Traumatic rupture of the aortic isthmus: An emergency?

Abstract

The objectives of this study were to explore the hypotheses that: (1) patients with traumatic rupture of the aortic isthmus (TRA) who have not exsanguinated into the pleural cavity upon hospital presentation are unlikely to develop rupture of the hematoma during the time necessary to investigate all injuries and attend to those of more immediate danger; and (2) appropriate medical therapy can prevent free rupture of the hematoma. The medical records of 112 patients who were proved to have TRA at the isthmus resulting from injury within the preceding 7 days were reviewed. Fifty of these patients received medical treatment aimed at decreasing aortic wall stress; 46 were managed under a formal protocol. The available English language and European literature for the past 15 years was surveyed for evidence of the effects of delay between injury and aortic repair. Eight patients died before aortic repair, six of aortic exsanguination (all within 4 hours of injury). Of 77 patients for whom the time of injury was recorded and the aorta was repaired, 36 were repaired within 12 hours of injury and 41 between 12 hours and 24 weeks; none developed aortic hemorrhage. No patient receiving adequate medical therapy died of rupture of the hematoma. Other major surgery preceded aortic repair in 33 patients. We conclude that the concept that traumatic rupture of the aorta should always take priority over other injuries is incorrect. Pharmacologic reduction of wall stress appears to decrease the probability of rupture of the periaortic hematoma.

Conventional surgical repair and endovascular treatment of acute traumatic aortic rupture☆

“…Under discussion are, in particular, the treatment of patients' extrathoracic and craniocerebral injuries or lung contusion and the fear of possible aggravation of intracranial, intra-abdominal, and pelvic bleeding through heparinization during surgery for the aortic rupture. By virtue of these considerations, the concept of delayed elective treatment of the rupture has been developed [7,10]. Based on the experience that those patients reaching the hospital alive are exposed to a constant threat of dying from a second rather than a free rupture during the following hours and days [1], we suggest operation of the rupture directly after its diagnosis, assuming that other actively bleeding injuries, especially of intra-abdominal organs, have been attended to [2].…”

“…Surgical repair with a delay between trauma and treatment, allowing the patient to recover first from other major injuries, has been advocated to improve the outcome of early conventional surgical treatment [5]. However, even in an apparently stable situation, approximately 2-5% of patients experience further rupture within the first week after the trauma [6,7].…”

Thoracic Vascular Trauma

“…Pate and colleagues demonstrated that the use of antihypertensive strategies in the management of acute traumatic aortic injuries eliminated in-hospital rupture of blunt aortic trauma when a delay in operative intervention was necessary [29]. In fact, the EAST Practice Management Guidelines Work Group recommends the use of vasodilators such as sodium nitroprusside or beta-blockade when non-operative or delayed management of blunt aortic injuries is considered [30].…”

Imaging blunt traumatic aortic injury: a Canadian tertiary care trauma centre case series

“…Many have demonstrated a greater than 99 percent negative predictive value for TAI by helical CT, eliminating the need for many unnecessary aortograms [17][18][19][20] . However, equivocal cases on single detector helical CT still require aortography.…”