Scientific paper
Traumatic rupture of the thoracic aorta: third decade of experience

Presented at the 88th Annual Meeting of the North Pacific Surgical Association, Victoria, British Columbia, November 8–11, 2001
https://doi.org/10.1016/S0002-9610(02)00851-6Get rights and content

Abstract

Background: Traumatic rupture of the thoracic aorta is a relatively common injury of deceleration accidents, usually high-speed motor vehicle accidents. Spinal cord injury has been a well-documented complication of surgical management. The use of nonheparinized partial bypass with a centrifugal pump was evaluated for protection against spinal cord injury and reduction of risk of associated injuries.

Methods: From 1989 to 1999, the third decade of the authors’ experience, traumatic rupture was diagnosed in 58 patients (male 46 and female 12; mean age 39.9 years, range 17 to 85). Associated injuries were documented in 98.3% (57 patients). In all, 45 patients (77.6%) had the opportunity for definitive surgical management; 42 (93.3%) were managed with partial cardiopulmonary bypass, 35 without the use of heparin. Full cardiopulmonary bypass was utilized in 1 patient while 2 had repair without cardiopulmonary bypass support. Thirteen patients did not have the opportunity for definitive surgical management, 1 death on arrival, 8 (61.5%) suspected, and 4 (30.8%) diagnosed.

Results: There were 6 deaths in the surgical group, 5 in nonheparinized patients. The causes were intraoperative hypovolemia (2), anoxic brain death after intraoperative cardiac arrest (1), sepsis (1), and adult respiratory distress syndrome (1). The other was in the simple aortic cross-clamp group from intraoperative pulmonary compromise. There was one spinal cord injury, paraparesis in 1 of the 2 patients managed without bypass support. The total hospital stay ranged from 8 to 112 days, primarily owing to management of associated injuries. Of the 13 patients who did not have the opportunity for definitive surgical management, 5 had unsuccessful emergency thoracotomy and 3 survived the hospital course without surgery. Of the total population, the overall mortality was 27.6%, whereas the mortality of the potentially operable patients was 25.8%. Of the surgical group, the intraoperative mortality was 6.7% and 30-day mortality was 13.3%.

Conclusions: Spinal cord injury was prevented by the use of partial cardiopulmonary bypass. Nonheparinized bypass was likely to be a contributory factor to lack of mortality directly related to associated injuries.

Section snippets

Methods

The medical records at Vancouver General Hospital and St. Paul’s Hospital of 58 patients who had traumatic rupture of the thoracic aorta between 1989 and 1999 were retrospectively reviewed. There were 46 male and 12 female patients. The mean age was 39.9 years, and the range was 17 to 85 years. Of the total population, 53 (91.4%) were victims of motor vehicle accidents. Among these were 3 pedestrians and 5 motorcyclists. Of the remainder, 3 (5.2%) fell from heights and 2 (3.4%) had either a

Results

Of the 58 patients, only 45 (77.6%) had the opportunity for definitive surgical management. The nonsurgical group comprised 13 patients (22.4%). Of the surgical group there were 39 survivors (86.7%) and 6 nonsurvivors (13.3%).

Of the 45 patients who had the opportunity for definitive management, the surgical approach was a standard posterolateral left thoracotomy, with endobronchial anaesthesia in all but 1 patient. This patient was managed by median sternotomy for aortic arch injury, with total

Comments

The third decade of the authors experience of traumatic rupture of the aorta was evaluated to determine the influence of nonheparinized cardiopulmonary bypass on controlling the risk of spinal cord injury complicating surgical management and reducing mortality contributed to by associated injuries. The 20-year experience, 1969 to 1989, was reported in 1991 by Kodali et al [1] and documented the incidence of paraplegia was 3.2% with cardiopulmonary bypass, 29% with simple aortic cross- clamping

Conclusions

The third decade of experience of traumatic rupture of the aorta at the University of British Columbia has demonstrated a major improvement in management with significant reduction of morbidity and mortality. At the end of the second decade of our experience, the use of nonheparinized partial cardiopulmonary bypass using the Medtronic Biomedicus centrifugal vortex pump and Carmeda bioactive surface coating of the extracorporeal circuitry was commenced to provide active distal perfusion for

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