Traumatic rupture of the thoracic aorta: cohort study and systematic review.

PURPOSE

Through a systematic review of the literature, we identified the optimal management of traumatic ruptures of the thoracic aorta (TRTA) and reported the results of a cohort of patients treated with the clamp-and-sew technique (CAS) at a tertiary trauma center.

METHODS

Studies were identified through Medline and the Cochrane library and from reference lists and papers from the authors' files. Studies with a single consistent protocol (CAS, Gott shunt [GS], left heart bypass [LHB], or partial cardiopulmonary bypass [PCPB]) that reported mortality and neurologic outcomes were included. Relevance, validity, and data extraction were performed in duplicate. A retrospective review of charts from June 1992 to August 2000 provided the database for our experience.

RESULTS

Twenty studies reporting on 618 patients were found to be relevant. Interobserver agreement for relevance and validity decisions was high. Mortality rates for repair with CAS, GS, LHB, and PCPB were 15%, 8%, 17%, and 10%, respectively, and for paraplegia they were 7%, 4%, 0%, and 2%, respectively. The difference in mortality rates was not statistically significant. CAS had a higher incidence of neurologic deficits than GS (odds ratio [OR], 1.8; 95% CI, 0.4-8), LHB (OR, 6.4; 95% CI, 0.8-50), and PCPB (OR, 3.4; 95% CI, 1-10). In our cohort of 25 patients, 21 underwent surgery with CAS. The median abbreviated injury severity score was 20 (range, 4-50). The mean aortic clamp time was 30 +/- 12 minutes. Aortic repair was achieved with graft interposition in 43% of patients, and simple suture was achieved in 57% of patients. Mortality (10%) and neurologic complication (paraplegia, 11%; paraparesis, 5%) rates were not statistically different from those reported in the literature.

CONCLUSION

CAS is associated with a similar mortality rate but a higher incidence of neurologic deficits than methods with distal aortic perfusion.