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Management of injuries to the suprarenal aorta
Managementof Injuries to the Suprarenal Aorta Kevin D. Accola, MD, David V. Feliciano, MD, Kenneth L. Mattox, MD, Carmel G. Bitondo, PA, Jon M. Burch, MD, Arthur C. BeaH, Jr., MD, and George L. Jordan, Jr., MD, Houston, Texas
The majority of injuries to the suprarenal aorta are secondary to gunshot wounds. Blunt injury to this area is a very rare occurrence [1-I 71.Typically, penetrating injuries to the suprarenal aorta are accompanied by multiple associated intraabdominal visceral and vascular injuries. Because of this, as well as difficulties in exposure and vascular control, an injury to the suprarenal aorta continues to be one of the most difficult problems faced by surgeons dealing with abdominal trauma. This is a retrospective review of all patients who sustained penetrating injuries to the suprarenal aorta over a 12 year period at the Ben Taub General Hospital, a level I trauma center affiliated with the Baylor College of Medicine in Houston, Texas. Material and Methods The records of all patients with injuries to the suprarenal aorta who were admitted between January 1974 and December 1986 were reviewed. Resuscitation and evaluation of patients with intraabdominal vascular injuries during this interval varied somewhat. Only methods used in recent years are described herein. Hypotensive patients with penetrating abdominal wounds underwent operation after resuscitation with warm crystalloid solutions, and in recent years, with typespecific packed red blood cells. Intravenous pyelography was performed in stable patients, and perioperative antibiotics were given to patients with perforation of the gastrointestinal tract under a rigidly controlled protocol [18]. In moribund patients with massive abdominal distention secondary to a hemoperitoneum, either emergency center or operating room thoracotomy with crossclamping of the descending thoracic aorta was occasionally necessary to prevent or treat cardiac arrest preoperatively or after release of peritoneal tamponade [19,20].
After transfer to the operating room, the anterior and lateral chest, abdomen, and thighs were prepared and draped. A midline incision was used to enter the abdomen. If active bleeding from the supramesocolic area or From the Cora and Webb Madtng Department of Surgery, Baylor College of Medicine and Tha Ben Taub General Hospital, Houston, Texas. Requests for reprints should be addressed to David V. Fellciano, MD, Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030. Presented at the 39th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26-29, 1987.
Volume 154. December 1987
base of the mesentery was present, manual compression was applied. In patients in whom exsanguinating hemorrhage could not be controlled by pressure, direct vascular control by dissection through the lesser omentum, lesser sac, or the base of the mesentery was performed. In patients in whom hemorrhage could be controlled by pressure and in those with a large pulsatile supramesocolic or mesenteric hematoma, a lateral approach with medial rotation of all intraabdominal viscera on the left side was performed in order to obtain proximal aortic control (Figures 1 and 2). Data reviewed in this study was obtained from individual patient charts and included age, sex, mechanism of injury, need for resuscitative thoracotomy, approach to and repair of the suprarenal aorta, associated injuries, blood replacement, postoperative complications, and death. Results
From January 1974 through December 1986,79 patients (69 men and 10 women) with penetrating injuries to the suprarenal aorta were treated. Gunshot wounds were the mechanism of injury in 66 patients (83 percent), whereas stab wounds and shotgun wounds occurred in 10 patients (13 percent) and three patients (4 percent), respectively. Five patients (6 percent) who presented to the emergency center in a moribund condition could not be resuscitated despite an emergency center thoracotomy, and they died before operation could be performed. Injuries to the suprarenal aorta were documented at autopsy in these patients. A systolic blood pressure of less than 90 mm Hg was recorded in 70 percent of the patients at the time of admission to the emergency center, and 88 percent of this group subsequently died. Twenty patients (25 percent), including the 5 aforementioned patients, required an emergency center thoracotomy for resuscitation and all died. Fourteen patients required an operating room thoracotomy and 3 (21 percent) survived. As 5 patients did not undergo laparotomy, the results reported encompass the remaining 74 patients. The operative approach was medial rotation in 61 patients (82 percent) and 19 (31 percent) survived, whereas 3 patients (4 percent) had a direct approach to the suprarenal aorta and 1(33 percent)
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Accola et al
Superior mesenteric a.
,
Left re
Figure 2. Exposure of the suprarenal aorta after completion of medial mobillxatlon.
Figure 1. For wounds of the suprarenal aorta, exposure is obtaitted by medlal moblllzatlon of all /ntraabdom/na/ VlSCeri3 on the letl side.
TABLE I
Repalr Versus Outcome Survived n %
Repair
Number
Aortorrhaphy Graft Patch End-to-end None
39 19 7 7 2
12 5 2 2
Total
74
21
Died n
%
..
27 14 5 5 2
69 74 71 71 100
28
53
72
31 26 29 29
survived. The remaining 10 patients had either a thoracoabdominal approach (1 patient) or the approach was not well described in the operative report (9 patients). One of the 10 patients survived (10 percent). Lateral aortorrhaphy was performed in 39 patients (53 percent) and 12 (31 percent) survived. Graft insertion was required in 19 patients (17 dacron and 2 polytetrafluoroethylene, 26 percent) and 5 survived (26 percent) (Table I). Patch aortoplasty or resection with an end-to-end anastomosis was performed in seven patients each (9 percent), and two patients (29 percent) survived in each group. The remaining two patients (3 percent) died in the operating room before repair of the suprarenal aorta could be completed. There were no postoperative prosthetic infections in the seven surviving patients who had synthetic material inserted as a tube graft (five patients) or aortic patch (two patients).
