Outcomes of Traumatic Aortic Injury in a Primary Open Surgical Approach Paradigm.

BACKGROUND: Multiple classifications can be used to define the magnitude of aortic injury. The Vancouver Classification (VC) is a new and simplified computed tomography-based Blunt Aortic Injury (BAI) grading system correlating with clinical outcomes. OBJECTIVES: The objectives of this study are: 1) to describe the severity of aortic injury in a center with a predominantly surgical approach to BAI; 2) to correlate the severity of aortic trauma to hospital survival rate and rate of adverse events according to the type of interventions performed during the hospital stay; and 3) to evaluate VC. PATIENTS AND METHODS: All patients referring to the Sacre-Coeur Hospital of Montreal between August 1998 and April 2011 for management of BAI were studied. Two radiologists reviewed all CT scan images individually and classified the aortic injuries using VC. RESULTS: Among the 112 patients presenting with BAI, 39 cases had local CT scans available for reconstruction. Seven patients were identified as suffering from grade I injuries (flap or thrombus of less than 1 cm), 6 from grade II injuries (flap or thrombus of more than 1 cm), and 26 from grade III injuries (pseudoaneurysm). Among the patients with grade I injuries, 57% were treated surgically and 43% medically with a survival rate of 100%. Among the patients with grade II injuries (67% treated surgically and 33% treated medically) survival was also 100%. Among patients with grade III injuries (85% treated surgically, 7% had Thoracic Endovascular Aortic Repair (TEVAR) and 8% treated medically) survival was 95%, 95% and 50%, respectively. There were no significant differences between groups as to clinical outcome. Inter-rater reliability was 0.81. CONCLUSIONS: VC is easy to use and has low inter-observer variability. Low grades of injury were associated with low mortality related to medical treatment.

A Floating Thrombus Anchored at the Proximal Anastomosis of a Woven Thoracic Graft Mimicking a Genuine Aortic Dissection.

An aortoesophageal fistula following surgery for a ruptured 6.6-cm thoracic aneurysm in a 69-year-old female was repaired using a 34-mm woven prosthetic graft. A follow-up computed tomography (CT) scan at 10 days postoperatively revealed a dissection-like picture in the region of the graft, which was treated conservatively. The patient eventually died from sepsis and multiorgan failure. At autopsy, the graft was retrieved in situ and studied by detailed gross, microscopy, and scanning electron microscopy (SEM) examination. Gross observation confirmed that the dissection resulted from the rolling of the internal capsule downstream. A massive thrombus anchored at the proximal anastomosis and held by a narrow head was also noted. The thrombus demonstrated reorganization in the area of the anastomosis, with a false lumen in its distal half. The reminder of the thrombus consisted of layered fibrin. After gross examination, the fabric graft was found to be flawless. Additional detailed studies were also done using microscopy, SEM, and gross examination.

Contemporary results of standard open repair of acute traumatic rupture of the thoracic aorta.

BACKGROUND: Open repair of acute traumatic rupture of the thoracic aorta has been the standard of care for the past half century. Traditional criteria of operative success have been patient survival and prevention of spinal cord ischemia. Historical series have reported a variability of surgical results with relation to the variety of operative approaches. This study aims to update the results obtained with a uniform surgical technique based on a systematic utilization of distal perfusion during aortic cross-clamping. METHODS: During a 35-year period (1974-2009), 138 consecutive patients with an acute traumatic rupture of the thoracic aorta were repaired with a Dacron graft interposition through a standard left thoracotomy. All patients received a method of circulatory support. A passive 9-mm Gott shunt inserted between the ascending and the descending aorta and delivering a median flow of 3 L/min was used in the first 40 cases. A partial left heart bypass realized from the left atrium to the descending aorta and driven with a centrifugal pump was used in the last 98 consecutive cases. A median flow of 4 L/min was recorded. Mean age of the patients was 27 years and 90.6% of them had associated injuries for a calculated mean ISS of 44. RESULTS: Two outcome variables were analyzed: hospital mortality and postoperative spinal cord ischemic injury. Overall hospital mortality is 5% (7/138 patients). This was improved from 7.5% (3/40) in patients perfused with the Gott shunt to 4% (4/98) in patients protected with the left heart bypass and lowered to 1.5% (1/68) in the last 68 patients. Among 134 cases with an intact preoperative spinal cord, one patient (0.7%) developed a new paraplegia due to a nonfunctional Gott shunt. Among 98 patients perfused with a centrifugal pump-driven left heart bypass, none of the 97 patients (0%) with a preoperative intact spinal cord developed a spinal cord ischemic deficit. CONCLUSION: Conventional open surgical repair of acute traumatic rupture of the thoracic aorta performed with an orderly monitored circulatory support can be accomplished with a very low rate of mortality and spinal cord injury. Compared with the Gott shunt, a left heart bypass propelled with a centrifugal pump is technically a more versatile method of perfusion, and it provides higher hemodynamic performance.