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J Thorac Cardiovasc Surg 2008;135:428-430
© 2008 The American Association for Thoracic Surgery

Brief Communication

Delayed surgery for traumatic rupture of aortic arch with dissection of the left anterior descending artery

John EV, MCh, DNBa,*, Gopalakrishnan Mundayat, MCha, Kodhandapani Chunduru, MCha, Jacob Abraham, MDb, Aruna Palliyil, MDb, Das Perimpa, DPTc

a Department of Cardiac Surgery, Medical Trust Hospital, Kochi, Kerala, India
b Department of Cardiac Anaesthesia, Medical Trust Hospital, Kochi, Kerala, India
c Department of Cardiac Perfusion, Medical Trust Hospital, Kochi, Kerala, India

Received for publication August 24, 2007; accepted for publication September 24, 2007.

* Address for reprints: John EV, MCh, DNB, Medical Trust Hospital, Cardiac Surgery, M G Road, Kochi, Kerala 682016, India. (Email: john1ev{at}hotmail.com).

High-velocity accidents are now being reported with alarming regularity. A number of these patients unfortunately do not reach the hospital.

Clinical Summary

A 21-year-old man presented with multiple fractures in the face and extremities. The electrocardiogram showed features of acute anteroseptal myocardial infarction. Echocardiography showed moderate left ventricular (LV) dysfunction with an ejection fraction of 0.4. Chest radiography showed mediastinal widening and minimal left pleural effusion. A spiral computed tomography angiogram revealed a huge mediastinal hematoma and transection of the arch of aorta between the left common carotid artery (LCCA) and the left subclavian artery (LSCA) with no active bleeding.

After various options were considered, the decision was made to treat the aortic and suspected coronary injury conservatively until the patient was stabilized. Repeat imaging revealed no worsening in the pleural effusion or hematoma.

A computed tomographic angiogram at 12 weeks revealed a pseudoaneurysm in the arch of aorta between the LCCA and the LSCA involving approximately three fourths of the circumference (Go Figure 1, A). Coronary angiogram demonstrated dissection of the proximal left anterior descending (LAD) artery (Go Figure 2, A). Echocardiogram and methoxyisobutyl isonitrile scan showed moderate LV dysfunction (ejection fraction of 0.4) with a small apical LV aneurysm.


Figure 1
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  		Figure 1. Sixty-four-slice computed tomographic angiogram reconstructions showing pseudoaneurysm of aortic arch (A) and postoperative picture of arch repair (B). LRA, Left radial artery; LAD, left anterior descending.

 

Figure 2
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  		Figure 2. Angiogram showing dissection in the proximal LAD (A) and postoperative computed tomography reconstruction showing patent LRA–LAD graft (B). LRA, Left radial artery; LAD, left anterior descending.

 
A single-stage procedure, including aortic arch repair, coronary artery bypass grafting of LAD, and LV aneurysm repair, was planned. With the patient under general anesthesia and in the supine position, the third part of the right subclavian artery was exposed through an infraclavicular incision, and an 8-mm polyester graft was sutured to it end to side. This was used as arterial inflow. The left radial artery (LRA) was harvested. A median sternotomy with extension into the neck on the anterior border of the left sternomastoid muscle gave adequate exposure of the arch of aorta and the neck vessels. The right atrium was cannulated for venous drainage, and the LV was vented through the right superior pulmonary vein. While cooling occurred, the distal end of the LRA was connected to the proximal LAD. At 18°C, deep hypothermic arrest was established. After snugging the innominate artery, antegrade cerebral perfusion was started at 900 mL/min, and retrograde flow through the LCCA and LSCA was noted. The aortic arch was opened between the LCCA and the LSCA into the pseudoaneurysm, and that segment of arch was replaced using an 18-mm polyester tube graft. The origins of the LCCA and LSCA were not affected and could be preserved by careful suturing (deep hypothermic arrest time: 50 minutes). On rewarming, the proximal of LRA was connected to the aorta. The small apical LV aneurysm was opened, parallel to the LAD, and a linear LV aneurysm repair was performed.

The patient was ventilated for 12 hours. The total drainage was 400 mL with transfusion of 1 unit of fresh whole blood. The intensive care unit stay was 2 days, and the hospital stay was 9 days.

Postoperative imaging showed intact arch repair (Figure 1, B) with a patent LRA to LAD graft (Figure 2, B). One month after the procedure, the patient was asymptomatic and the echocardiogram showed a marginal increase in systolic function (ejection fraction of 0.45) with no apical aneurysm.

Discussion

Deceleration injury to the aorta has been reported; the most common site is the descending thoracic aorta just distal to the LSCA origin. Aortic arch injuries are rare,1,2Go probably because most patients with these injuries do not reach the hospital alive. Few isolated coronary artery injuries have been reported.3,4Go A combined aortic arch and coronary artery injury must be one of the rarest. This young man was fortunate to survive this accident and reach the hospital.

At presentation, the surgical treatment was deferred because the patient already had features of acute anteroseptal myocardial infarction. Thrombolysis was not considered for acute coronary syndrome because of the fear of lysing the "life-saving" mediastinal hematoma. Also, the cause of acute coronary syndrome was thought to be dissection rather than thrombosis. Only unfragmented heparin was given under close supervision and monitoring. Antiplatelet drugs were commenced after 48 hours.

The patient's young age, the position of pseudoaneurysm, the LAD lesion with viable muscle in that territory, and the need for general anesthesia in orthopedic procedures clearly demanded the need for surgical treatment.

The LRA was chosen as the conduit because the fate of the LSCA was not clear at the start of the operation. The right subclavian artery cannulation was of immense help in providing the antegrade cerebral circulation without any additional cannulae or tubings in the field. A linear LV aneurysm repair was performed because the septal scar was not clearly visible.

Delayed surgical treatment can provide optimal results in combined aortic and coronary injuries, provided a stable clinical condition can be achieved with conservative management consisting of rest, careful monitoring, periodic reassessment, and antiplatelet drugs.

References

  1. Serna DL, Miller JS, Chen EP. Aortic reconstruction after complex injury to mid-transverse arch. Ann Thorac Surg 2006;81:1112-1114.[Abstract/Free Full Text]
  2. Carter YM, Karmy-Jones R, Alder GS. Delayed surgical management of a traumatic aortic arch injury. Ann Thorac Surg 2002;73:294-296.[Abstract/Free Full Text]
  3. Smayra T, Noun R, Tohme-Noun C. Left anterior descending artery dissection after blunt chest trauma: assessment by Multidetector row computed tomography. J Thorac Cardiovasc Surg 2007;133:811-812.[Free Full Text]
  4. Korach A, Hunter CT, Lazar HL, Shemin RJ, Shapira OM. OPCAB for acute LAD dissection due to blunt chest trauma. Ann Thorac Surg 2006;82:312-314.[Abstract/Free Full Text]




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