614
Associated injuries were present in 63 patients for whom complete data were available and averaged 2.9 injuries per patient. The most common associated injuries were to intraabdominal vascular structures in 40 patients (63 percent), to the liver in 32 patients (51 percent), to the spleen in 20 patients (32 percent), to the stomach in 19 patients (30 percent), and to the small bowel in 18 patients (29 percent). Nine of the 40 patients with associated intraabdominal vascular injuries had injury to the inferior vena cava and all died. Ten of the 40 patients with associated intraabdominal vascular injuries survived (25 percent). Twenty-one of 74 patients who underwent laparotomy survived (28 percent). A total of 21 of the 79 patients with injuries to the suprarenal aorta survived (27 percent). By eliminating the 20 patients who presented in a moribund condition and required emergency center thoracotomy, the survival rate increased to 36 percent (21 of 59 patients). Survival rates were 26 percent (17 of 66 patients), 30 percent (3 of 10 patients), and 33 percent (1 of 3 patients) for patients with gunshot wounds, stab wounds, and shotgun wounds, respectively. Of interest is the fact that the survival rate was 43 percent (6 patients) in the 14 patients in whom the surgeon accurately described an injury to the diaphragmatic portion of the suprarenal aorta. The cause of death was hemorrhagic shock and transfusion-associated coagulopathy in 51 of 58 patients (88 percent), all of whom died within 24 hours of injury. The average blood ieplacement in the patients who died was 23.8 units per patient, and surviving patients had an average blood replacement of 16.1 units per patient. The remaining seven patients (12 percent) died in the late postoperative period from sepsis and multiple organ failure (five patients), respiratory failure (one patient), and midgut necrosis (one patient).
The American Journal of Surgery
SuprarenalAorta Injuryand Menagement
Among the 21 of 74 patients who survived (28 percent), intraabdominal sepsis or a wound infection occurred in 11, whereas respiratory failure, renal failure, and postoperative hemorrhage occurred in 7,6, and 3 patients, respectively. There was also one patient with a pancreatic fistula, one with a perforated cecum, and one with an episode of deep venous thrombosis. cotnlnents In previous years, the basic principles regarding management of aortic injuries were largely based on military experience [21-261. More recently, multiple civilian reports have appeared in the literature [16,27-321. All civilian clinical reports must be analyzed in light of the postmortem study of 456 patients reported by Parmley el al [24], in which they noted that approximately 15 percent of patients with penetrating aortic trauma survived the initial injury and 85 percent died [24]. In survivors who do not have immediate treatment, the formation of pseudoaneurysms and arteriovenous fistulas may occur [24J8,33]. On exploration, patients with injuries to the suprarenal aorta most commonly have exsanguinating hemorrhage, which should be directly controlled with digital pressure, an aortic compression device, or a pulsatile supramesocolic midline hematoma. In 82 percent of the patients in the present study, proximal control was obtained by medial rotation of all intraabdominal viscera on the left side. This maneuver is a modification of that previously described by DeBakey et al [34] in 1956 which was subsequently utilized by others [34-361. In 1974, Mattox et al [16] reported a modified technique in which the plane of dissection is posterior to the left kidney, which is an area that is often separate from the supramesocolic hematoma. Hence, the left kidney is mobilized in addition to the left side of the colon, tail of the pancreas, and spleen when approaching the suprarenal aorta [16]. This has remained our preferred approach for pulsatile supramesocolic midline hematomas and for injuries of the suprarenal aorta, celiac axis, or proximal superior mesenteric artery. To improve exposure for the most proximal wounds of the suprarenal aorta, the left crus of the diaphragm may be incised and a radial left phrenotomy performed. Some investigators have advocated the use of a simultaneous left anterolateral thoracotomy incision to obtain proximal control of the wounded suprarenal aorta [29,32]. In this series, preliminary or concurrent thoracotomies were used for resuscitation rather than exposure. There are two factors which, if present upon opening the abdomen and exposing the injury to the suprarenal aorta, may have a significant effect on survival. The first of these is the presence of a con-
Volume 154, December 1987
tamed retroperitoneal hematoma around the aortic injury rather than hemorrhage into the peritoneal cavity. Millikan and Moore [37’Jnoted a 91 percent survival rate in patients with abdominal vascular injuries who were stable on admission because of the tamponade effect of the retroperitoneum. A second and related factor is the increased tamponade effect from dense periaortic neural and lymphatic tissues and the overlying diaphragmatic crura which occurs when the injury to the suprarenal aorta is at the hiatus of the diaphragm [29,31,32,38]. In series in which injuries were classified as occurring in the diaphragmatic portion of the suprarenal aorta (crura to celiac axis), 7 of 14 patients survived [29,31,32]. This is in sharp contrast to what occurred in patients with injuries to the visceral portion (celiac axis to renal arteries) as only 4 of 15 of these patients survived (27 percent) [29,31,32]. In the present study, the 42 percent survival rate for diaphragmatic injuries was similar to that reported elsewhere and confirms the tamponade effect of the periaortic tissues at the hiatus. The majority of injuries to the suprarenal aorta (53 percent) were amenable to primary aortorrhaphy in this series as they were primarily due to low-velocity civilian handgun injuries [39]. It is of interest, however, that over a third of the patients in the present study were treated with insertion of a prosthetic graft or patch. In a recent review of the literature on aortic injuries by Feliciano [40], only one reported infection in a suprarenal aortic graft has occurred after trauma, despite the presence of gastrointestinal contamination in many of these patients. Practically speaking, if total replacement of the suprarenal aorta is necessary, the 12 to 16 mm size of the suprarenal aorta precludes replacement with an autogenous saphenous vein