Anatomical considerations in the surgical management of blunt thoracic aortic injury.

Abstract

Blunt aortic injury (BAI) involving the thoracic aorta is usually described as occurring at the isthmus. We hypothesized that injuries 1 cm or less from the inferior border of the left subclavian artery (LSCA) are associated with an increased mortality rate compared with injuries that are more distal. A retrospective review of patients admitted with the diagnosis of BAI was performed. Injuries were divided into two groups: group I, injuries that were 1 cm or less from the junction of the LSCA and the thoracic aorta; group II, injuries that were more than 1 cm from the LSCA. Primary outcome measures included cross-clamp time, rupture, and death. In a 14-year period, 122 patients were admitted with BAI. The anatomy relative to the LSCA could be determined in 91 patients who underwent operative repair. Forty-two injuries (46%) were classified as group I, and 49 injuries were classified as group II. Group I injuries were characterized by an increased mortality rate (18/42 or 43% in group I vs 11/49 or 22% in group II, P = .04), intraoperative rupture rate (7/42 or 17% in group I vs 1/49 or 2% in group II, P = .003), and cross-clamp time (39.5 +/- 21.9 minutes in group I vs 28.4 +/- 13 minutes in group II, P = .04). Three ruptures occurred while proximal control was being obtained. Increased technical difficulty and risk of rupture characterize injuries that occur proximally in the descending thoracic aorta, 1 cm from the LSCA. These injuries may be better managed by instituting bypass before attempting to obtain proximal control and by routinely clamping proximal to the LSCA.