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Is traumatic rupture of the aorta misunderstood?
Is Traumatic Rupture of the Aorta Misunderstood? James W. Pate, MD Department of Surgery, The University of Tennessee and Elvis Presley Trauma Center, Memphis, Tennessee
V
esalius reported a case of traumatic rupture of the aorta (TRA) in 1557, and traumatic aneurysms were resected in the early 1950s. The natural history was not appreciated until 1958, when Parmley and associates [l] reported autopsy findings in 296 cases of TRA-an article that has been referred to in almost every report on the subject since. Successful surgical repair of acute TRA followed the next year. It is important to understand the natural (untreated) history of a disease to make appropriate clinical decisions as well as to form a baseline for comparison of different treatments. Careful autopsy studies form a good basis for delineating these histories. However, when reviewing the natural course, several factors are essential: (1) limitations of the study must be recognized, (2) the study must be properly interpreted and analyzed, and valid “conclusions” must be obtained, (3)the series must represent the same universe of patients to be considered in the group to be compared, and (4) conclusions of the autopsy series must be appropriately applied to the clinical setting. See also page 726.
Most references to the Parmley report mention that 89.7% of the unoperated patients died within 6 hours of injury and less than 9% survived more than 24 hours. This led to the generally accepted clinical concept that immediate diagnosis and aortic repair are mandatory. Serious limitations with the Parmley study are evident when it is related to live patients. It is a study of the autopsy files of the Armed Forces Institute of Pathology, until 1957. (The first autopsy specimens in the Armed Forces Institute of Pathology date from September 1862, at the beginning of the Civil War [Ruth Lee, Armed Forces Institute of Pathology; personal communication, July 19931.) The criteria for selection were only “non-penetrating . . . injury of the aorta” and, except for 2 surgical patients, autopsy within 4 years of injury. There is no denominator; patients who survived without recognition of the injury, those who left the military, and those who were not autopsied are not included. The subjects are primarily young, otherwise healthy, military men. Many mutilated aircraft crash victims are included. More than half of the patients had other multiple, frequently fatal, injuries. The actual relation of the aortic injuries to the deaths is not known. Traumatic rupture of the aorta kills by free rupture into the pleural space with exsanguination. No data on this finding are given, but, instead, “. . . serious trauma usually produces . . . other body injury so extensive that death would be inevitable irrespective of the cardiovascuAddress reprint requests to Dr Pate, 956 Court Ave, Memphis, TN 38163.
0 1994 by The Society of Thoracic Surgeons
lar insult.” Only 45% of the injuries were at the aortic isthmus-the location in more than 90% of clinical cases. There were only 24 victims with aortic isthmus injuries who lived longer than 1 hour after injury (possibly in time to arrive at a hospital). One died within 6 hours of admission, 3 others died within 24 hours, and 18 (75%) lived from 1 day to 4 years. (It appears that some who refer to the article have not read it.) The Armed Forces Institute of Pathology series is quite different from clinical patients in key elements. The “conclusion” of the Parmley study appropriate to clinical series is the observation that only 1 patient (4.2%)with rupture at the isthmus died between 1 and 6 hours of injury, and only 3 (12.5%)additional patients died in less than 24 hours. No cause of death is given for these patients. Our almost panic-stricken rush to the operating room “before the hematoma ruptures and the patient bleeds to death’ leads to operation on unstable patients, high mortality from intraabdominal hemorrhage, head or lung injury, and frequently paraplegia (related to shock or hypoxia in the perioperative period). This concept leads to aortograms being done and patients operated on in hospitals without equipment and personnel to optimally handle such injuries. I believe the unscientific legal climate contributes to these decisions. When paraplegia results (up to 40%of the time), legal action may result; when it is elected to transfer the patient, and he or she dies before repair elsewhere, liability may be claimed because of misinterpretations of Parmley’s report. Many patients have undergone laparotomy, orthopedic, and other procedures before aortic repair, with only a rare instance of rupture of the pseudoaneurysm. For example, Xabregas and colleagues [Z] reported 13 cases of TRA with delays up to 16 days (mean, 3 days) between injury and repair, with no free ruptures. Cernaianu and associates [3] noted that there was no difference in time spent to make the diagnosis of TRA between survivors and nonsurvivors, nor was there a difference in time of arrival in the operating room. In this issue of The Annals, Williams and associates [4] report a 5-year autopsy study that is more current, uniform, and clinically meaningful than the widely quoted Parmley report. They report 90 victims of motor vehicle accidents (from among 530 fatalities) who were found to have TRA-68 (75.5%)at the aortic isthmus. Four patients lived more than 1 and less than 24 hours after injury; 99% were dead in less than 24 hours. However, as in the Parmley report, the cause of death, or whether death was related to the TRA, is unknown. There is an implication that in all 90 cases the TRA . . was a major factor in the fatal outcome,” but no data are given to support this opinion. Massive hemothorax is not mentioned. Most I‘.
