Bouchart F, Bessou J P, Tabley A, Litzler P Y, Haas-Hubscher C, Redonnet M, Soyer R
Service de chirurgie thoracique et cardiovasculaire, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen, France.
Ann Chir. 2001 Apr;126(3):201-11. doi: 10.1016/s0003-3944(01)00494-1.
The aim of this retrospective study was to report a series of 102 patients with acute traumatic rupture of the thoracic aorta and its branches (TRA) and to evaluate long-term results.
From April 1977 to April 2000, 102 patients with RTA were admitted to our unit. Age ranged between 12 and 74 years (mean age: 33 years). Localisation was: ascending aorta (n = 3), aortic arch (n = 1), isthmus (n = 92), descending aorta (n = 1), innominate artery (n = 3), and left subclavian artery (n = 2). Associated injuries mainly included craniocerebral lesions (n = 76), rib fractures (n = 68), and thoracic (n = 38), and abdominal (n = 24) lesions. Average time between trauma and surgery was 37 hours. Aortography was used routinely for diagnosis. Five patients were inoperable; the procedure was delayed in three patients. In all but two patients with rupture of the isthmus, descending aorta and subclavian artery, the operation included venous arterial femorofemoral assistance. Rupture was partial in 37 patients (37 direct sutures), and complete in 55 patients (40 direct sutures). In two cases of left subclavian artery desinsertion, the operation included suture of the aortic tear and reimplantation of the artery. In patients with rupture of the ascending aorta and aortic arch, surgery was carried out under cardiopulmonary bypass with deep hypothermia for aortic arch rupture. Repair consisted of direct suture. In patients with rupture of the innominate artery, the lesion was treated under cardiopulmonary bypass by direct suture. In five cases, abdominal injuries required emergency procedure before aortic repair.
Four patients died. No postoperative paraplegia occurred. The high morbidity rate was in relation to the associated injuries. Among the 93 survivors, the aortic clinical status was satisfactory in 91 patients (two patients were lost to follow-up). Two patients died from cancer and myocardial infarction 2 and 7 years later respectively. One patient had prosthetic sepsis and was reoperated on with homograft. Angiographic control by aortography (n = 60) and angioMRI (n = 22) was normal in 76 patients. There were five stenoses at the level of the prosthesis, four with a gradient < 20 mmHg and one with a gradient > 50 mmHg and one aneurysm at the level of the isthmus. These last two patients were reoperated on with good result.
RTA remains a surgical emergency with multiple difficulties. Despite the development of new imaging modalities, angiography remains the gold standard for the work-up of these patients. Venous arterial femorofemoral assistance with a pump remains the best procedure in order to avoid paraplegia and vascular prosthesis implantation when possible. Endovascular stent graft insertion, although still under investigation, holds tremendous promise for non-surgical treatment of these patients.
本回顾性研究旨在报告102例胸主动脉及其分支急性创伤性破裂（TRA）患者的情况，并评估长期结果。
1977年4月至2000年4月，102例TRA患者入住我科。年龄在12至74岁之间（平均年龄：33岁）。病变部位为：升主动脉（n = 3）、主动脉弓（n = 1）、峡部（n = 92）、降主动脉（n = 1）、无名动脉（n = 3）和左锁骨下动脉（n = 2）。合并伤主要包括颅脑损伤（n = 76）、肋骨骨折（n = 68）以及胸部（n = 38）和腹部（n = 24）损伤。创伤至手术的平均时间为37小时。常规采用主动脉造影进行诊断。5例患者无法手术；3例患者手术延迟。除2例峡部、降主动脉和锁骨下动脉破裂患者外，所有手术均包括股股静脉 - 动脉辅助。37例患者为部分破裂（37例行直接缝合），55例患者为完全破裂（40例行直接缝合）。2例左锁骨下动脉离断患者的手术包括主动脉裂口缝合和动脉再植。升主动脉和主动脉弓破裂患者在体外循环和深低温下进行手术，主动脉弓破裂采用直接缝合修复。无名动脉破裂患者在体外循环下通过直接缝合治疗病变。5例患者腹部损伤在主动脉修复前需要急诊手术。
4例患者死亡。无术后截瘫发生。高发病率与合并伤有关。93例幸存者中，91例患者的主动脉临床状况良好（2例患者失访）。2例患者分别在2年和7年后死于癌症和心肌梗死。1例患者发生人工血管感染，接受同种异体移植再次手术。60例患者通过主动脉造影和22例患者通过血管磁共振成像（angioMRI）进行血管造影检查，76例结果正常。人工血管部位有5处狭窄，4处压差<20 mmHg，1处压差>50 mmHg，峡部有1个动脉瘤。最后这2例患者接受再次手术，效果良好。
TRA仍然是一种存在多种困难的外科急症。尽管有新的成像方式出现，但血管造影仍然是这些患者检查的金标准。股股静脉 - 动脉泵辅助在可能的情况下仍是避免截瘫和血管假体植入的最佳方法。血管内支架植入术尽管仍在研究中，但对这些患者的非手术治疗具有巨大潜力。
