Introduction
MUST be ruled out in any high-energy trauma. Most common location is distal to the L subclavian artery, probably because the mobile aortic arch is continuous with the immobile descending thoracic aorta at this point (shear stress). Many of these injuries are fatal, however those that survive deserve immediate attention – a 15 year series of 114 thoracic aorta ruptures following blunt-trauma (Maryland Shock Trauma) showed that, despite a 78% initial survival rate (resuscitation) the overall survival rate was only 47% [Cowley RA et al. J Thorac Cardiovasc Surg 100: 652, 1990]. Traditionally, ALL of these patients have gone to surgery immediately, however the wisdom and data to support this have recently come into question. [Galli R et al. Ann Thorac Surg 65: 461, 1998; Pate JW et al. World J Surg 23: 59, 1999]
Surgical Considerations
Repair of a thoracic aortic injury is associated with significant morbidity. Data from Maryland Shock Trauma showed that 28% of patient who survived to surgery died during or after the repair, and 14$ of survivors became paraplegic [Cowley RA et al. J Thorac Cardiovasc Surg 100: 652, 1990]. The optimal treatment may not be known, but partial-bypass techniques have been advocated – note that Read et al.’s series, which used partial left heart bypass and did not report any cases of paraplegia, only included 16 patients, making it impossible to evaluate its true efficacy (since the incidence of paraplegia is ~ 15%). [Read RA et al. Arch Surg 128: 746, 1993]
Non-Surgical Management
More recently, some authors have attempted to treat selected patients non-operatively [Galli R et al. Ann Thorac Surg 65: 461, 1998] or with delayed surgery [Pate JW et al. World J Surg 23: 59, 1999], with Galli et al. achieving a mortality rate of 0% in 21 patients, and Pate et al. achieving a mortality rate of 13.3% in a population of 15 patients who underwent surgery between 2 days and 25 months after the injury.
