptied. The left lung is lifted above the heart and the descending aorta is clamped belowthe rupture. At this stage, femoral perfusion is started.
CASE 1
In December 1983, a 52-year-old man was admitted to our department after a motor vehicleaccident. He had several injuries, including a flailed chest from the third to the sixth left rib, a leftacetabulum fracture, and a complex facial injury. The chest radiograph showed left-sidedhemothorax and aortography revealed a rupture of the aortic isthmus with arch involvement (Fig. 2). Because of the complexity of the lesion, the operation was performed through a sternotomy withcardiopulmonary bypass.
After opening the left pleura, we faced a complete transection of the aortic isthmus with alongitudinal tear of the transverse arch concavity. A Dacron graft was placed in the descending aortaand the longitudinal tear was repaired with interrupted sutures over Teflon felt pledgets. Thepostoperative course was obscured by an oligoanuria, which necessitated 7 days of hemodialysis.The head trauma included ocular wounds, which caused blindness. Eight years later, despite lossof vision, the patient is living a normal life.
CASE 2
In July 1986, a 19-year-old man was admitted to another hospital after a motor vehicle accident. Hehad multiple injuries including a major fracture of the pelvis. During the orthopedic procedure,hemodynamic instability with collapse prompted the surgeon to ask for a chest radiograph, whichshowed a complete left-sided hemothorax. The patient was immediately transferred to our center fortreatment of a suspected rupture of the aorta. The patient arrived in the operating room in cardiacarrest. During cardiopulmonary resuscitation, a sternotomy was performed. When the pericardiumwas opened, the heart protruded as a result of the pressure of the hemothorax. This was enough to restore efficient cardiac activity. Extracorporeal circulation wasstarted. The left pleura was then opened and several liters of blood were sucked out. The aorticisthmus was totally ruptured. The repair necessitated the placement of a Dacron graft. This patientis now leading a normal life at 5 years of follow-up.
CASE 3
In July 1990, a 28-year-old man was admitted to our department after a motor vehicle accident. Onclinical examination, the patient was found to be paraplegic. The chest radiograph showed amediastinal enlargement and a fracture of the sixth thoracic vertebra. Aortography revealed atransection of the mid descending aorta. Because of the spinal lesion, the patient was operated onin a rigid shell, which made thoracotomy impossible. A sternotomy was performed withcardiopulmonary bypass. At the level of rupture, the dorsal aspect of the aorta was incarceratedbetween the luxated vertebral bodies of the sixth and the seventh thoracic vertebrae. The aorta wasrepaired with a Dacron graft. Postoperative myelography showed a spinal cord compression relatedto the luxation of the spine (Fig. 3). The patient recovered totally from his paraplegia and was discharged 75 days later. Sixteen monthsafter his accident, the patient is living a normal life.
Recent reports on traumatic rupture of the thoracic arota have emphasized the high mortality raterelated to the severity of the associated injuries.
1 In case of massive hemorrhage from the lefthemithorax, emergency thoracotomy appears to be unsuccessful. 2 We therefore believe that median sternotomymay sometimes be more effective.
In case 1, we preferred sternotomy because of the possible involvement of the aortic arch and theunstable fracture of the pelvis. In case 2, the patient was in cardiac arrest. Median sternotomy canbe more easily and promptly performed during cardiac resuscitation than a left thoracotomy.Pericardiotomy first, in cases of cardiac arrest caused by massive and compressive left-sidedhemothorax, immediately restores an efficient cardiac function and avoids the risk of completeexsanguination from pleurotomy first. In case 3, the patient was already paraplegic. The spinalinjuries, especially those accompanied by neurologic deficit, may not physically tolerate a lateraldecubitus position, which can increase the spinal cord compression. Sternotomy allowed us tooperate with the patient in a dorsal position within a rigid shell. The cardiopulmonary bypass with asustained spinal cord perfusion avoided adding the effects of ischemic to those of the traumaticspinal cord injuries. 3,4 This patient recovered totally from his paraplegia.
Obviously, the exposure of the descending thoracic aorta is better through a left thoracotomy thanthrough a median sternotomy. Use of the median sternotomy approach should be rare. However, webelieve that it is an alternative in the most severe cases of acute traumatic rupture of thedescending thoracic aorta: total rupture of the aorta, associated unstable spinal or pelvic fracture,and associated injuries of the transverse arch.
References
-
Kirklin JW, Barratt-Boyes BG. Acute traumatic transection. In: Kirklin JW, Barrett-Boyes BG, eds.Cardiac surgery: morphology, diagnostic criteria, natural history, techniques, and indications. New York: Wiley, 1986.
-
Cowley RA, Turney SZ, Hankins JR, Rodriguez R, Attar S, Shankar BS. Rupture of thoracic aortacaused by blunt trauma: a fifteen-year experience. J THORAC CARDIOVASC SURG 1990;100:652-61.[Abstract]
-
Rabinsky I, Sidhu GS, Wagner RB. Mid descending aortic traumatic aneurysms. Ann Thorac Surg1990;50:155-60.
-
Katz NM, Blackstone EH, Kirklin JW, Karp RB. Incremental risk factors for spinal cord injuryfollowing operation for acute traumatic aortic transection. J THORAC CARDIOVASC SURG 1981;81:669-74.[Abstract]