graft, therefore, we do not hesitate to use prosthetic graft material when necessary, which is a common practice in other centers [32,37,41,42]. Eighty-nine percent of the deaths in the review by Kashuk et al [31] of 123 patients with major abdominal vascular injuries and 88 percent of the deaths in the present study were due to continued hemorrhage, half of which occurred after control of major bleeding sites [31]. It has been shown both experimentally and clinically that a refractory coagulopathy occurs in patients with a core temperature of less than 31.2”C and an arterial pH of less than 7.21 [31,43]. In order to avoid or limit this problem, most surgeons advocate the infusion of warm crystalloids mixed with blood or a variety of blood warmers, warming blankets, heating cascades on anesthesia machines, and the infusion of bicarbonate for hypothermia and an arterial pH below 7.2. With component blood banking now established in most centers, the infusion of packed red blood cells must be accompanied by the infusion of fresh frozen plasma
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TABLE
II
Survival Rates Survived
Reference Lim [29] Mattox et al [ 161 Kashuk et al [ 3 7] Millikan & Moore [ 371 Present study Total
n
%
17 28 9 15 74
5 10 4 7 21
29 38 44 47 28
143
47
33
Number
(ratio of 4 packed red blood cells to 1 fresh frozen plasma). The need for infusion of platelet packs is less clear at this time, but they continue to be administered in most centers (ratio of 1 packed red blood cell to 6 platelet packs) [44]. In the report by Kashuk et al [31], patients who died had received 1 unit of fresh frozen plasma for each 8 units of packed red blood cells transfused, whereas survivors more commonly received the fresh frozen plasma in the usually recommended ratio [31]. Injuries to the visceral arteries are often associated with injury to the suprarenal aorta. The celiac axis may generally be safely ligated in young trauma patients if simple repair cannot be performed; however, repair or reanastomosis of the superior mesenteric artery should be carried out [45]. If associated vascular injuries are present, the outcome for patients with injuries to the suprarenal aorta is usually much worse. In the review by Kashuk et al [31] of 123 patients with major abdominal vascular injuries, 36 percent had more than one vascular injury and only 39 percent survived. In contrast, 76 percent survived when only a single vascular injury was present. These results are comparable to those in the present study, in which only 25 percent of patients with associated intraabdominal vascular injuries survived. There has been no significant change in the survival rate of patients with injuries to the suprarenal aorta in the last 20 years, despite improvements in emergency medical services, prehospital transport, and methods of resuscitation [16,29-321 (Table II). Although data are limited, the use of larger caliber guns may be increasing the magnitude and number of intraabdominal injuries and precluding any marked improvements in survival [46]. Summary During a 12 year period, 79 patients with a diagnosis of a penetrating wound to the suprarenal aorta were treated. An analysis of the records of these patients has led to the following conclusions: With a midline penetrating wound and presence of a supramesocolic hematoma or hemorrhage, injury to the suprarenal aorta should be suspected. If a midline supramesocolic hematoma is present or if hemor-
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rhage can be controlled by direct pressure, a lateral approach with medial mobilization of the intraabdominal viscera on the left side allows rapid vascular control. Although lateral aortorrhaphy is preferred, patch grafting, an end-to-end anastomosis, or insertion of a prosthetic graft was required in 46 percent of the patients who underwent repair. As in all previous series, the insertion of synthetic patches or prostheses was not complicated by infection. The average survival rate for injuries to the suprarenal aorta in series reported since 1974 is 33 percent. Finally, the continuing problem of irreversible shock suggests the need for rapid transport from the field to the hospital for victims of penetrating wounds to the abdomen. Acknowledgment: We thank Mary LeJeune, Carolyn Accola, and Jim Schmidt from the Department of Medical Illustration, Baylor College of Medicine for their technical assistance. References 1. Painter MW, Britt LG. Distal bullet embolism after gunshot wound to the chest: a case report. Am Surg 197 1; 37: 1068. 2. Perdue GD Jr, Smith RB Ill. Intra-abdominal vascular injury. Surgery 1968; 64: 562-8. 3. Allen TW, Reul GJ, Morton JR, Beak AC Jr. Surgical management of aortic trauma. J Trauma 1972; 12: 862-8. 4. Myles RA, Yellin AE. Traumatic injuries of the abdominal aorta. Am J Surg 1979; 138: 273-7. 5. Stone HH, Oxford WM. Austin JT. Penetrating wounds of the abdominal aorta. South Med J 1973; 66: 1351-5. 6. Sirinek KR. Gaskill HV Ill. Root HD. Levine BA. Truncal vascular injury-factors influencing survival. J Trauma 1983; 23: 372-7. 7. Stiles QR, Cohlmia GS, Smith JH, Dunn JT, Yellin AE. Management of injuries of the thoracic and abdominal aorta. Am J Surg 1985; 150: 132-40. 8. Lilienthal H. Thoracic surgery: the surgical treatment of thoracic disease. Philadelphia: WB Saunders, 1926: 489. 9. Wildegans H. Verletzungen der aorta. Dtsch Med Wochenschr 1926; 52: 1810-4. 10. Blalock A. Successful suture of a wound of the ascending aorta. JAMA 1934; 103: 1617-8. 11. Elkin DC. Wounds of the heart. Ann Surg 1944; 120: 8 17-2 1. 12. Elkin DC. The diagnosis and treatment of cardiac trauma. Ann Surg 1941; 114: 169-85. 13. Dubinskiy MB. Suture of the abdominal aorta. Khirurgiya 1944; 4: 71. 14. Jensen AR. Bullet wound of the abdominal aorta with survival. J Fla Med Assoc 1963; 49: 656-7. 15. Love CR, Evans SS. Gunshot wound of the abdominal aorta and anoxic cardiac arrest: report of a survival. Ann Surg 1963; 49: 131-7. 16. Mattox KL, McCollum WB, Beall AC Jr, Jordan GL Jr, DeBakey ME. Management of penetrating injuries of the suprarenal aorta. J Trauma 1975; 15: 808-15. 17. Lassonde J, Laurendeau F. Blunt injury of the abdominal aorta. Ann Surg 1981; 194: 745-8. 18. Feliciano DV, Gentry LO, Bitondo CG, et al. Single agent cephalosporin prophylaxis for penetrating abdominal trauma. Results and comment on the emergence of the enterococcus. Am J Surg 1986; 152: 674-81. 19. Ledgerwood AM, Kazmers M, Lucas CE. The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma 1976: 16: 610-5.
