Penetrating abdominal aortic trauma: A report of 129 cases Miguel A. Lopez-Viego, MD, William H. Snyder III, MD, R. James Valentine, MD, and G. Patrick Clagett, MD, Dallas, Texas The clinical presentation, resuscitation, and operative management of 129 patients with penetrating injuries to the abdominal aorta treated between 1960 and 1989 were reviewed. This is the largest reported civilian or military experience with this specific injury; our review of the literature was limited to reports focusing on the detailed analysis of the management and outcome of aortic trauma. Eighty-two percent of patients were in shock; 18 patients (14%) underwent emergency room thoracotomies, with no survivors. O f 46 patients requiring operating room thoracotomies, only 20% survived. All patients underwent exploration. Thirty percent had three or more visceral injuries; only 2% had no concurrent visceral injury. There were associated vascular injuries i n 5 8 % of patients, the inferior vena cava being the most frequent (37%). The most significant predictor of death was continued bleeding at operation. Ninety percent of patients with free intraperitoneal bleeding died, in contrast to 35% with a contained retroperitoneal hematoma (p < 0.001). Aortic injuries were supraceliac in 25% of patients, between the celiac and renal arteries in 25%, and infrarenal in 50%. The respective mortality rates were 70%, 80%, and 47% (p < 0.05). Repair of the aortic defect was possible in 103 patients (80%). The most common repair was lateral arteriorrhaphy in 53% of patients, foUowed by end-to-end anastomosis in 15% and prosthetic repairs in 8%. The overall mortality rate was 62°,6, which is similar to that of previous reports. Despite advances in trauma care, a functioning paramedic system, and the use of aggressive means to obtain aortic control, penetrating aortic trauma remains highly lethal. (J VASC SURG 1992;16:332-6.)
Penetrating trauma to the subdiaphragmatic aorta is one of the most challenging problems confronting surgeons treating abdominal vascular trauma. The mortality rates of these serious injuries have been reported to range from 52% to 73% in series containing small numbers (average of 30 patients) of patients.l-12 We reviewed the much larger Parkland Memorial Hospital experience with the resuscitation and operative management of these injuries to examine variables associated with poor outcome and to delineate factors that might be useful in improving survival. PATIENTS A N D M E T H O D S A review was conducted of all patients admitted to Parkland Memorial Hospital between 1960 and From the Department of Surgery, University of Texas Southwestern Medical Center and Parkland Memorial Hospital, Dallas. Presented at the Sixteenth Annual Meeting of the Southern Association for Vascular Surgery, St. Thomas, Virgin Islands, Jan. 22-25, 1992. Reprint requests: G. PatrickClagett, MD, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9031. 24/6/39287 332
1989 who underwent surgery for penetrating wounds of the abdominal aorta. One hundred twenty-nine medical records were believed to be suitable for inclusion in the study; these w e r e reviewed to determine the prehospital and hospital courses of these patients. Specific data collected included age, sex, mechanism of injury, time interval from injury to presentation and operation, physical findings, initial systolic blood pressure, location of the aortic injury, associated visceral and vascular injuries, presence of a contained retroperitoneal hematoma, technique used for vascular control and repair, and morbidity and mortality rates. The data were analyzed for causes of death, a}swell as determinants of survival. Comparisons between categoric parameters were performed with the X2 test. Comparisons between groups of unpaired data were made with the unpaired Student t test. Differences were considered significant at thep < 0.05 level. RESULTS The patient population included 129 patients with an average age of 28 years (range 11 to 52 years). There were 108 male (84%) and 21 female
Volume 16 Number 3 September 1992
Penetrating abdominal aortic trauma
Table I. Penetrating abdominal aortic injuries at Parkland Memorial Hospital from 1960 to 1969 (129 patients) n
Patient population Males Females Mechanismof injury Gunshot wounds Stab wounds Shotgun wounds Total Hemodynamic status Normotensive Hypotensive No blood pressure Total
%
~lortali~ (%)
108 21
84 16
62 62
94
73
19 16
15 12
64 37~ 81
129
100
23 106 58 129
18 82 45 100
22P 71 79 62
*p < 0.05, stab wounds versus missile wounds. tp < 0.001, normotensive versus all hypotensive patients.
