Prospective Study of Blunt Aortic Injury

TLDR

Blunt aortic injury is a leading cause of death from blunt trauma, and evolving diagnostic and operative techniques have reshaped its management, though aortography remains the standard diagnostic method. In this prospective multicenter trial, 274 patients were evaluated with chest CT (75 % diagnostic) and TEE (80 % diagnostic), and 207 stable cases underwent thoracotomy with repair using clamp‑and‑sew (35 %) or bypass (65 %) techniques. The study reported a 31 % overall mortality (63 % from aortic rupture) that was not influenced by repair method, an 8.7 % paraplegia rate, and identified clamp‑and‑sew and cross‑clamp times ≥ 30 min as risk factors for paraplegia, while bypass techniques reduced paraplegia incidence.

Abstract

Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years.This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma.There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia.Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.