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Suprarenal Aorta Injury and h4magement
20. Feliciano DV, Bitondo CG, Cruse PA, &at. Liberal use of emergency center thoracotomy. Am J Surg 1988; 152: 854-9. 21. Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 1970; lo: 359-88. 22. Hughes CW. Arterial repair during the Korean War. Ann Surg 1958; 147: 55-81. 23. DeBakey ME, Sirneone FA. Battle injuries of the arteries in World War II: an analysis of 2,741 cases. Ann Surg 1948; 123: 534-79. 24. Parmley LF, Mattingly TW, Manion WC. Penetrating wounds of the heart and aorta. Circulation 1958; 17: 953-73. 25. Billy LJ, Amato JJ, Rich NM. Aortic injuries in Vietnam. Surgery 1971; 70: 385-91. 28. Rich NM, Hughes CW. The fate of prosthetic material used to repair vascular injuries in contaminated wounds. J Trauma 1972; 12: 459-87. 27. Beail AC Jr. Penetrating wounds of the aorta. Am J Surg 1960; 99: 770-4. 28. Drapanas T, Hewitt RL, Weichert RF Ill, Smith AD. Civilian vascular injuries: a critical appraisal of three decades of management. Ann Surg 1970; 172: 351-60. 29. Lim RC Jr, Trunkey DD, Blaisdell FW. Acute abdominal aortic injury. An analysis of operative and postoperative management. Arch Surg 1974; 109: 706-l 1. 30. Buchness MP, LoGerfo FW, Mason GR. Gunshot wounds of the suprarenal abdominal aorta. Am Surg 1978; 42: 1-7. 3 1. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma: a unified approach. J Trauma 1982; 22: 672-9. 32. Brinton M, Miller SE, Lim RC Jr, Trunkey DD. Acute abdominal aortic injuries. J Trauma 1982; 22: 481-6. 33. Kollmeyer KR, Hunt JL. Aortoazygous fistula from gunshot wound to the suprarenal abdominal aorta. J Trauma 1985; 25: 257-9. 34. DeBakey ME, Creech 0 Jr, Morris GC Jr. Aneurysm of thorace-abdominal aorta involving the celiac, superior mesenteric, and renal arteries. Report of four cases treated by resection and homograft replacement. Ann Surg 1958; 144: 549-73. 35. Buscaglia LC, Blaisdell FW, Lim RC Jr. Penetrating abdominal vascular injuries. Arch Surg 1969; 99: 764-9. 36. Elklns RC, DeMeester TR, Brawley RK. Surgical exposure of the upper abdominal aorta and its branches. Surgery 197 1; 70: 622-7. 37. Millikan JS, Moore EE. Critical factors in determining mortality from abdominal aortic trauma. Surg Gynecol Obstet 1985; 160: 313-6. 38. Richards AJ Jr, Lamis PA Jr, Rogers JT Jr, Brandham GB. Laceration of abdominal aorta and study of intact abdominal wall as tamponade: report of survival and literature review. Ann Surg 1966; 184: 321-4. 39. Moore HG Jr, Nyhus LM, Kamar EA, Harkins HN. Gunshot wounds of major arteries. An experimental study with clinical implications. Surg Gynecol Obstet 1954; 96: 129-47. 40. Feliciano DV, Burch JM, Graham JM. Abdominal vascular injury. In: Mattox KL, Moore EE. Feliciano DV, eds. Trauma. New York: Appleton-Century-Crofts, 1987: 519-36. 4 1. Martin TD, Mattox KL, Feliciano DV. Prosthetic grafts in vascular trauma: a controversy. Compr Ther 1985; 11: 41-5. 42. Fromm SH, Carrasquilla C, Lucas C. The management of gunshot wounds of the aorta. Arch Surg 1970; 101: 38890. 43. Dunn EL, Moore EE, Breslich DL, Galloway WB. Acidosisinduced coagulopathy. Surg Forum 1979; 30: 471-2. 44. Reed RE Ill, Ciavarella D, Heimbach DM, et al. Prophylactic platelet administration during massive transfusion. A prospective, randomized, double-blind clinical study. Ann Surg 1986; 203: 40-6. 45. Accola KD, Feliciano DV, Mattox KL. Burch JM, Beall AC Jr, Jordan GL Jr. Management of injuries to the superior mesenteric artery. J Trauma 1988; 26: 313-9.
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48, Rapaport A, Felioiano DV, Mattox KL. An epidemiologic profile of urban trauma in America-Houston style. Texas Med 1982; 78: 44-50.
Discussion Ernest E. Moore (Denver, CO): Dr. Accola, you stated that gastrointestinal contamination does not preclude a prosthetic graft, which was an important observation made by Dr. Charles Lucas nearly two decades ago. Indeed, nearly a third of your patients required synthetic material to reconstruct the aorta. Could you provide a more complete analysis of patient survival? In our experience, the three most important prognostic factors are whether the injury is contained in the retroperitoneum; the location of injury in the visceral or diaphragmatic segment; and whether there are concomitant abdominal vascular injuries. You also observed that half the deaths attributed to hemorrhage were due to coagulopathy and have underscored the importance of preventing hypothermia and profound acidosis, stressing the need for more rapid prehospital transport. I would like your advice on operative maneuvers to reduce the period of shock. Specifically, do you employ preliminary left thoracotomy with aortic cross-clamping prior to entering the abdomen or the more recently popularized technique of transfemoral balloon occlusion prior to laparotomy? In an effort to reduce cross-clamp time to less than 30 minutes, we now routinely use the intraluminal dacron graft for suprarenal aortic injuries as well as descending thoracic aortic tears. What is your experience with this prosthesis? John A. Weigelt (Dallas, TX): Dr. Accola, please clarify this business about prosthetic material. I think it goes against general surgical principles that we all have been taught, and I think before we have a major institution reporting that dacron is safe to put in these patients with major contamination, we had better have a little more explanation from you. In particular, what were the associated injuries in the seven patients who had prosthetic grafts? Ronald C. Elkins (Oklahoma City, OK): There is an alternative approach to the medial rotation maneuver which allows exposure of this part of the aorta without delving into Gerota’s fascia and mobilizing the left kidney. It is one that was described from the group at Johns Hopkins. I was a coauthor on that study in 1972. The important aspect that I think comes from this is that surgeons do need to know how to approach that part of the aorta, and probably one thing that most people need to recognize is that simply by dividing the crus of the diaphragm, one can expose an additional 3 cm or more of the aorta, and that allows cross-clamping before the visceral vessels are dealt with. Dr. Accola, I agree that, in most patients, a dacron graft can be utilized as this graft can be well covered, and I do think that there is a role for the use of the prosthe placed inside the aorta.
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Ronald Jones (Dallas, TX): Dr. Accola, you had several emergency room thoracotomies. Can you describe your facilities at Ben Taub for emergency room thoracotomies and what your survival rate was in that group?
Kevin D. Accola (closing): Dr. Moore, there was a change in numbers in the manuscript because more data became available after the abstract was submitted. As in your experience, those patients with a more proximal or diaphragmatic aortic injury often presented with a contained supramesocolic hematoma and clearly had a higher survival rate. The most common associated vascular injury was to the inferior vena cava. This occurred in nine patients, all of whom died. We have periodically used the
616
aortic balloon occluder for abdominal vascular trauma, although not in the present study. We have not used the intraaortic dacron prosthesis to date, but it is certainly a technically appealing option. Dr. Weigelt, in spite of gastrointestinal contamination, we continue to use prosthetic materials in intraabdominal vascular trauma. A comprehensive review of every study on abdominal aortic injuries in the surgical literature since 1970, including this one, reveals only one prosthetic graft infection among survivors [29]. Dr. Jones, all 20 patients who underwent an emergency center thoracotomy died. Five died in the emergency center and 15 in the operating room after attempted repair. Of the 14 patients who underwent an anterolateral thoracotomy in the operating room, 3 survived.