Ann Thorac Surg 1994;57:53&1
0003-4975/94/$7.00
EDITORIAL PATE TRAUMATIC RUPTURE OF AORTA
Ann Thorac Surg 1994;57530-1
observers have noted that approximately half of all deaths in patients with TRA are unrelated to the TRA [5, 61. Data on other major injuries reported by Williams and associates allow us to compare their autopsy series with clinical series. The injuries suffered by their patients are obviously different from patients who reach the hospital alive. Lacerations of the heart were found in 34% of their patients; this is almost unheard of in clinical series. Cardiac contusions are found in from 7.8% [6] to 17.9% [7] of clinical series, with a mean of 7.4% [7]. Head injuries were found in 42%of Williams and associates’ series but in only 10% to 28%of the clinical series from Boston [8], Duke [7], and Memphis [6]. First rib and sternal fractures were common in the autopsy series, but very rare in clinical cases of isthmus rupture. Thus, Williams and associates’ patients also represent a different universe from those patients seen in surgical practice. Their data fail to support the myth that patients must be rushed immediately to the operating room before proper evaluation and treatment of other lesions. Hartford and co-workers [5] attempted to find all victims with TRA in the Irving, CA, area in 1980 and 1981, including autopsied victims who did not reach a hospital alive, as well as all patients admitted to the area hospitals. Of their 86 patients, 37 died at the accident scene-about half (20.9%) of exsanguination from the aorta. There were 16 patients evaluated at hospitals; 7 died without aortic repair, only 1 of exsanguination from TRA. Our classification would seem to offer an appropriate framework to allow uniform standards for comparison between groups and more clinically useful conclusions: class I = acute, less than 8 days after injury; A = with free hemorrhage into pleural space, and B = with periaortic hematoma contained in the mediastinum; class I1 = chronic pseudoaneurysms present more than 1 week after injury. There are now several series of class I-B patients who have been given Pblockers and antihypertensive agents before an elective delayed operation, without free rupture
531
[8, 91. Such pharmacologic aortic wall stress reduction appears to reduce the risk of rupture of the pseudoaneurysm and make it safer to delay operation while other injuries are managed [lo]. Our concepts of the course of unoperated TRA should not be based on autopsy series that are not representative of patients. In patients who reach a hospital alive and not exsanguinated into the pleural cavity TRA can be rationally considered and managed in parallel with other life-threatening injuries. Aortography and aortic repair in unstable patients with critical injuries elsewhere is not justified on the assumption that TRA will invariably be imminently fatal.
References 1. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17: 108.5101. 2. Xabregas AA, Molloy PJ, Feint JA. Traumatic rupture of the thoracic aorta: ten-year experience with follow up. Aust N Z J Surg 1991;61:839-43. 3. Cernaianu AC, Cilley JH Jr, Baldino WA, Spence RK, DelRossi AJ. Determinants of outcome in lesions of the thoracic aorta in patients with multi organ system trauma. Chest 1992;101:331-5. 4. Williams JS, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicular trauma. Ann Thorac Surg 1994;5772WO. 5. Hartford JM, Fayer RL, Shaver TE, et al. Transection of the thoracic aorta: assessment of a trauma system. Am J Surg 1986;151:224-9. 6. Pate JW. Traumatic rupture of the aorta: emergency operation. Ann Thorac Surg 1985;39:531-7. 7. Duhaylongsod FG, Glower DD, Wolfe WG. Acute traumatic aortic aneurysm: the Duke experience from 1970 to 1990. J Vasc Surg 1992;15:33143. 8. Hilgenberg AD, Logan DL, Akins CW, et al. Blunt injuries of the thoracic aorta. Ann Thorac Surg 1992;53:23%9. 9. Lee RB, Stahlman GC, Sharp KW. Treatment priorities in patients with traumatic rupture of the thoracic aorta. Am Surg 1992;58:3743. 10. Walker WA, Pate JW. Medical management of acute traumatic rupture of the aorta. Ann Thorac Surg 1990;5096.!%7.
