Traumatic rupture of the thoracic aorta is most frequently caused by a traffic accident with deceleration. Approximately 80% of these patients die immediately. In 29 patients (1973-1986) reaching surgical treatment, all aortic lesions were located at the aortic isthmus (28 covered and 1 free rupture). 25 (86%) of them had serious associated injuries of the head, other thoracic or intraabdominal organs and/or the extremities. A seat belt could not prevent the deceleration injury of the aorta but reduced associated injuries of the head and the intraabdominal organs. 2) The widely accepted surgical rule that every diagnosed traumatic aortic rupture should have an immediate surgical repair is no longer acceptable. In all patients with a clinically and angiographically stable covered rupture of the aorta with serious associated injuries and symptoms of shock the surgical treatment of the aortic lesion should be undertaken with delayed emergency after some hours or several days. This changed surgical concept is based both on the rarity of secondary free rupture of the aortic lesion and on the chance to stabilize the circulatory condition by a primary shock treatment including the surgical elimination of other sources of blood loss. The group with such a delayed aortic vascular repair (n = 12) showed a remarkably improved outcome with reduced operative mortality and reduced risk of paraplegia (47% vs. 25% respectively 35% vs. ca. 10%). None of these patients with a delay up to 17 days for vascular repair developed a secondary free aortic rupture. Up to recently this risk has been obviously overestimated on the basis of earlier studies in the sixties. 3) The immediate repair of the aortic rupture with its high operative mortality and high rate of ischemic paraplegia can be restricted to a few exceptional cases with a secondary free rupture in the hospital. The transvenous DSA is the best approach for an early diagnosis and for the surgical decision to perform vascular repair immediately or with delay.
