Acute traumatic rupture of the thoracic aorta and its branches. Results ofsurgical management.

Study aim: The aim of this retrospective study was to report a series of 10 2 patients with acute traumatic rupture of the thoracic aorta and its branc hes (TRA) and to evaluate long-term results. Patients and methods: From April 1977 to April 2000, 102 patients with RTA were admitted to our unit. Age ranged between 12 and 74 years (mean age: 33 years). Localisation was: ascending aorta (n = 3), aortic arch (n = 1), is thmus (n = 92), descending aorta (n = 1), innominate artery (n=3), and left subclavian artery (n = 2). Associated injuries mainly included craniocereb ral lesions (n = 76), rib fractures (n = 68), and thoracic (n = 38), and ab dominal (n = 24) lesions. Average time between trauma and surgery was 37 ho urs. Aortography was used routinely for diagnosis. Five patients were inope rable; the procedure was delayed in three patients. In all but two patients with rupture of the isthmus, descending aorta and subclavian artery, the o peration included venous arterial femorofemoral assistance. Rupture was par tial in 37 patients (37 direct sutures), and complete in 55 patients (40 di rect sutures). In two cases of left subclavian artery desinsertion, the ope ration included suture of the aortic tear and reimplantation of the artery. In patients with rupture of the ascending aorta and aortic arch, surgery w as carried out under cardiopulmonary bypass with deep hypothermia for aorti c arch rupture. Repair consisted of direct suture. In patients with rupture of the innominate artery, the lesion was treated under cardiopulmonary byp ass by direct suture. In five cases, abdominal injuries required emergency procedure before aortic repair. Results: Four patients died. No postoperative paraplegia occurred. The high morbidity rate was in relation to the associated injuries. Among the 93 su rvivors, the aortic clinical status was satisfactory in 91 patients (two pa tients were lost to follow-up). Two patients died from cancer and myocardia l infarction 2 and 7 years later respectively. One patient had prosthetic s epsis and was reoperated on with homograft. Angiographic control by aortogr aphy (n = 60) and angioMRI (n = 22) was normal in 76 patients. There were f ive stenoses at the level of the prosthesis, four with a gradient < 20 mmHg and one with a gradient > 50 mmHg and one aneurysm at the level of the ist hmus. These last two patients were reoperated on with good result. Conclusion: RTA remains a surgical emergency with multiple difficulties. De spite the development of new imaging modalities, angiography remains the go ld standard for the work-up of these patients. Venous arterial femorofemora l assistance with a pump remains the best procedure in order to avoid parap legia and vascular prosthesis: implantation when possible. Endovascular ste nt graft insertion, although still under investigation, holds tremendous pr omise for non-surgical treatment of these patients. (C) 2001 Editions scien tifiques et medicales Elsevier SAS.