Case Study
Polytrauma to right diaphragm, descending thoracic aorta, and innominate artery
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(9) 1075–1078 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314533558 aan.sagepub.com
Mohammad Salman Siddiqi, Ashok Kumar Sharma and Hilal Al Sabti
Abstract Traumatic diaphragmatic rupture with concomitant great vessel injuries is a catastrophic and life-threatening injury group that requires immediate identification and management. It can be both diagnostically and therapeutically very challenging. We report a case of combined traumatic diaphragmatic, aortic and innominate artery injuries, which was managed successfully. To have a fruitful outcome, management of this injury complex should preferably be staged depending on the hemodynamic stability of the patient. In a patient with traumatic diaphragmatic injuries, one should also have a high index of suspicion of associated great vessel injuries.
Keywords Accidents, traffic, Aorta, thoracic, Brachiocephalic trunk, Hernia, diaphragmatic, traumatic, Multiple trauma, Thoracic injuries
Introduction Traumatic large vessel injury with a diaphragmatic tear can be catastrophic and life-threatening. It requires immediate recognition, a high index of suspicion, knowledge of trauma mechanisms, and coordination of all units involved.1 The incidence of diaphragmatic injury with aortic injury is reported to be as high as 10%. Only one case of right diaphragmatic rupture with traumatic aortic dissection has been described.2 We report the case of a 21-year-old man who was struck by a motor vehicle while crossing the road. The combination of traumatic aortic dissection, innominate artery injury, and right diaphragm injury has not been reported previously, to the best of our knowledge. Innominate artery injury after blunt trauma is uncommon and is mostly observed at its origin from the aorta.
pleural effusion with a mediastinal hematoma. Concomitant injuries found at the initial examination were a Glasgow coma scale of 9/15 and multiple limb fractures. A right-sided chest tube was inserted and it immediately drained 1600 mL of fresh blood. The patient was intubated and put on a ventilator. Urgent abdominal and chest computed tomography showed a traumatic tear of the aorta with a pseudoaneurysm and mediastinal hematoma, right hemothorax and lung contusion, as well as liver injury with a hematoma around the liver (Figure 1). He was immediately taken to the operating room and underwent a right thoracotomy which showed a diaphragmatic tear with arterial bleeding from the torn margin, along with a superficial hepatic laceration that was packed with Surgicel. The diaphragmatic tear was repaired with
Case report
Cardiothoracic Surgery Division, Sultan Qaboos University Hospital, Muscat, Oman
A 21-year-old man was hit by a car while crossing the road, and brought to the emergency department. Upon arrival, he was hemodynamically unstable. After initial resuscitation, a chest radiograph showed a right-sided
Corresponding author: Ashok Kumar Sharma, Cardiothoracic Surgery Division, PO Box 35, Sultan Qaboos University Hospital, Post Code 123, Muscat, Oman. Email: [email protected]
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
1076
Asian Cardiovascular & Thoracic Annals 23(9)
Figure 1. Three-dimensional computed tomography reconstruction of the vascular injury complex.
Vicryl sutures. Intraoperative transesophageal echocardiography confirmed the finding of traumatic aortic rupture. A left thoracotomy could not be performed at that time because the patient was severely acidotic and hemodynamically unstable. He was moved to the intensive care unit for stabilization. The next day when his hemodynamics were stable, he was taken to the operating room for repair of the aortic rupture. Because endovascular repair facilities were not available at our center at that time, he underwent a left thoracotomy and resection of the ruptured portion of the aorta, followed by replacement with a 20-mm Hemashield interposition graft via the clamp-and-sew technique (Figure 2). Two days later, a repeat computed tomography angiogram revealed an approximately 2.5-cm pseudoaneurysm of the innominate artery, which was operated on the same day via a mid sternotomy with right neck dissection and repair of the innominate artery pseudoaneurysm with a pericardial patch (Figure 3). The patient was extubated after 5 days but suffered a cardiac arrest the next day. He was revived and reintubated. Later, a tracheostomy was performed and he was gradually weaned off the ventilator. The tracheostomy tube was removed after one month. He was gradually started on regular physiotherapy and speech therapy, and was mobilized. He was ultimately discharged from the hospital after two and a half months, with regular follow-up for physiotherapy and speech therapy as well as occupational therapy and rehabilitation.
Figure 2. Operative photograph showing (a) the tear in the descending thoracic aorta, and (b) the end result after repair.
Discussion Upon arrival in the emergency room, the top priority on initial assessment and management of patients with polytrauma is to keep them alive. Thus timing and priorities have to be followed with strict adherence to set protocols that have been shown to improve the overall outcome of severely injured patients (Figure 4).3 Concomitant diaphragmatic and aortic injuries resulting from high-impact blunt trauma are well known and have been reported previously by Rieff and colleagues.4 Diaphragmatic injury is seen in approximately 7% of cases of thoracic injury and 22% of cases of thoracoabdominal injury.5 The incidence of diaphragmatic injury is approximately 1% of all trauma admissions. The most common cause of injury to the diaphragm is a direct blow to the abdomen, and this is commonly associated with injuries to the thoracic aorta, liver, spleen, and pelvis. Left-sided diaphragmatic injury is 5-times more common than right-sided injuries.6 Traumatic aortic rupture is a life-threatening consequence of high-impact blunt trauma to chest, and its diagnosis and treatment have always been challenging. It should be suspected in all patients who have sustained injury by a deceleration or acceleration mechanism, especially if physical or radiographic findings are
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
Siddiqi et al.