The American Journal of Surgery
The majority of injuries to the suprarenal aorta are secondary to gunshot wounds. Blunt injury to this area is a very rare occurrence [1-I 71.Typically, penetrating injuries to the suprarenal aorta are accompanied by multiple associated intraabdominal visceral and vascular injuries. Because of this, as well as difficulties in exposure and vascular control, an injury to the suprarenal aorta continues to be one of the most difficult problems faced by surgeons dealing with abdominal trauma. This is a retrospective review of all patients who sustained penetrating injuries to the suprarenal aorta over a 12 year period at the Ben Taub General Hospital, a level I trauma center affiliated with the Baylor College of Medicine in Houston, Texas. Material and Methods The records of all patients with injuries to the suprarenal aorta who were admitted between January 1974 and December 1986 were reviewed. Resuscitation and evaluation of patients with intraabdominal vascular injuries during this interval varied somewhat. Only methods used in recent years are described herein. Hypotensive patients with penetrating abdominal wounds underwent operation after resuscitation with warm crystalloid solutions, and in recent years, with typespecific packed red blood cells. Intravenous pyelography was performed in stable patients, and perioperative antibiotics were given to patients with perforation of the gastrointestinal tract under a rigidly controlled protocol [18]. In moribund patients with massive abdominal distention secondary to a hemoperitoneum, either emergency center or operating room thoracotomy with crossclamping of the descending thoracic aorta was occasionally necessary to prevent or treat cardiac arrest preoperatively or after release of peritoneal tamponade [19,20].
After transfer to the operating room, the anterior and lateral chest, abdomen, and thighs were prepared and draped. A midline incision was used to enter the abdomen. If active bleeding from the supramesocolic area or From the Cora and Webb Madtng Department of Surgery, Baylor College of Medicine and Tha Ben Taub General Hospital, Houston, Texas. Requests for reprints should be addressed to David V. Fellciano, MD, Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030. Presented at the 39th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26-29, 1987.
Volume 154. December 1987
base of the mesentery was present, manual compression was applied. In patients in whom exsanguinating hemorrhage could not be controlled by pressure, direct vascular control by dissection through the lesser omentum, lesser sac, or the base of the mesentery was performed. In patients in whom hemorrhage could be controlled by pressure and in those with a large pulsatile supramesocolic or mesenteric hematoma, a lateral approach with medial rotation of all intraabdominal viscera on the left side was performed in order to obtain proximal aortic control (Figures 1 and 2). Data reviewed in this study was obtained from individual patient charts and included age, sex, mechanism of injury, need for resuscitative thoracotomy, approach to and repair of the suprarenal aorta, associated injuries, blood replacement, postoperative complications, and death. Results
From January 1974 through December 1986,79 patients (69 men and 10 women) with penetrating injuries to the suprarenal aorta were treated. Gunshot wounds were the mechanism of injury in 66 patients (83 percent), whereas stab wounds and shotgun wounds occurred in 10 patients (13 percent) and three patients (4 percent), respectively. Five patients (6 percent) who presented to the emergency center in a moribund condition could not be resuscitated despite an emergency center thoracotomy, and they died before operation could be performed. Injuries to the suprarenal aorta were documented at autopsy in these patients. A systolic blood pressure of less than 90 mm Hg was recorded in 70 percent of the patients at the time of admission to the emergency center, and 88 percent of this group subsequently died. Twenty patients (25 percent), including the 5 aforementioned patients, required an emergency center thoracotomy for resuscitation and all died. Fourteen patients required an operating room thoracotomy and 3 (21 percent) survived. As 5 patients did not undergo laparotomy, the results reported encompass the remaining 74 patients. The operative approach was medial rotation in 61 patients (82 percent) and 19 (31 percent) survived, whereas 3 patients (4 percent) had a direct approach to the suprarenal aorta and 1(33 percent)
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Accola et al
Superior mesenteric a.
,
Left re
Figure 2. Exposure of the suprarenal aorta after completion of medial mobillxatlon.
Figure 1. For wounds of the suprarenal aorta, exposure is obtaitted by medlal moblllzatlon of all /ntraabdom/na/ VlSCeri3 on the letl side.
TABLE I
Repalr Versus Outcome Survived n %
Repair
Number
Aortorrhaphy Graft Patch End-to-end None
39 19 7 7 2
12 5 2 2
Total
74
21
Died n
%
..
27 14 5 5 2
69 74 71 71 100
28
53
72
31 26 29 29
survived. The remaining 10 patients had either a thoracoabdominal approach (1 patient) or the approach was not well described in the operative report (9 patients). One of the 10 patients survived (10 percent). Lateral aortorrhaphy was performed in 39 patients (53 percent) and 12 (31 percent) survived. Graft insertion was required in 19 patients (17 dacron and 2 polytetrafluoroethylene, 26 percent) and 5 survived (26 percent) (Table I). Patch aortoplasty or resection with an end-to-end anastomosis was performed in seven patients each (9 percent), and two patients (29 percent) survived in each group. The remaining two patients (3 percent) died in the operating room before repair of the suprarenal aorta could be completed. There were no postoperative prosthetic infections in the seven surviving patients who had synthetic material inserted as a tube graft (five patients) or aortic patch (two patients).
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Associated injuries were present in 63 patients for whom complete data were available and averaged 2.9 injuries per patient. The most common associated injuries were to intraabdominal vascular structures in 40 patients (63 percent), to the liver in 32 patients (51 percent), to the spleen in 20 patients (32 percent), to the stomach in 19 patients (30 percent), and to the small bowel in 18 patients (29 percent). Nine of the 40 patients with associated intraabdominal vascular injuries had injury to the inferior vena cava and all died. Ten of the 40 patients with associated intraabdominal vascular injuries survived (25 percent). Twenty-one of 74 patients who underwent laparotomy survived (28 percent). A total of 21 of the 79 patients with injuries to the suprarenal aorta survived (27 percent). By eliminating the 20 patients who presented in a moribund condition and required emergency center thoracotomy, the survival rate increased to 36 percent (21 of 59 patients). Survival rates were 26 percent (17 of 66 patients), 30 percent (3 of 10 patients), and 33 percent (1 of 3 patients) for patients with gunshot wounds, stab wounds, and shotgun wounds, respectively. Of interest is the fact that the survival rate was 43 percent (6 patients) in the 14 patients in whom the surgeon accurately described an injury to the diaphragmatic portion of the suprarenal aorta. The cause of death was hemorrhagic shock and transfusion-associated coagulopathy in 51 of 58 patients (88 percent), all of whom died within 24 hours of injury. The average blood ieplacement in the patients who died was 23.8 units per patient, and surviving patients had an average blood replacement of 16.1 units per patient. The remaining seven patients (12 percent) died in the late postoperative period from sepsis and multiple organ failure (five patients), respiratory failure (one patient), and midgut necrosis (one patient).