patients (16%) (Table I). Overall m o r t ~ t y rates (62%) were identical in male and female patients. All aortic injuries were the result of penetrating trauma, with 94 (73%) cases caused by gunshot wounds, 19 (15%) from stab wounds, and 16 (12%) from shotgun wounds. Shotgun wounds were the most lethal mechanism of injury, with a mortality rate of 81%. Aortic gunshot wounds led to a 64% mortality rate and stab wounds had the lowest mortaliw rate, 37% (p < 0.05). No significant differences in management techniques were noted between the first and second 15-year periods of the study. The majority of patients (82%) were in shock (blood pressure < 90 mm Hg) (Table I). Fifty-five percent of these hypotensive patients had no pulse on arrival at the emergency room. Only 23 patients (18%) had normal blood pressure on admission. Stable patients (blood pressure >90 mm Hg) sustained a mortality rate of 22% (p < 0.001), compared with 71% and 79% for patents either in shock or pulseless, respectively. The most common sites for external entrance wounds were the upper abdomen (57%), followed by the lower abdomen (23%) and chest (12%). Only 6% of the patients had isolated back wounds. All patients underwent celiotomy and localization of the aortic wound. The injuries were classified as either supraceliac, suprarenal (between the renal arteries and the celiac axis), or infrarenal (Table II). Twenty-five percent of patients had supraceliac injuries, associated with a 70% mortality rate. Another 25% of injuries were located between the renal arteries and celiac trunk. A mortality rate of 84% was noted with these injuries. Fifty percent of our cases
333
Table II. Location of aortic injury n
%
32 32 65
25 25 50
129
100
Supracdiac Suprarenal Infrarenal Total
Mortality (%)
70 84 47* 62
*p < 0.01, infrarenal versus supraceliac and suprarenal injuries.
Table III. Associated injuries Visceral 0 1-2 _>3 Vascular 0 1 >2
n
%
MortaligJ (%)
3 85 40
2 66 31
67 51 66
53 41 35
41 32 27
46* 72 79
*p < 0.05, no injuryversus any injuries.
involved the infrarenal aorta or aortic bifurcation and had a 47% mortality rate. The difference in mortality rates between the infrarenal and combined suprarenal and supracdiac injuries was significant (p < 0.05)~ The overall operative mortality rate was 62%, with 40% of deaths occurring in the operating room and 22% in the intensive care unit. Associated visceral and vascular injuries were common (Table III). The most frequently injured viscera were the small bowel (53%), liver (46%), stomach (43%), colon (36%), pancreas (35%), and duodenum (35%). Only 3 (2%) of the 129 patients with penetrating aortic injuries did not suffer an associated visceral injury. Sixty-six percent of patients had one to two visceral injuries, and this was associated with a 51% mortality rate. When three or more visceral injuries were present (30% of patients), the mortality rate rose to 66%. The most comanonly injured vascular structure was the inferior vena cava (37%). Fifty-two patients (42%) had no associated vascular injuries; the mortality rate among these was 46%. A single associated vascular injury raised the mortality rate to 72%; this occurred in 39 patients (32%). Thirty-three patients (27%) had two or more associated vascular injuries, and in this group the mortality rate was 79% (Table III). The difference in mortality rates between patients with and without associated vascular injuries was significant Co < 0.05). A contained retroperitoneal hematoma was noted in 63 patients (49%), whereas a hemoperitoneum
334
Journal of VASCULAR SURGERY
Lopez-Viego et al.
Table IV. Abdominal aortic injuries Author Stone et al.4 Lirn e t al. 7 Myles and Yellin 5 Brinton et al.9 Millikan and Moore 3 Frame et al.2 Parkland
Year
City
n
Mortality (%)
Shock (%)
1973 1974 1979 1982 1985 1990 1991
Atlanta San Francisco Los Angeles San Francisco Denver New Orleans Dallas
51 30 24 14 23 46 129
69 63 52 53 56 73 62
94 91 60 91 80 86 84
was present in 58 patients (45%). In eight patients (6%) this information was unobtainable. Contained hematomas were associated with a 35% mortality rate compared with 90% for a decompressed hematoma (p < 0.001). Eighteen patients (14%) underwent emergency thoracotomy and descending thoracic aortic crossclamping before laparotomy. There were no survivors in this group (to < 0.001). Forty-six patients (36%) required thoracotomy in the operating room before laparotomy; the mortality rate in this group was 80%. Repair of the aortic defect was accomplished in 103 patients (80%). The most common type of repair was a lateral arteriorrhaphy, which was performed in 69 patients (53%). An end-to-end aortic repair was possible in 21 patients (16%). Eleven patients (9%) underwent prosthetic replacement, and two patients (2%) underwent venous or prosthetic patch repair of the injury. When the repair was accomplished with a lateral arteriorrhaphy, the mortality rate was 42%. This was significantly lower than the mortality rate for other repairs (p < 0.01). The overall mortality rate during the study period was 62%. This did not change in the two 15-year periods before and after Jan. 1, 1975. The mortality rate for the period from 1960 to 1975 was 56%, and from 1975 to 1989 it was 66%. DISCUSSION