V
esalius reported a case of traumatic rupture of the aorta (TRA) in 1557, and traumatic aneurysms were resected in the early 1950s. The natural history was not appreciated until 1958, when Parmley and associates [l] reported autopsy findings in 296 cases of TRA-an article that has been referred to in almost every report on the subject since. Successful surgical repair of acute TRA followed the next year. It is important to understand the natural (untreated) history of a disease to make appropriate clinical decisions as well as to form a baseline for comparison of different treatments. Careful autopsy studies form a good basis for delineating these histories. However, when reviewing the natural course, several factors are essential: (1) limitations of the study must be recognized, (2) the study must be properly interpreted and analyzed, and valid “conclusions” must be obtained, (3)the series must represent the same universe of patients to be considered in the group to be compared, and (4) conclusions of the autopsy series must be appropriately applied to the clinical setting. See also page 726.
Most references to the Parmley report mention that 89.7% of the unoperated patients died within 6 hours of injury and less than 9% survived more than 24 hours. This led to the generally accepted clinical concept that immediate diagnosis and aortic repair are mandatory. Serious limitations with the Parmley study are evident when it is related to live patients. It is a study of the autopsy files of the Armed Forces Institute of Pathology, until 1957. (The first autopsy specimens in the Armed Forces Institute of Pathology date from September 1862, at the beginning of the Civil War [Ruth Lee, Armed Forces Institute of Pathology; personal communication, July 19931.) The criteria for selection were only “non-penetrating . . . injury of the aorta” and, except for 2 surgical patients, autopsy within 4 years of injury. There is no denominator; patients who survived without recognition of the injury, those who left the military, and those who were not autopsied are not included. The subjects are primarily young, otherwise healthy, military men. Many mutilated aircraft crash victims are included. More than half of the patients had other multiple, frequently fatal, injuries. The actual relation of the aortic injuries to the deaths is not known. Traumatic rupture of the aorta kills by free rupture into the pleural space with exsanguination. No data on this finding are given, but, instead, “. . . serious trauma usually produces . . . other body injury so extensive that death would be inevitable irrespective of the cardiovascuAddress reprint requests to Dr Pate, 956 Court Ave, Memphis, TN 38163.
0 1994 by The Society of Thoracic Surgeons
lar insult.” Only 45% of the injuries were at the aortic isthmus-the location in more than 90% of clinical cases. There were only 24 victims with aortic isthmus injuries who lived longer than 1 hour after injury (possibly in time to arrive at a hospital). One died within 6 hours of admission, 3 others died within 24 hours, and 18 (75%) lived from 1 day to 4 years. (It appears that some who refer to the article have not read it.) The Armed Forces Institute of Pathology series is quite different from clinical patients in key elements. The “conclusion” of the Parmley study appropriate to clinical series is the observation that only 1 patient (4.2%)with rupture at the isthmus died between 1 and 6 hours of injury, and only 3 (12.5%)additional patients died in less than 24 hours. No cause of death is given for these patients. Our almost panic-stricken rush to the operating room “before the hematoma ruptures and the patient bleeds to death’ leads to operation on unstable patients, high mortality from intraabdominal hemorrhage, head or lung injury, and frequently paraplegia (related to shock or hypoxia in the perioperative period). This concept leads to aortograms being done and patients operated on in hospitals without equipment and personnel to optimally handle such injuries. I believe the unscientific legal climate contributes to these decisions. When paraplegia results (up to 40%of the time), legal action may result; when it is elected to transfer the patient, and he or she dies before repair elsewhere, liability may be claimed because of misinterpretations of Parmley’s report. Many patients have undergone laparotomy, orthopedic, and other procedures before aortic repair, with only a rare instance of rupture of the pseudoaneurysm. For example, Xabregas and colleagues [Z] reported 13 cases of TRA with delays up to 16 days (mean, 3 days) between injury and repair, with no free ruptures. Cernaianu and associates [3] noted that there was no difference in time spent to make the diagnosis of TRA between survivors and nonsurvivors, nor was there a difference in time of arrival in the operating room. In this issue of The Annals, Williams and associates [4] report a 5-year autopsy study that is more current, uniform, and clinically meaningful than the widely quoted Parmley report. They report 90 victims of motor vehicle accidents (from among 530 fatalities) who were found to have TRA-68 (75.5%)at the aortic isthmus. Four patients lived more than 1 and less than 24 hours after injury; 99% were dead in less than 24 hours. However, as in the Parmley report, the cause of death, or whether death was related to the TRA, is unknown. There is an implication that in all 90 cases the TRA . . was a major factor in the fatal outcome,” but no data are given to support this opinion. Massive hemothorax is not mentioned. Most I‘.
