Traumatic rupture of the aortic isthmus: Program of selective management

Two hypotheses were investigated: (1) helical computed tomography (CT) of t he chest on victims of decelerating trauma can yield a diagnosis of, or "ru le out," a traumatic rupture of the aorta (TRA) without the need for an aor togram; and (2) selective delay of aortic repair can be safely accomplished through a medical management protocol, Screening helical CT examinations w ere done on 6169 victims of blunt thoracic trauma; 47 were found to have TR A; in 8, indirect but nondiagnostic findings not clarified by an aortogram led to surgical exploration. The sensitivity; of helical CT was higher than that of aortograms, and a "normal" helical CT scan was never associated wi th a proved TRA, It is estimated that the use of helical CT has resulted in at least a 40% to 50% decrease in the need for aortograms, in addition to yielding rapid, noninvasive valuable information about other injuries, Drug s (beta-blockers +/- vasodilators) to decrease the stress in the aortic wal l were used in 93 patients when the diagnosis was suspected and were contin ued as necessary through the evaluation, stabilization, and until the aorta was cross-clamped at operation. Elective, delayed operation was done betwe en 2 days and 25 months in 15 patients who were deemed to be excessive risk s for emergency aortic repair; there were 2 deaths (13.3%). Eleven patients never had aortic repair. No patient maintained on this protocol, whether r epaired emergently, electively, or not at all, developed free rupture of th e periaortic hematoma and death from TRA.