Penetrating abdominal aortic injuries are highly lethal but fortunately uncommon. Only 39 operative cases of abdominal aortic trauma were recorded in the entire Vietnam experience (Vietnam Vascular Registry). 1 Information regarding the resuscitation and operative management of these wounds is equally scarce, with most series from large urban trauma centers reporting an average of only 24 cases in their rettospectivc reviews (range 3 to 51 cases) (Table IV). z-9 Table IV includes series that specifically address management of and outcome from penetrating abdominal aortic trauma. It does not include
larger epidemiologic studies, such as that of Mattox et a1.,13that do not provide detailed outcome analysis. Despite advances in the management of trauma, the mortality rate associated with this injury has remained essentially unchanged during the past 25 years. The average mortality rate in six urban series from the past two decades was 61%. This is nearly identical to the overall mortality rate in our series (62%), which is the largest group of patients reported. In this series, principal determinants of death in patients with penetrating injuries of the aorta included degree of hemorrhage, presenting blood pressure, and mechanism of injury. Perhaps the most important among these is the status of the retroperitoneal hematoma seen at operation. When a contained hematoma was present, the mortality rate was 35%. Free hemorrhage at the time of celiotomy, however, was associated with a 90% mortality rate (p < 0.001). This finding has been noted by others. 2,6 The hemodynamic stares of the patient on admission also had a dramatic influence on mortality rates; normotensive patients had a mortality rate of 22%, compared with mortality rates in excess of 70% for patients in shock (p < 0.001). Not surprisingly, the mechanism of injury was an important determinant of outcome. Victims of stab wounds survived aortic injury in 63% of cases, whereas only 26% of patients with gunshot wounds and 19% of patients with shotgun wounds survived. Our study suggests that patients who are admitted in extremis and undergo emergency thoracotomy as part of their resuscitation uniformly die (100% mortality rate) at the time of celiotomy. This fact should not be used as an argument against an aggressive attempt at resuscitation; rather it should serve as an impetus to develop therapeutic adjuncts that may improve patient survival. We found that the location of the aortic injury had a significant effect on outcome. Injuries at, or proximal to, the level of the renal arteries are associated with almost twice the mortality rates of
Volume 16 Number 3 September 1992
infrarenal wounds (47% vs 70% to 8 4 % ; p < 0.05). This m o s t likely relates to the difficulty o f exposing the visceral aorta and the higher n u m b e r o f associated critical visceral and vascular structures in that area. Associated vascular injuries greatly increase the mortality rate o f aortic wounds, with a single associated vascular injury leading to a 72% mortality rate and two or more vascular injuries resulting in a 79% mortality rate. This compares to a 46% mortality rate in patients with no associated vascular injuries. Perhaps the saddest information gained from this study is the fact that little i m p r o v e m e n t in the mortality rates with this injury have occurred during the past three decades. This, in part, is the result o f improved city-wide paramedic services that lead to the transport o f partially resuscitated victims w h o would previously have died in the field. Penetrating aortic trauma thus continues to be highly lethal, and it appears that only societal changes will have an impact on this dismal disease. REFERENCES
1. BiLlyLJ, Amato JJ, Rich NM. Aortic injuries in Vietnam. Surgery 1971;70:385-91. 2. Frame SB, Timerlake GA, Rush DS, McSwain NE, Kerstien MD. Penetrating injuries of the abdominal aorta. Am Surg 1990;59:651-4.
Penetrating abdominal aortic trauma
335
3. Millikan JS, Moore EE. Critical factors in determining mortality from abdominal aortic trauma. Surg GynecolObstet 1985;160:313-6. 4. Stone HI-I, Oxford WM, Austin JT. Penetrating wounds of the abdominal aorta. South Med J 1973;66:13514. 5. Myles R,A, Yellin AE. Traumatic injuries of the abdominal aorta. Am ~ Surg 1979;138:272-7. 6. BuscagliaLC, BlaisdellFW, Lim RC. Penetrating abdominal vascular injuries. Arch Surg 1969;99:764-8. 7. Lim RC, T_mnkeyDD, BlaisdellFW. Acute abdominal aortic injury. Arch Surg 1974;109:706-11. 8. Yeo MT, Domanskis EJ, Barllett RH, Guzzangia AB. Penetrating injuries of the abdominal aorta. Arch Surg 1974;108:839-42. 9. Brinton M, MiLler SE, Lim RC, Tmnkey DD. Acute abdominal aortic injuries. J Trauma 1982;22:481-6. 10. Mattox KL, McCollumWB, Jordan GL, Beall AC, DeBakery ME. Management of upper abdominal vasculartrauma. Am J Surg 1974;128:823-8. 11. Accola KD, Feliciano DV, Mattox KL, et al. Management of ir~juries to the suprarenal aorta. Am J Surg 1987;154: 613-8. 12. Mattox KL, Whisermard HH, Espada R, BeaUAC. Management of acute combined injuries to the aorta and inferior vena cava. Am J Surg 1975;130:720-4. i3. Mattox KL, Feliciano DV, Burch J, Beall AC, Jordan GL, Debakey ME. Five thousand, seven hundred sixty cardiovascular injuries in 4459 patients. Aun Surg 1989;209:698707. Submitted Feb. 14, 1992; accepted May 11, 1992.