Ann Thorac Surg 1994;57:53&1
0003-4975/94/$7.00
EDITORIAL PATE TRAUMATIC RUPTURE OF AORTA
Ann Thorac Surg 1994;57530-1
observers have noted that approximately half of all deaths in patients with TRA are unrelated to the TRA [5, 61. Data on other major injuries reported by Williams and associates allow us to compare their autopsy series with clinical series. The injuries suffered by their patients are obviously different from patients who reach the hospital alive. Lacerations of the heart were found in 34% of their patients; this is almost unheard of in clinical series. Cardiac contusions are found in from 7.8% [6] to 17.9% [7] of clinical series, with a mean of 7.4% [7]. Head injuries were found in 42%of Williams and associates’ series but in only 10% to 28%of the clinical series from Boston [8], Duke [7], and Memphis [6]. First rib and sternal fractures were common in the autopsy series, but very rare in clinical cases of isthmus rupture. Thus, Williams and associates’ patients also represent a different universe from those patients seen in surgical practice. Their data fail to support the myth that patients must be rushed immediately to the operating room before proper evaluation and treatment of other lesions. Hartford and co-workers [5] attempted to find all victims with TRA in the Irving, CA, area in 1980 and 1981, including autopsied victims who did not reach a hospital alive, as well as all patients admitted to the area hospitals. Of their 86 patients, 37 died at the accident scene-about half (20.9%) of exsanguination from the aorta. There were 16 patients evaluated at hospitals; 7 died without aortic repair, only 1 of exsanguination from TRA. Our classification would seem to offer an appropriate framework to allow uniform standards for comparison between groups and more clinically useful conclusions: class I = acute, less than 8 days after injury; A = with free hemorrhage into pleural space, and B = with periaortic hematoma contained in the mediastinum; class I1 = chronic pseudoaneurysms present more than 1 week after injury. There are now several series of class I-B patients who have been given Pblockers and antihypertensive agents before an elective delayed operation, without free rupture
531
[8, 91. Such pharmacologic aortic wall stress reduction appears to reduce the risk of rupture of the pseudoaneurysm and make it safer to delay operation while other injuries are managed [lo]. Our concepts of the course of unoperated TRA should not be based on autopsy series that are not representative of patients. In patients who reach a hospital alive and not exsanguinated into the pleural cavity TRA can be rationally considered and managed in parallel with other life-threatening injuries. Aortography and aortic repair in unstable patients with critical injuries elsewhere is not justified on the assumption that TRA will invariably be imminently fatal.
References 1. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17: 108.5101. 2. Xabregas AA, Molloy PJ, Feint JA. Traumatic rupture of the thoracic aorta: ten-year experience with follow up. Aust N Z J Surg 1991;61:839-43. 3. Cernaianu AC, Cilley JH Jr, Baldino WA, Spence RK, DelRossi AJ. Determinants of outcome in lesions of the thoracic aorta in patients with multi organ system trauma. Chest 1992;101:331-5. 4. Williams JS, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicular trauma. Ann Thorac Surg 1994;5772WO. 5. Hartford JM, Fayer RL, Shaver TE, et al. Transection of the thoracic aorta: assessment of a trauma system. Am J Surg 1986;151:224-9. 6. Pate JW. Traumatic rupture of the aorta: emergency operation. Ann Thorac Surg 1985;39:531-7. 7. Duhaylongsod FG, Glower DD, Wolfe WG. Acute traumatic aortic aneurysm: the Duke experience from 1970 to 1990. J Vasc Surg 1992;15:33143. 8. Hilgenberg AD, Logan DL, Akins CW, et al. Blunt injuries of the thoracic aorta. Ann Thorac Surg 1992;53:23%9. 9. Lee RB, Stahlman GC, Sharp KW. Treatment priorities in patients with traumatic rupture of the thoracic aorta. Am Surg 1992;58:3743. 10. Walker WA, Pate JW. Medical management of acute traumatic rupture of the aorta. Ann Thorac Surg 1990;5096.!%7.