CABG for Chronic Disease During Repair of Traumatic Ascending Aortic Rupture

Abstract

T raumatic rupture of the thoracic aorta is a well-described phenomenon involving significant morbidity and mortality. Classically, this injury occurs at the aortic isthmus, where the aorta is tethered by ligamentous fibers. Although less common, several cases of ascending aortic rupture have been documented in the literature. Here we report a case of traumatic ascending aortic injury requiring emergent surgical repair. At the time of the procedure, the patient was noted to have severely calcified coronary arteries with evidence of previous myocardial damage and decreased ventricular function. Coronary artery bypass grafting (CABG) concomitant with placement of the aortic transposition graft was performed. CASE REPORTA 45-year-old Native American male lost control of his motorcycle at high speed and was ejected over 20 feet. He lost consciousness initially, but was taken to the local hospital where he was oriented on arrival and was noted to have an acetabular fracture and several rib fractures.He underwent intubation and fluid resuscitation and was airlifted to the regional level I trauma center for further evaluation. Vital signs on admission were a heart rate of 108 bpm and blood pressure of 135/81 mm Hg. AP portable CXR demonstrated right rib fractures, clavicle fracture, pulmonary contusion, enlarged cardiac silhouette, and a widened superior mediastinum (Fig. 1).CT scans of the head, abdomen, and pelvis were normal, except for a complex acetabular fracture. CT scan of the chest showed multiple displaced right rib fractures with a hemopneumothorax, pulmonary contusion, left scapula fracture, L 1 compression fracture, and a contour abnormality in the ascending aorta (Fig. 2) concerning for traumatic aortic injury. The descending aorta appeared intact. Arch aortogram demonstrated a 1 cm flap approximately 2 cm distal to the aortic valve consistent with traumatic aortic injury (Fig. 3).The patient underwent emergent repair of the aortic transection.Repair of the ascending aortic injury consisted of placing the patient on cardiopulmonary bypass (CPB) with cannulation of the aortic arch and the right atrium. The transection was identified approximately 1 cm distal to the left main

Ascending Aortic Injuries Following Blunt Trauma

“…We reviewed cases of ascending aortic injury from 1998 to present using PubMed with the search terms “traumatic ascending aortic injury.” We found 43 cases (including our present patient presentation) in the literature and details are summarized in Table and Table . There were five cohort observations which included 24 cases (Table ) and 19 case reports (Table ) . The patients demographics were available in a total of 19 cases, which consisted of the majority of male patients with mean age of 45.4 years old (Table ).…”

“…The injury was caused by motor vehicle accident (MVA) in 15 of 19 patients (78.9%), crush injury in 4 of 19 patients (12, 15, and 16, ours) (21%) and explosion injury in one patient (5.2%) …”

“…Associated injuries were reported in 16 of 19 patients (84.2%) including cardiac injury, pulmonary injury, bone fractures, and closed head injuries . Aortic valve injury and regurgitation occurred in five of 19 patients (26.3%), and all of these five patients had their aortic valve replaced …”

“…Once the diagnosis was established, emergent repair was carried out in 8/19 (42.1%) patients, and the mortality rate was 12.5% (1/8) . Delayed repair was performed in 7/19 (36.8%) patients and none of them died .…”

“…The actual operative technique has undergone few minor changes. Graft interposition or patch repair was performed in 11 cases . A St. Jude composite mechanical valve‐Dacron graft conduit was implanted in three patients .…”