DISCUSSION
Dr. Gordon L. Hyde (Lexington, Ky.). My own long but limited anecdotal experience with these injuries supports your conclusions. As long as society permits the use of guns, people will die of these injuries. Why has there been no change in outcome dttring the 30-year period your reknowned Dallas emergency medical service system has improved? If patients survived the first 24 hours, were there any prognostic predictors? Would it not be helpfifl to consider using multivariant analysis? For instance, colon, bladder, and supraceliac bleeding might be 100% fatal and give some predictors to withhold treatment. Is there a role for percutaneous control of these injuries? Your experience confirms the hopelessness of emergency room thoracotomy for-penetrating aortic injury. Because of my own reported experience, percutaneously controlling hemorrhage from ruptured abdominal aortic aneurysms by retrograde passage of a transbrachial aortic balloon, I have suggested percutaneous control for exsanguhaating hemorrhage in trauma patients as the only likely way to improve the dismal results (i.e., by stopping the bleeding). Catheters are now available for retrograde
passage from the groin to occlude the thoracic aorta percutaneously. It should be possible to pass catheters retrograde in the majority of young trauma patients. By the location of the injuries in your series, this would control the bleeding in at least 80% to 90% of the patients. The only problem I can foresee is that the catheter could penetrate the aortic injury and cause immediate exsanguination, which would be very unlikely. With practice, these catheters can be passed in 1 to 2 minutes after penetrating the artery of access. The percutaneous approach seems to be the logical step to control the bleeding and allow repair. Prevention of this injury is the only long-term resolution, but this will require an incredible change in our society's attitudes about guns, violence, treatment of underlying alcohol and drugs, and many other behavioral issues. Facetiously I ask, what is the chance that Texas wilt legislate gun control? Dr. Miguel A. Lopez-Viego. I think one of the reasons we have not seen a significant improvement in survival during the past 30 years may be that the emergency medical treatment system in Dallas has improved to such a
336
Lopez-Viego et aL
degree that patients are being transported to our institution who previously would have died in the field and never have undergone medical therapy. In other words, we are receiving sicker patients who previously would never have reached the hospital. As far as predictors of survival after the initial 24 hours, we looked at the amount of blood product resuscitation and the length of the operative procedure, and these appeared to have some influence on whether the patients survived more than 24 hours after the initial resuscitation and operation. We also addressed several therapeutic adjuncts that were popular during part of the study period, and this included the use of military antishock trousers for stabilization during transport of the patient. This did not appear to have a positive influence on patient survival. We did not derive any meaningful data from reviewing the use of the cell saver. We have no experience with percutaneous control of these injuries, although this may be an adjunct that will be useful. Because of the pioneer mentality, I doubt that Texas will ever enact gun-control laws. They may, however, have to start passing out guns in the hospital emergency room for physician self-protection. Dr. George Johnson, Jr. (Chapel Hill, N.C.). Most of us do not see this much vascular trauma in the abdomen. From what you have learned from this study, what are your recommendations? Is there ever an indication for preoperative arteriography? Once in the abdomen and a hematoma is seen, do you alter your approach? Do you approach them all anteriorly, or do you reflect the left side of the colon or perhaps the right side of the colon for different sites? Dr. Lopez-Viego. We do not perform arteriography in patients with gunshot wounds or penetrating wounds to
Journal of VASCULAR SURGERY
the abdomen. If they have classic indications for exploration, they undergo celiotomy. As far as the approaches to exploring the hematoma, the study indicated that the size and location of the hematoma affected to some degree what approach people used for the exploration. Many infrarenal injuries were explored through a lateral approach mobilizing the viscera medially because obviously the exact point of penetration of the aorta was not evident. The lateral approach was used more often during the second half of the study period. We did not derive any information indicating that this approach was more beneficial. Perhaps in the patient with a penetrating wound to the abdomen who is found to have a periaortic hematoma on exploration, the safest approach would be to attempt to control the aorta at the diaphragmatic hiatus and then explore the injury directly through whatever appears to be the least affected route through the most uninvolved tissue planes and do that as quickly as possible. Dr. Atef A. Salam (Atlanta, Ga.). I would like you to share with us the experience with the combined injuries of the terminal aorta and the confluence of the iliac veins. In 1985 we described an approach to this complex injury whereby the right common lilac artery is transected and its proximal end, together with the entire aorta, is retracted to the left to uncover both iliac veins and inferior vena cava. This approach is useful in repairing aortic wounds involving the posterior wall. What is your experience with these complex injuries and do you use this approach? Dr. Lopez-Viego. Injuries to the terminal aorta and the bifurcation are frequently associated with iliac vein injuries. On several occasions this technique has been used to expose an injury in that area, with good technical results.