1077
Figure 3. Operative photograph showing (a) the pseudoaneurysm of the innominate artery, (b) the tear in the innominate artery, and (c) repair of the innominate artery tear with a pericardial patch.
Figure 4. Proposed algorithm for the initial assessment and management of polytrauma patients.
suggestive of mediastinal injury. Diagnosis should be followed by early intervention. Nowadays, there is a preference for endovascular repair over open repair because of lower mortality and fewer blood transfusions. However, there are only a few centers that have endovascular expertise, so open surgical techniques are still common. Surgical techniques include both direct suture repair and interposition of a prosthetic graft, as used in our case. The most dreaded complications of traumatic aortic rupture repair are paraplegia and renal failure, both of which result from ischemia during the repair. Ischemic complications correlate with the time the aorta is clamped. To counter these, various methods of distal perfusion ranging from heparinbonded (Gott) shunts to partial or full cardiac bypass, with and without systemic heparinization, have been used to minimize distal ischemia. Cardarelli and colleagues,7 in a series of 219 patients, found paraplegia was associated with aortic occlusion without lower body perfusion for longer than 30 min. Bhaskar and colleagues,8 in their series of 20 patients, recommended the clamp-and-sew technique without bypass if the crossclamp time is less than 30 min. Most injuries of the innominate artery (approximately 81.8%) occur at its origin from the aorta.
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
1078
Asian Cardiovascular & Thoracic Annals 23(9)
Anatomically, the proximal portion of the innominate artery is tightly fixed to the aortic arch, compared to the distal part which is more mobile and flexible. Abrupt deceleration causes simultaneous extension of the neck and rotation of the head, which creates great tension on the proximal innominate artery and results in proximal innominate artery injury.9 The most common type of innominate artery injury is an intimal tear and pseudoaneurysm formation. The first successful repair of the innominate artery after blunt trauma was reported by Binet and colleagues10 in 1962. In the majority of cases, primary repair or patch closure is possible; otherwise aorto-innominate bypass can be performed if primary repair is not possible. The association of diaphragmatic injury and thoracic aortic rupture are not rare, but injury to the innominate artery following high-impact blunt trauma to the chest and abdomen is uncommon. Chest radiography and high-resolution computed tomography can be useful for confirming the diagnosis. The planning of operative treatment of this injury complex is often very challenging. Consequently, we believe that early recognition, alertness, knowledge of trauma mechanisms, a high-degree of suspicion, and cooperation and coordination between interdisciplinary treating teams are essential for successful management of the patient. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
2. Zisis C, Fragoulis S, Kaskarelis I, Dedeilias P, Bolos K and Bellenis I. Right diaphragm rupture with extended traumatic dissection of the descending aorta. Ann Thorac Surg 2006; 82: e1–e2. 3. Stahel PF, Heyde CE, Ertel W. Current concepts of polytrauma management. Eur J Trauma 2005;31:200–11. Available at: http://link.springer.com/article/10.1007%2 Fs00068-005-2028-6. Accessed April 07, 2014. 4. Reiff DA, McGwin G, Metzger J, Windham ST, Doss M and Rue LW. Identifying injuries and motor vehicle collision characteristics that together are suggestive of diaphragmatic rupture. J Trauma 2002; 53: 1139–1145. 5. Kara E, Kaya Y, Zeybek R, et al. A case of a diaphragmatic rupture complicated with lacerations of the stomach and spleen caused by a violent cough presenting with mediastinal shift. Ann Acad Med Singapore 2004; 33: 649–650. 6. George L, Rehman SU and Khan FA. Diaphragmatic rupture: a complication of violent cough. Chest 2000; 117: 1200–1201. 7. Cardarelli MG, McLaughlin JS, Downing SW, Brown JM, Attar S and Griffith BP. Management of traumatic aortic rupture: 30-year experience. Ann Surg 2002; 236: 465–470. 8. Bhaskar J, Foo J and Sharma AK. Clamp-and-sew technique for traumatic injuries of the aorta: 20-year experience. Asian Cardiovasc Thorac Ann 2010; 18: 161–165. 9. Preˆtre R, Chilcott M, Mu¨rith N and Panos A. Blunt injury to the supra-aortic arteries. Br J Surg 1997; 84: 603–609. 10. Binet JP, Langlois J, Cormier JM and de Saint Florent G. A case of recent traumatic avulsion of the innominate artery at its origin from the aortic arch. Successful surgical repair with deep hypothermia. J Thorac Cardiovasc Surg 1962; 43: 670–676.
References 1. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma 1997; 42: 374–380.