The American Journal of Surgery
SuprarenalAorta Injuryand Menagement
Among the 21 of 74 patients who survived (28 percent), intraabdominal sepsis or a wound infection occurred in 11, whereas respiratory failure, renal failure, and postoperative hemorrhage occurred in 7,6, and 3 patients, respectively. There was also one patient with a pancreatic fistula, one with a perforated cecum, and one with an episode of deep venous thrombosis. cotnlnents In previous years, the basic principles regarding management of aortic injuries were largely based on military experience [21-261. More recently, multiple civilian reports have appeared in the literature [16,27-321. All civilian clinical reports must be analyzed in light of the postmortem study of 456 patients reported by Parmley el al [24], in which they noted that approximately 15 percent of patients with penetrating aortic trauma survived the initial injury and 85 percent died [24]. In survivors who do not have immediate treatment, the formation of pseudoaneurysms and arteriovenous fistulas may occur [24J8,33]. On exploration, patients with injuries to the suprarenal aorta most commonly have exsanguinating hemorrhage, which should be directly controlled with digital pressure, an aortic compression device, or a pulsatile supramesocolic midline hematoma. In 82 percent of the patients in the present study, proximal control was obtained by medial rotation of all intraabdominal viscera on the left side. This maneuver is a modification of that previously described by DeBakey et al [34] in 1956 which was subsequently utilized by others [34-361. In 1974, Mattox et al [16] reported a modified technique in which the plane of dissection is posterior to the left kidney, which is an area that is often separate from the supramesocolic hematoma. Hence, the left kidney is mobilized in addition to the left side of the colon, tail of the pancreas, and spleen when approaching the suprarenal aorta [16]. This has remained our preferred approach for pulsatile supramesocolic midline hematomas and for injuries of the suprarenal aorta, celiac axis, or proximal superior mesenteric artery. To improve exposure for the most proximal wounds of the suprarenal aorta, the left crus of the diaphragm may be incised and a radial left phrenotomy performed. Some investigators have advocated the use of a simultaneous left anterolateral thoracotomy incision to obtain proximal control of the wounded suprarenal aorta [29,32]. In this series, preliminary or concurrent thoracotomies were used for resuscitation rather than exposure. There are two factors which, if present upon opening the abdomen and exposing the injury to the suprarenal aorta, may have a significant effect on survival. The first of these is the presence of a con-
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tamed retroperitoneal hematoma around the aortic injury rather than hemorrhage into the peritoneal cavity. Millikan and Moore [37’Jnoted a 91 percent survival rate in patients with abdominal vascular injuries who were stable on admission because of the tamponade effect of the retroperitoneum. A second and related factor is the increased tamponade effect from dense periaortic neural and lymphatic tissues and the overlying diaphragmatic crura which occurs when the injury to the suprarenal aorta is at the hiatus of the diaphragm [29,31,32,38]. In series in which injuries were classified as occurring in the diaphragmatic portion of the suprarenal aorta (crura to celiac axis), 7 of 14 patients survived [29,31,32]. This is in sharp contrast to what occurred in patients with injuries to the visceral portion (celiac axis to renal arteries) as only 4 of 15 of these patients survived (27 percent) [29,31,32]. In the present study, the 42 percent survival rate for diaphragmatic injuries was similar to that reported elsewhere and confirms the tamponade effect of the periaortic tissues at the hiatus. The majority of injuries to the suprarenal aorta (53 percent) were amenable to primary aortorrhaphy in this series as they were primarily due to low-velocity civilian handgun injuries [39]. It is of interest, however, that over a third of the patients in the present study were treated with insertion of a prosthetic graft or patch. In a recent review of the literature on aortic injuries by Feliciano [40], only one reported infection in a suprarenal aortic graft has occurred after trauma, despite the presence of gastrointestinal contamination in many of these patients. Practically speaking, if total replacement of the suprarenal aorta is necessary, the 12 to 16 mm size of the suprarenal aorta precludes replacement with an autogenous saphenous vein graft, therefore, we do not hesitate to use prosthetic graft material when necessary, which is a common practice in other centers [32,37,41,42]. Eighty-nine percent of the deaths in the review by Kashuk et al [31] of 123 patients with major abdominal vascular injuries and 88 percent of the deaths in the present study were due to continued hemorrhage, half of which occurred after control of major bleeding sites [31]. It has been shown both experimentally and clinically that a refractory coagulopathy occurs in patients with a core temperature of less than 31.2”C and an arterial pH of less than 7.21 [31,43]. In order to avoid or limit this problem, most surgeons advocate the infusion of warm crystalloids mixed with blood or a variety of blood warmers, warming blankets, heating cascades on anesthesia machines, and the infusion of bicarbonate for hypothermia and an arterial pH below 7.2. With component blood banking now established in most centers, the infusion of packed red blood cells must be accompanied by the infusion of fresh frozen plasma