Penetrating trauma to the subdiaphragmatic aorta is one of the most challenging problems confronting surgeons treating abdominal vascular trauma. The mortality rates of these serious injuries have been reported to range from 52% to 73% in series containing small numbers (average of 30 patients) of patients.l-12 We reviewed the much larger Parkland Memorial Hospital experience with the resuscitation and operative management of these injuries to examine variables associated with poor outcome and to delineate factors that might be useful in improving survival. PATIENTS A N D M E T H O D S A review was conducted of all patients admitted to Parkland Memorial Hospital between 1960 and From the Department of Surgery, University of Texas Southwestern Medical Center and Parkland Memorial Hospital, Dallas. Presented at the Sixteenth Annual Meeting of the Southern Association for Vascular Surgery, St. Thomas, Virgin Islands, Jan. 22-25, 1992. Reprint requests: G. PatrickClagett, MD, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9031. 24/6/39287 332
1989 who underwent surgery for penetrating wounds of the abdominal aorta. One hundred twenty-nine medical records were believed to be suitable for inclusion in the study; these w e r e reviewed to determine the prehospital and hospital courses of these patients. Specific data collected included age, sex, mechanism of injury, time interval from injury to presentation and operation, physical findings, initial systolic blood pressure, location of the aortic injury, associated visceral and vascular injuries, presence of a contained retroperitoneal hematoma, technique used for vascular control and repair, and morbidity and mortality rates. The data were analyzed for causes of death, a}swell as determinants of survival. Comparisons between categoric parameters were performed with the X2 test. Comparisons between groups of unpaired data were made with the unpaired Student t test. Differences were considered significant at thep < 0.05 level. RESULTS The patient population included 129 patients with an average age of 28 years (range 11 to 52 years). There were 108 male (84%) and 21 female
Volume 16 Number 3 September 1992
Penetrating abdominal aortic trauma
Table I. Penetrating abdominal aortic injuries at Parkland Memorial Hospital from 1960 to 1969 (129 patients) n
Patient population Males Females Mechanismof injury Gunshot wounds Stab wounds Shotgun wounds Total Hemodynamic status Normotensive Hypotensive No blood pressure Total
%
~lortali~ (%)
108 21
84 16
62 62
94
73
19 16
15 12
64 37~ 81
129
100
23 106 58 129
18 82 45 100
22P 71 79 62
*p < 0.05, stab wounds versus missile wounds. tp < 0.001, normotensive versus all hypotensive patients.
patients (16%) (Table I). Overall m o r t ~ t y rates (62%) were identical in male and female patients. All aortic injuries were the result of penetrating trauma, with 94 (73%) cases caused by gunshot wounds, 19 (15%) from stab wounds, and 16 (12%) from shotgun wounds. Shotgun wounds were the most lethal mechanism of injury, with a mortality rate of 81%. Aortic gunshot wounds led to a 64% mortality rate and stab wounds had the lowest mortaliw rate, 37% (p < 0.05). No significant differences in management techniques were noted between the first and second 15-year periods of the study. The majority of patients (82%) were in shock (blood pressure < 90 mm Hg) (Table I). Fifty-five percent of these hypotensive patients had no pulse on arrival at the emergency room. Only 23 patients (18%) had normal blood pressure on admission. Stable patients (blood pressure >90 mm Hg) sustained a mortality rate of 22% (p < 0.001), compared with 71% and 79% for patents either in shock or pulseless, respectively. The most common sites for external entrance wounds were the upper abdomen (57%), followed by the lower abdomen (23%) and chest (12%). Only 6% of the patients had isolated back wounds. All patients underwent celiotomy and localization of the aortic wound. The injuries were classified as either supraceliac, suprarenal (between the renal arteries and the celiac axis), or infrarenal (Table II). Twenty-five percent of patients had supraceliac injuries, associated with a 70% mortality rate. Another 25% of injuries were located between the renal arteries and celiac trunk. A mortality rate of 84% was noted with these injuries. Fifty percent of our cases
333
Table II. Location of aortic injury n
%
32 32 65
25 25 50
129
100
Supracdiac Suprarenal Infrarenal Total
Mortality (%)
70 84 47* 62
*p < 0.01, infrarenal versus supraceliac and suprarenal injuries.
