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Case report: Open replacement of incomplete semi-circular traumatic ruptures of the ascending and descending aorta
© The Author(s). 2016
Received: 21 August 2015
Accepted: 24 May 2016
Published: 16 July 2016
An incomplete traumatic rupture of the ascending aorta is a rare but life-threatening condition. Hence, the assessment of the extent of the injury prior to therapy is crucial. We report a case of a 50-year-old male with traumatic aortic rupture who underwent emergency surgery after the evaluation of computed tomography scan (CT-scan). The surgical treatment involved replacement of the ascending aorta and stent implantation in descending aorta due to its covered rupture.
Traumatic aortic rupture is a life-threatening condition associated with high mortality and morbidity requiring immediate surgical treatment. The involvement of the thoracic aorta displays a potential fatal injury causing death in 75-90 % of cases at the time of the injury [1, 2]. Bending stress of aorta occurs as it is flexed over the left pulmonary artery and left bronchus. A recent analysis of traumatic aortic injury elucidated that torsion is a possible mechanism in an ascending aortic injury, which occurs above the aortic valve through rotational displacement of the heart at the time of the impact [3, 4]. In order to improve the outcome of thoracic aortic injury and the degree of multi-organ damage, it is crucial to accurately evaluate the priority of treatment .
Thoracic aortic rupture is a devastating injury and it rarely occurs as a sole traumatic entity. The acknowledgment of concomitant thoracic, abdominal, head injuries, and fractures after thoracic aortic rupture is of paramount importance . Algorithms for the diagnosis and treatment of traumatic thoracic aortic injury have undergone changes in recent years .
Endovascular surgery of aortic injury became the treatment of choice, especially for patients with associated severe injuries and risk of bleeding . Conventional surgical treatment is always indicated for young patients with stable hemodynamic condition, low risk of bleeding and when surgery can be delayed for several hours .
A 50-year-old patient was brought to the emergency room after a failed suicide attempt by jumping from a 12 m high Psychiatric Clinic building, where he received treatment for his depression.
On admission, the intubated patient had a GCS of 3 points and was in certain unstable hemodynamic state with low inotropic support. The clinical evaluation showed multiple rib fractures and suppressed breath sounds on the right side. The vital signs at this point showed blood pressure of 80/55 mmHg without vasopressors, pulse of 100 bpm, oxygen saturation of 100 % on ventilation and temperature of 33.7 °C. External bleeding was not observed. Central and peripheral pulses in all four extremities were palpable but weak. No abdominal pain or tenderness was observed. The blood analysis showed following results: hemoglobin 144.0 g/l, hematocrit 0.41/l, erythrocytes 4.24 10 s9/l.
Further, an external fixation of symphysis with left sacrum and right sacroiliac joint (SIJ) was performed followed by chest ventrolateral wall stabilization from the 4 - 6th ribs. After 20 days of intensive care, the patient was transferred to the cardiac surgical ward. During the postoperative course the patient developed pneumonia, which was successfully treated with antibiotics. There were no surgery related complications. The postoperative follow-up CT control imaging showed a good result. The patient was discharged 21 days after the surgery to further rehabilitation under psychiatric control.
This case report describes the management of an incomplete aortic semi-circular traumatic rupture caused by failed suicide attempt due jumping from 12 m height, by replacement of the ascending aorta and stent implantation in descending aorta. Traumatic aortic injury is a lesion extending from the intima to the adventitia. The region subjected to the greatest strain involves the area around the isthmus where the relatively mobile thoracic aorta joins the fixed aortic arch and the insertion of the arterial ligament. This region is the rupture site in 80 % according to pathological series and up to 95 % in clinical series. Lesions of the thoracic aortic wall occur in transverse manner, either segmental (55 %) or circular (45 %) like in our case. The CT-scan presents an excellent imaging tool to assess the extent of aortic trauma and is used as a standard diagnostic method in cases of multiple trauma and aortic dissection [11–13]. Other imaging tools used in the diagnosis of aortic rupture involve TOE and angiography [14, 15]. TOE has a high degree of sensitivity [~100 %] and 98 % specificity in the detection of aortic injury . TOE guidance is considered appropriate in endovascular thoracic aortic procedures for monitoring, procedural guidance, and/or endovascular graft leak detection (Class IIa, Level of Evidence: B) . CT-Scan is the standard approach in diagnosis of aortic rupture. However, if CT-scan is not conclusive like in our case additional imaging like TOE is useful to enhance detection of aortic injury.
CT-scan, computer tomography scan; GCS, the Glasgow coma scale; TOE, transesophageal echocardiography.
MiM planned and prepare the manuscript. MG supervised manuscript preparation, carried out final approval of the version to be published. JS carried out manuscript preparation and update of literature. MaM performed anesthesia and perioperative echocardiography. FE operated the Patient carried out final approval of the version to be published. All authors read and approved the final manuscript. LG performed Thoracic Stent Graft implantation.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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