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TABLE
II
Survival Rates Survived
Reference Lim [29] Mattox et al [ 161 Kashuk et al [ 3 7] Millikan & Moore [ 371 Present study Total
n
%
17 28 9 15 74
5 10 4 7 21
29 38 44 47 28
143
47
33
Number
(ratio of 4 packed red blood cells to 1 fresh frozen plasma). The need for infusion of platelet packs is less clear at this time, but they continue to be administered in most centers (ratio of 1 packed red blood cell to 6 platelet packs) [44]. In the report by Kashuk et al [31], patients who died had received 1 unit of fresh frozen plasma for each 8 units of packed red blood cells transfused, whereas survivors more commonly received the fresh frozen plasma in the usually recommended ratio [31]. Injuries to the visceral arteries are often associated with injury to the suprarenal aorta. The celiac axis may generally be safely ligated in young trauma patients if simple repair cannot be performed; however, repair or reanastomosis of the superior mesenteric artery should be carried out [45]. If associated vascular injuries are present, the outcome for patients with injuries to the suprarenal aorta is usually much worse. In the review by Kashuk et al [31] of 123 patients with major abdominal vascular injuries, 36 percent had more than one vascular injury and only 39 percent survived. In contrast, 76 percent survived when only a single vascular injury was present. These results are comparable to those in the present study, in which only 25 percent of patients with associated intraabdominal vascular injuries survived. There has been no significant change in the survival rate of patients with injuries to the suprarenal aorta in the last 20 years, despite improvements in emergency medical services, prehospital transport, and methods of resuscitation [16,29-321 (Table II). Although data are limited, the use of larger caliber guns may be increasing the magnitude and number of intraabdominal injuries and precluding any marked improvements in survival [46]. Summary During a 12 year period, 79 patients with a diagnosis of a penetrating wound to the suprarenal aorta were treated. An analysis of the records of these patients has led to the following conclusions: With a midline penetrating wound and presence of a supramesocolic hematoma or hemorrhage, injury to the suprarenal aorta should be suspected. If a midline supramesocolic hematoma is present or if hemor-
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rhage can be controlled by direct pressure, a lateral approach with medial mobilization of the intraabdominal viscera on the left side allows rapid vascular control. Although lateral aortorrhaphy is preferred, patch grafting, an end-to-end anastomosis, or insertion of a prosthetic graft was required in 46 percent of the patients who underwent repair. As in all previous series, the insertion of synthetic patches or prostheses was not complicated by infection. The average survival rate for injuries to the suprarenal aorta in series reported since 1974 is 33 percent. Finally, the continuing problem of irreversible shock suggests the need for rapid transport from the field to the hospital for victims of penetrating wounds to the abdomen. Acknowledgment: We thank Mary LeJeune, Carolyn Accola, and Jim Schmidt from the Department of Medical Illustration, Baylor College of Medicine for their technical assistance. References 1. Painter MW, Britt LG. Distal bullet embolism after gunshot wound to the chest: a case report. Am Surg 197 1; 37: 1068. 2. Perdue GD Jr, Smith RB Ill. Intra-abdominal vascular injury. Surgery 1968; 64: 562-8. 3. Allen TW, Reul GJ, Morton JR, Beak AC Jr. Surgical management of aortic trauma. J Trauma 1972; 12: 862-8. 4. Myles RA, Yellin AE. Traumatic injuries of the abdominal aorta. Am J Surg 1979; 138: 273-7. 5. Stone HH, Oxford WM. Austin JT. Penetrating wounds of the abdominal aorta. South Med J 1973; 66: 1351-5. 6. Sirinek KR. Gaskill HV Ill. Root HD. Levine BA. Truncal vascular injury-factors influencing survival. J Trauma 1983; 23: 372-7. 7. Stiles QR, Cohlmia GS, Smith JH, Dunn JT, Yellin AE. Management of injuries of the thoracic and abdominal aorta. Am J Surg 1985; 150: 132-40. 8. Lilienthal H. Thoracic surgery: the surgical treatment of thoracic disease. Philadelphia: WB Saunders, 1926: 489. 9. Wildegans H. Verletzungen der aorta. Dtsch Med Wochenschr 1926; 52: 1810-4. 10. Blalock A. Successful suture of a wound of the ascending aorta. JAMA 1934; 103: 1617-8. 11. Elkin DC. Wounds of the heart. Ann Surg 1944; 120: 8 17-2 1. 12. Elkin DC. The diagnosis and treatment of cardiac trauma. Ann Surg 1941; 114: 169-85. 13. Dubinskiy MB. Suture of the abdominal aorta. Khirurgiya 1944; 4: 71. 14. Jensen AR. Bullet wound of the abdominal aorta with survival. J Fla Med Assoc 1963; 49: 656-7. 15. Love CR, Evans SS. Gunshot wound of the abdominal aorta and anoxic cardiac arrest: report of a survival. Ann Surg 1963; 49: 131-7. 16. Mattox KL, McCollum WB, Beall AC Jr, Jordan GL Jr, DeBakey ME. Management of penetrating injuries of the suprarenal aorta. J Trauma 1975; 15: 808-15. 17. Lassonde J, Laurendeau F. Blunt injury of the abdominal aorta. Ann Surg 1981; 194: 745-8. 18. Feliciano DV, Gentry LO, Bitondo CG, et al. Single agent cephalosporin prophylaxis for penetrating abdominal trauma. Results and comment on the emergence of the enterococcus. Am J Surg 1986; 152: 674-81. 19. Ledgerwood AM, Kazmers M, Lucas CE. The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma 1976: 16: 610-5.