Table III. Associated injuries Visceral 0 1-2 _>3 Vascular 0 1 >2
n
%
MortaligJ (%)
3 85 40
2 66 31
67 51 66
53 41 35
41 32 27
46* 72 79
*p < 0.05, no injuryversus any injuries.
involved the infrarenal aorta or aortic bifurcation and had a 47% mortality rate. The difference in mortality rates between the infrarenal and combined suprarenal and supracdiac injuries was significant (p < 0.05)~ The overall operative mortality rate was 62%, with 40% of deaths occurring in the operating room and 22% in the intensive care unit. Associated visceral and vascular injuries were common (Table III). The most frequently injured viscera were the small bowel (53%), liver (46%), stomach (43%), colon (36%), pancreas (35%), and duodenum (35%). Only 3 (2%) of the 129 patients with penetrating aortic injuries did not suffer an associated visceral injury. Sixty-six percent of patients had one to two visceral injuries, and this was associated with a 51% mortality rate. When three or more visceral injuries were present (30% of patients), the mortality rate rose to 66%. The most comanonly injured vascular structure was the inferior vena cava (37%). Fifty-two patients (42%) had no associated vascular injuries; the mortality rate among these was 46%. A single associated vascular injury raised the mortality rate to 72%; this occurred in 39 patients (32%). Thirty-three patients (27%) had two or more associated vascular injuries, and in this group the mortality rate was 79% (Table III). The difference in mortality rates between patients with and without associated vascular injuries was significant Co < 0.05). A contained retroperitoneal hematoma was noted in 63 patients (49%), whereas a hemoperitoneum
334
Journal of VASCULAR SURGERY
Lopez-Viego et al.
Table IV. Abdominal aortic injuries Author Stone et al.4 Lirn e t al. 7 Myles and Yellin 5 Brinton et al.9 Millikan and Moore 3 Frame et al.2 Parkland
Year
City
n
Mortality (%)
Shock (%)
1973 1974 1979 1982 1985 1990 1991
Atlanta San Francisco Los Angeles San Francisco Denver New Orleans Dallas
51 30 24 14 23 46 129
69 63 52 53 56 73 62
94 91 60 91 80 86 84
was present in 58 patients (45%). In eight patients (6%) this information was unobtainable. Contained hematomas were associated with a 35% mortality rate compared with 90% for a decompressed hematoma (p < 0.001). Eighteen patients (14%) underwent emergency thoracotomy and descending thoracic aortic crossclamping before laparotomy. There were no survivors in this group (to < 0.001). Forty-six patients (36%) required thoracotomy in the operating room before laparotomy; the mortality rate in this group was 80%. Repair of the aortic defect was accomplished in 103 patients (80%). The most common type of repair was a lateral arteriorrhaphy, which was performed in 69 patients (53%). An end-to-end aortic repair was possible in 21 patients (16%). Eleven patients (9%) underwent prosthetic replacement, and two patients (2%) underwent venous or prosthetic patch repair of the injury. When the repair was accomplished with a lateral arteriorrhaphy, the mortality rate was 42%. This was significantly lower than the mortality rate for other repairs (p < 0.01). The overall mortality rate during the study period was 62%. This did not change in the two 15-year periods before and after Jan. 1, 1975. The mortality rate for the period from 1960 to 1975 was 56%, and from 1975 to 1989 it was 66%. DISCUSSION
Penetrating abdominal aortic injuries are highly lethal but fortunately uncommon. Only 39 operative cases of abdominal aortic trauma were recorded in the entire Vietnam experience (Vietnam Vascular Registry). 1 Information regarding the resuscitation and operative management of these wounds is equally scarce, with most series from large urban trauma centers reporting an average of only 24 cases in their rettospectivc reviews (range 3 to 51 cases) (Table IV). z-9 Table IV includes series that specifically address management of and outcome from penetrating abdominal aortic trauma. It does not include
