Contemporary results of standard open repair of acute traumatic rupture of the thoracic aorta

Abstract

Open repair of acute traumatic rupture of the thoracic aorta has been the standard of care for the past half century. Traditional criteria of operative success have been patient survival and prevention of spinal cord ischemia. Historical series have reported a variability of surgical results with relation to the variety of operative approaches. This study aims to update the results obtained with a uniform surgical technique based on a systematic utilization of distal perfusion during aortic cross-clamping. During a 35-year period (1974-2009), 138 consecutive patients with an acute traumatic rupture of the thoracic aorta were repaired with a Dacron graft interposition through a standard left thoracotomy. All patients received a method of circulatory support. A passive 9-mm Gott shunt inserted between the ascending and the descending aorta and delivering a median flow of 3 L/min was used in the first 40 cases. A partial left heart bypass realized from the left atrium to the descending aorta and driven with a centrifugal pump was used in the last 98 consecutive cases. A median flow of 4 L/min was recorded. Mean age of the patients was 27 years and 90.6% of them had associated injuries for a calculated mean ISS of 44. Two outcome variables were analyzed: hospital mortality and postoperative spinal cord ischemic injury. Overall hospital mortality is 5% (7/138 patients). This was improved from 7.5% (3/40) in patients perfused with the Gott shunt to 4% (4/98) in patients protected with the left heart bypass and lowered to 1.5% (1/68) in the last 68 patients. Among 134 cases with an intact preoperative spinal cord, one patient (0.7%) developed a new paraplegia due to a nonfunctional Gott shunt. Among 98 patients perfused with a centrifugal pump-driven left heart bypass, none of the 97 patients (0%) with a preoperative intact spinal cord developed a spinal cord ischemic deficit. Conventional open surgical repair of acute traumatic rupture of the thoracic aorta performed with an orderly monitored circulatory support can be accomplished with a very low rate of mortality and spinal cord injury. Compared with the Gott shunt, a left heart bypass propelled with a centrifugal pump is technically a more versatile method of perfusion, and it provides higher hemodynamic performance.