Acute traumatic rupture of the thoracic aorta :  is aortic stenting the real answer?

Alain G. Verdant, MD FRCS(C) Cardiovascular and Thoracic Surgeon
Hôpital du Sacré-Coeur de Montréal, 5400 boul Gouin O, Montréal, QC

Objective:  A reappraisal of a single institution experience with a highly standardized technique of aortic repair and it’s consequences on survival and spinal cord protection.

Methods:  126 patients with a mean age of 27 years had Dacron graft interposition within a mean delay of 12 hours to repair a traumatic descending aortic tear.  Most (92%) had associated injuries (60% orthopedic, 40% abdominal and 30% cerebral) for a mean ISS of 44 (median: 41).  The aortic tear was at high risk in 19 cases: 3 developed an hypovolemic shock at arrival with a preoperative chest drainage of 5 liters, 12 liters and 16 liters respectively.  Ten had a severe coarctation syndrome (mean gradient of 63 mmHg) resulting in preoperative paraplegia (4), anuria (5) intestinal gangrene (1).  In 6 cases an associated subclavian artery tear challenged the surgical technique. Distal circulatory support was established as a priority.  In the first 40 cases, a passive 9 mm Gott shunt inserted between the ascending and the descending aorta was used.  In the last 86 cases, organ protection was assured through an atrio-aortic left heart bypass driven with a Biomedicus pump delivering a median flow of 4000 ml/min.

Results:  The overall survival rate is 95,2% (120/126).  Six deaths were due to associated injuries.  No mortality occurred in the last 56 cases.   Excluding 4 paraplegia observed prior to the aortic repair, 1 new paraplegia occurred (0,8%) due to an unfunctional Gott shunt.  No paraplegia occurred in 86 patients protected with the left heart bypass.

Conclusion:  Open repair of traumatic rupture of the thoracic aorta performed by an experienced team is extremely safe even in adverse physiological conditions if optimal circulatory support is used.  These results should question the overenthusiastic use of stents as a primary choice to treat this lesion.