larger epidemiologic studies, such as that of Mattox et a1.,13that do not provide detailed outcome analysis. Despite advances in the management of trauma, the mortality rate associated with this injury has remained essentially unchanged during the past 25 years. The average mortality rate in six urban series from the past two decades was 61%. This is nearly identical to the overall mortality rate in our series (62%), which is the largest group of patients reported. In this series, principal determinants of death in patients with penetrating injuries of the aorta included degree of hemorrhage, presenting blood pressure, and mechanism of injury. Perhaps the most important among these is the status of the retroperitoneal hematoma seen at operation. When a contained hematoma was present, the mortality rate was 35%. Free hemorrhage at the time of celiotomy, however, was associated with a 90% mortality rate (p < 0.001). This finding has been noted by others. 2,6 The hemodynamic stares of the patient on admission also had a dramatic influence on mortality rates; normotensive patients had a mortality rate of 22%, compared with mortality rates in excess of 70% for patients in shock (p < 0.001). Not surprisingly, the mechanism of injury was an important determinant of outcome. Victims of stab wounds survived aortic injury in 63% of cases, whereas only 26% of patients with gunshot wounds and 19% of patients with shotgun wounds survived. Our study suggests that patients who are admitted in extremis and undergo emergency thoracotomy as part of their resuscitation uniformly die (100% mortality rate) at the time of celiotomy. This fact should not be used as an argument against an aggressive attempt at resuscitation; rather it should serve as an impetus to develop therapeutic adjuncts that may improve patient survival. We found that the location of the aortic injury had a significant effect on outcome. Injuries at, or proximal to, the level of the renal arteries are associated with almost twice the mortality rates of
Volume 16 Number 3 September 1992
infrarenal wounds (47% vs 70% to 8 4 % ; p < 0.05). This m o s t likely relates to the difficulty o f exposing the visceral aorta and the higher n u m b e r o f associated critical visceral and vascular structures in that area. Associated vascular injuries greatly increase the mortality rate o f aortic wounds, with a single associated vascular injury leading to a 72% mortality rate and two or more vascular injuries resulting in a 79% mortality rate. This compares to a 46% mortality rate in patients with no associated vascular injuries. Perhaps the saddest information gained from this study is the fact that little i m p r o v e m e n t in the mortality rates with this injury have occurred during the past three decades. This, in part, is the result o f improved city-wide paramedic services that lead to the transport o f partially resuscitated victims w h o would previously have died in the field. Penetrating aortic trauma thus continues to be highly lethal, and it appears that only societal changes will have an impact on this dismal disease. REFERENCES
1. BiLlyLJ, Amato JJ, Rich NM. Aortic injuries in Vietnam. Surgery 1971;70:385-91. 2. Frame SB, Timerlake GA, Rush DS, McSwain NE, Kerstien MD. Penetrating injuries of the abdominal aorta. Am Surg 1990;59:651-4.
Penetrating abdominal aortic trauma
335
3. Millikan JS, Moore EE. Critical factors in determining mortality from abdominal aortic trauma. Surg GynecolObstet 1985;160:313-6. 4. Stone HI-I, Oxford WM, Austin JT. Penetrating wounds of the abdominal aorta. South Med J 1973;66:13514. 5. Myles R,A, Yellin AE. Traumatic injuries of the abdominal aorta. Am ~ Surg 1979;138:272-7. 6. BuscagliaLC, BlaisdellFW, Lim RC. Penetrating abdominal vascular injuries. Arch Surg 1969;99:764-8. 7. Lim RC, T_mnkeyDD, BlaisdellFW. Acute abdominal aortic injury. Arch Surg 1974;109:706-11. 8. Yeo MT, Domanskis EJ, Barllett RH, Guzzangia AB. Penetrating injuries of the abdominal aorta. Arch Surg 1974;108:839-42. 9. Brinton M, MiLler SE, Lim RC, Tmnkey DD. Acute abdominal aortic injuries. J Trauma 1982;22:481-6. 10. Mattox KL, McCollumWB, Jordan GL, Beall AC, DeBakery ME. Management of upper abdominal vasculartrauma. Am J Surg 1974;128:823-8. 11. Accola KD, Feliciano DV, Mattox KL, et al. Management of ir~juries to the suprarenal aorta. Am J Surg 1987;154: 613-8. 12. Mattox KL, Whisermard HH, Espada R, BeaUAC. Management of acute combined injuries to the aorta and inferior vena cava. Am J Surg 1975;130:720-4. i3. Mattox KL, Feliciano DV, Burch J, Beall AC, Jordan GL, Debakey ME. Five thousand, seven hundred sixty cardiovascular injuries in 4459 patients. Aun Surg 1989;209:698707. Submitted Feb. 14, 1992; accepted May 11, 1992.
