Traumatic rupture of the thoracic aorta: third decade of experience

Background: Traumatic rupture of the thoracic aorta is a relatively common injury of deceleration accidents, usually high-speed motor vehicle accidents. Spinal cord injury has been a well-documented complication of surgical management. The use of nonheparinized partial bypass with a centrifugal pump was evaluated for protection against spinal cord injury and reduction of risk of associated injuries. Methods: From 1989 to 1999, the third decade of the authors’ experience, traumatic rupture was diagnosed in 58 patients (male 46 and female 12; mean age 39.9 years, range 17 to 85). Associated injuries were documented in 98.3% (57 patients). In all, 45 patients (77.6%) had the opportunity for definitive surgical management; 42 (93.3%) were managed with partial cardiopulmonary bypass, 35 without the use of heparin. Full cardiopulmonary bypass was utilized in 1 patient while 2 had repair without cardiopulmonary bypass support. Thirteen patients did not have the opportunity for definitive surgical management, 1 death on arrival, 8 (61.5%) suspected, and 4 (30.8%) diagnosed. Results: There were 6 deaths in the surgical group, 5 in nonheparinized patients. The causes were intraoperative hypovolemia (2), anoxic brain death after intraoperative cardiac arrest (1), sepsis (1), and adult respiratory distress syndrome (1). The other was in the simple aortic cross-clamp group from intraoperative pulmonary compromise. There was one spinal cord injury, paraparesis in 1 of the 2 patients managed without bypass support. The total hospital stay ranged from 8 to 112 days, primarily owing to management of associated injuries. Of the 13 patients who did not have the opportunity for definitive surgical management, 5 had unsuccessful emergency thoracotomy and 3 survived the hospital course without surgery. Of the total population, the overall mortality was 27.6%, whereas the mortality of the potentially operable patients was 25.8%. Of the surgical group, the intraoperative mortality was 6.7% and 30-day mortality was 13.3%. Conclusions: Spinal cord injury was prevented by the use of partial cardiopulmonary bypass. Nonheparinized bypass was likely to be a contributory factor to lack of mortality directly related to associated injuries.