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Suprarenal Aorta Injury and h4magement
20. Feliciano DV, Bitondo CG, Cruse PA, &at. Liberal use of emergency center thoracotomy. Am J Surg 1988; 152: 854-9. 21. Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 1970; lo: 359-88. 22. Hughes CW. Arterial repair during the Korean War. Ann Surg 1958; 147: 55-81. 23. DeBakey ME, Sirneone FA. Battle injuries of the arteries in World War II: an analysis of 2,741 cases. Ann Surg 1948; 123: 534-79. 24. Parmley LF, Mattingly TW, Manion WC. Penetrating wounds of the heart and aorta. Circulation 1958; 17: 953-73. 25. Billy LJ, Amato JJ, Rich NM. Aortic injuries in Vietnam. Surgery 1971; 70: 385-91. 28. Rich NM, Hughes CW. The fate of prosthetic material used to repair vascular injuries in contaminated wounds. J Trauma 1972; 12: 459-87. 27. Beail AC Jr. Penetrating wounds of the aorta. Am J Surg 1960; 99: 770-4. 28. Drapanas T, Hewitt RL, Weichert RF Ill, Smith AD. Civilian vascular injuries: a critical appraisal of three decades of management. Ann Surg 1970; 172: 351-60. 29. Lim RC Jr, Trunkey DD, Blaisdell FW. Acute abdominal aortic injury. An analysis of operative and postoperative management. Arch Surg 1974; 109: 706-l 1. 30. Buchness MP, LoGerfo FW, Mason GR. Gunshot wounds of the suprarenal abdominal aorta. Am Surg 1978; 42: 1-7. 3 1. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma: a unified approach. J Trauma 1982; 22: 672-9. 32. Brinton M, Miller SE, Lim RC Jr, Trunkey DD. Acute abdominal aortic injuries. J Trauma 1982; 22: 481-6. 33. Kollmeyer KR, Hunt JL. Aortoazygous fistula from gunshot wound to the suprarenal abdominal aorta. J Trauma 1985; 25: 257-9. 34. DeBakey ME, Creech 0 Jr, Morris GC Jr. Aneurysm of thorace-abdominal aorta involving the celiac, superior mesenteric, and renal arteries. Report of four cases treated by resection and homograft replacement. Ann Surg 1958; 144: 549-73. 35. Buscaglia LC, Blaisdell FW, Lim RC Jr. Penetrating abdominal vascular injuries. Arch Surg 1969; 99: 764-9. 36. Elklns RC, DeMeester TR, Brawley RK. Surgical exposure of the upper abdominal aorta and its branches. Surgery 197 1; 70: 622-7. 37. Millikan JS, Moore EE. Critical factors in determining mortality from abdominal aortic trauma. Surg Gynecol Obstet 1985; 160: 313-6. 38. Richards AJ Jr, Lamis PA Jr, Rogers JT Jr, Brandham GB. Laceration of abdominal aorta and study of intact abdominal wall as tamponade: report of survival and literature review. Ann Surg 1966; 184: 321-4. 39. Moore HG Jr, Nyhus LM, Kamar EA, Harkins HN. Gunshot wounds of major arteries. An experimental study with clinical implications. Surg Gynecol Obstet 1954; 96: 129-47. 40. Feliciano DV, Burch JM, Graham JM. Abdominal vascular injury. In: Mattox KL, Moore EE. Feliciano DV, eds. Trauma. New York: Appleton-Century-Crofts, 1987: 519-36. 4 1. Martin TD, Mattox KL, Feliciano DV. Prosthetic grafts in vascular trauma: a controversy. Compr Ther 1985; 11: 41-5. 42. Fromm SH, Carrasquilla C, Lucas C. The management of gunshot wounds of the aorta. Arch Surg 1970; 101: 38890. 43. Dunn EL, Moore EE, Breslich DL, Galloway WB. Acidosisinduced coagulopathy. Surg Forum 1979; 30: 471-2. 44. Reed RE Ill, Ciavarella D, Heimbach DM, et al. Prophylactic platelet administration during massive transfusion. A prospective, randomized, double-blind clinical study. Ann Surg 1986; 203: 40-6. 45. Accola KD, Feliciano DV, Mattox KL. Burch JM, Beall AC Jr, Jordan GL Jr. Management of injuries to the superior mesenteric artery. J Trauma 1988; 26: 313-9.
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48, Rapaport A, Felioiano DV, Mattox KL. An epidemiologic profile of urban trauma in America-Houston style. Texas Med 1982; 78: 44-50.
Discussion Ernest E. Moore (Denver, CO): Dr. Accola, you stated that gastrointestinal contamination does not preclude a prosthetic graft, which was an important observation made by Dr. Charles Lucas nearly two decades ago. Indeed, nearly a third of your patients required synthetic material to reconstruct the aorta. Could you provide a more complete analysis of patient survival? In our experience, the three most important prognostic factors are whether the injury is contained in the retroperitoneum; the location of injury in the visceral or diaphragmatic segment; and whether there are concomitant abdominal vascular injuries. You also observed that half the deaths attributed to hemorrhage were due to coagulopathy and have underscored the importance of preventing hypothermia and profound acidosis, stressing the need for more rapid prehospital transport. I would like your advice on operative maneuvers to reduce the period of shock. Specifically, do you employ preliminary left thoracotomy with aortic cross-clamping prior to entering the abdomen or the more recently popularized technique of transfemoral balloon occlusion prior to laparotomy? In an effort to reduce cross-clamp time to less than 30 minutes, we now routinely use the intraluminal dacron graft for suprarenal aortic injuries as well as descending thoracic aortic tears. What is your experience with this prosthesis? John A. Weigelt (Dallas, TX): Dr. Accola, please clarify this business about prosthetic material. I think it goes against general surgical principles that we all have been taught, and I think before we have a major institution reporting that dacron is safe to put in these patients with major contamination, we had better have a little more explanation from you. In particular, what were the associated injuries in the seven patients who had prosthetic grafts? Ronald C. Elkins (Oklahoma City, OK): There is an alternative approach to the medial rotation maneuver which allows exposure of this part of the aorta without delving into Gerota’s fascia and mobilizing the left kidney. It is one that was described from the group at Johns Hopkins. I was a coauthor on that study in 1972. The important aspect that I think comes from this is that surgeons do need to know how to approach that part of the aorta, and probably one thing that most people need to recognize is that simply by dividing the crus of the diaphragm, one can expose an additional 3 cm or more of the aorta, and that allows cross-clamping before the visceral vessels are dealt with. Dr. Accola, I agree that, in most patients, a dacron graft can be utilized as this graft can be well covered, and I do think that there is a role for the use of the prosthe placed inside the aorta.
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Ronald Jones (Dallas, TX): Dr. Accola, you had several emergency room thoracotomies. Can you describe your facilities at Ben Taub for emergency room thoracotomies and what your survival rate was in that group?
Kevin D. Accola (closing): Dr. Moore, there was a change in numbers in the manuscript because more data became available after the abstract was submitted. As in your experience, those patients with a more proximal or diaphragmatic aortic injury often presented with a contained supramesocolic hematoma and clearly had a higher survival rate. The most common associated vascular injury was to the inferior vena cava. This occurred in nine patients, all of whom died. We have periodically used the
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aortic balloon occluder for abdominal vascular trauma, although not in the present study. We have not used the intraaortic dacron prosthesis to date, but it is certainly a technically appealing option. Dr. Weigelt, in spite of gastrointestinal contamination, we continue to use prosthetic materials in intraabdominal vascular trauma. A comprehensive review of every study on abdominal aortic injuries in the surgical literature since 1970, including this one, reveals only one prosthetic graft infection among survivors [29]. Dr. Jones, all 20 patients who underwent an emergency center thoracotomy died. Five died in the emergency center and 15 in the operating room after attempted repair. Of the 14 patients who underwent an anterolateral thoracotomy in the operating room, 3 survived.
The American Journal of Surgery