DISCUSSION
Dr. Gordon L. Hyde (Lexington, Ky.). My own long but limited anecdotal experience with these injuries supports your conclusions. As long as society permits the use of guns, people will die of these injuries. Why has there been no change in outcome dttring the 30-year period your reknowned Dallas emergency medical service system has improved? If patients survived the first 24 hours, were there any prognostic predictors? Would it not be helpfifl to consider using multivariant analysis? For instance, colon, bladder, and supraceliac bleeding might be 100% fatal and give some predictors to withhold treatment. Is there a role for percutaneous control of these injuries? Your experience confirms the hopelessness of emergency room thoracotomy for-penetrating aortic injury. Because of my own reported experience, percutaneously controlling hemorrhage from ruptured abdominal aortic aneurysms by retrograde passage of a transbrachial aortic balloon, I have suggested percutaneous control for exsanguhaating hemorrhage in trauma patients as the only likely way to improve the dismal results (i.e., by stopping the bleeding). Catheters are now available for retrograde
passage from the groin to occlude the thoracic aorta percutaneously. It should be possible to pass catheters retrograde in the majority of young trauma patients. By the location of the injuries in your series, this would control the bleeding in at least 80% to 90% of the patients. The only problem I can foresee is that the catheter could penetrate the aortic injury and cause immediate exsanguination, which would be very unlikely. With practice, these catheters can be passed in 1 to 2 minutes after penetrating the artery of access. The percutaneous approach seems to be the logical step to control the bleeding and allow repair. Prevention of this injury is the only long-term resolution, but this will require an incredible change in our society's attitudes about guns, violence, treatment of underlying alcohol and drugs, and many other behavioral issues. Facetiously I ask, what is the chance that Texas wilt legislate gun control? Dr. Miguel A. Lopez-Viego. I think one of the reasons we have not seen a significant improvement in survival during the past 30 years may be that the emergency medical treatment system in Dallas has improved to such a
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degree that patients are being transported to our institution who previously would have died in the field and never have undergone medical therapy. In other words, we are receiving sicker patients who previously would never have reached the hospital. As far as predictors of survival after the initial 24 hours, we looked at the amount of blood product resuscitation and the length of the operative procedure, and these appeared to have some influence on whether the patients survived more than 24 hours after the initial resuscitation and operation. We also addressed several therapeutic adjuncts that were popular during part of the study period, and this included the use of military antishock trousers for stabilization during transport of the patient. This did not appear to have a positive influence on patient survival. We did not derive any meaningful data from reviewing the use of the cell saver. We have no experience with percutaneous control of these injuries, although this may be an adjunct that will be useful. Because of the pioneer mentality, I doubt that Texas will ever enact gun-control laws. They may, however, have to start passing out guns in the hospital emergency room for physician self-protection. Dr. George Johnson, Jr. (Chapel Hill, N.C.). Most of us do not see this much vascular trauma in the abdomen. From what you have learned from this study, what are your recommendations? Is there ever an indication for preoperative arteriography? Once in the abdomen and a hematoma is seen, do you alter your approach? Do you approach them all anteriorly, or do you reflect the left side of the colon or perhaps the right side of the colon for different sites? Dr. Lopez-Viego. We do not perform arteriography in patients with gunshot wounds or penetrating wounds to
Journal of VASCULAR SURGERY
the abdomen. If they have classic indications for exploration, they undergo celiotomy. As far as the approaches to exploring the hematoma, the study indicated that the size and location of the hematoma affected to some degree what approach people used for the exploration. Many infrarenal injuries were explored through a lateral approach mobilizing the viscera medially because obviously the exact point of penetration of the aorta was not evident. The lateral approach was used more often during the second half of the study period. We did not derive any information indicating that this approach was more beneficial. Perhaps in the patient with a penetrating wound to the abdomen who is found to have a periaortic hematoma on exploration, the safest approach would be to attempt to control the aorta at the diaphragmatic hiatus and then explore the injury directly through whatever appears to be the least affected route through the most uninvolved tissue planes and do that as quickly as possible. Dr. Atef A. Salam (Atlanta, Ga.). I would like you to share with us the experience with the combined injuries of the terminal aorta and the confluence of the iliac veins. In 1985 we described an approach to this complex injury whereby the right common lilac artery is transected and its proximal end, together with the entire aorta, is retracted to the left to uncover both iliac veins and inferior vena cava. This approach is useful in repairing aortic wounds involving the posterior wall. What is your experience with these complex injuries and do you use this approach? Dr. Lopez-Viego. Injuries to the terminal aorta and the bifurcation are frequently associated with iliac vein injuries. On several occasions this technique has been used to expose an injury in that area, with good technical results.