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
Polytrauma to right diaphragm, descending thoracic aorta, and innominate artery
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(9) 1075–1078 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314533558 aan.sagepub.com
Mohammad Salman Siddiqi, Ashok Kumar Sharma and Hilal Al Sabti
Abstract Traumatic diaphragmatic rupture with concomitant great vessel injuries is a catastrophic and life-threatening injury group that requires immediate identification and management. It can be both diagnostically and therapeutically very challenging. We report a case of combined traumatic diaphragmatic, aortic and innominate artery injuries, which was managed successfully. To have a fruitful outcome, management of this injury complex should preferably be staged depending on the hemodynamic stability of the patient. In a patient with traumatic diaphragmatic injuries, one should also have a high index of suspicion of associated great vessel injuries.
Keywords Accidents, traffic, Aorta, thoracic, Brachiocephalic trunk, Hernia, diaphragmatic, traumatic, Multiple trauma, Thoracic injuries
Introduction Traumatic large vessel injury with a diaphragmatic tear can be catastrophic and life-threatening. It requires immediate recognition, a high index of suspicion, knowledge of trauma mechanisms, and coordination of all units involved.1 The incidence of diaphragmatic injury with aortic injury is reported to be as high as 10%. Only one case of right diaphragmatic rupture with traumatic aortic dissection has been described.2 We report the case of a 21-year-old man who was struck by a motor vehicle while crossing the road. The combination of traumatic aortic dissection, innominate artery injury, and right diaphragm injury has not been reported previously, to the best of our knowledge. Innominate artery injury after blunt trauma is uncommon and is mostly observed at its origin from the aorta.
pleural effusion with a mediastinal hematoma. Concomitant injuries found at the initial examination were a Glasgow coma scale of 9/15 and multiple limb fractures. A right-sided chest tube was inserted and it immediately drained 1600 mL of fresh blood. The patient was intubated and put on a ventilator. Urgent abdominal and chest computed tomography showed a traumatic tear of the aorta with a pseudoaneurysm and mediastinal hematoma, right hemothorax and lung contusion, as well as liver injury with a hematoma around the liver (Figure 1). He was immediately taken to the operating room and underwent a right thoracotomy which showed a diaphragmatic tear with arterial bleeding from the torn margin, along with a superficial hepatic laceration that was packed with Surgicel. The diaphragmatic tear was repaired with
Case report
Cardiothoracic Surgery Division, Sultan Qaboos University Hospital, Muscat, Oman
A 21-year-old man was hit by a car while crossing the road, and brought to the emergency department. Upon arrival, he was hemodynamically unstable. After initial resuscitation, a chest radiograph showed a right-sided
Corresponding author: Ashok Kumar Sharma, Cardiothoracic Surgery Division, PO Box 35, Sultan Qaboos University Hospital, Post Code 123, Muscat, Oman. Email: [email protected]
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
1076
Asian Cardiovascular & Thoracic Annals 23(9)
Figure 1. Three-dimensional computed tomography reconstruction of the vascular injury complex.
Vicryl sutures. Intraoperative transesophageal echocardiography confirmed the finding of traumatic aortic rupture. A left thoracotomy could not be performed at that time because the patient was severely acidotic and hemodynamically unstable. He was moved to the intensive care unit for stabilization. The next day when his hemodynamics were stable, he was taken to the operating room for repair of the aortic rupture. Because endovascular repair facilities were not available at our center at that time, he underwent a left thoracotomy and resection of the ruptured portion of the aorta, followed by replacement with a 20-mm Hemashield interposition graft via the clamp-and-sew technique (Figure 2). Two days later, a repeat computed tomography angiogram revealed an approximately 2.5-cm pseudoaneurysm of the innominate artery, which was operated on the same day via a mid sternotomy with right neck dissection and repair of the innominate artery pseudoaneurysm with a pericardial patch (Figure 3). The patient was extubated after 5 days but suffered a cardiac arrest the next day. He was revived and reintubated. Later, a tracheostomy was performed and he was gradually weaned off the ventilator. The tracheostomy tube was removed after one month. He was gradually started on regular physiotherapy and speech therapy, and was mobilized. He was ultimately discharged from the hospital after two and a half months, with regular follow-up for physiotherapy and speech therapy as well as occupational therapy and rehabilitation.
Figure 2. Operative photograph showing (a) the tear in the descending thoracic aorta, and (b) the end result after repair.
Discussion Upon arrival in the emergency room, the top priority on initial assessment and management of patients with polytrauma is to keep them alive. Thus timing and priorities have to be followed with strict adherence to set protocols that have been shown to improve the overall outcome of severely injured patients (Figure 4).3 Concomitant diaphragmatic and aortic injuries resulting from high-impact blunt trauma are well known and have been reported previously by Rieff and colleagues.4 Diaphragmatic injury is seen in approximately 7% of cases of thoracic injury and 22% of cases of thoracoabdominal injury.5 The incidence of diaphragmatic injury is approximately 1% of all trauma admissions. The most common cause of injury to the diaphragm is a direct blow to the abdomen, and this is commonly associated with injuries to the thoracic aorta, liver, spleen, and pelvis. Left-sided diaphragmatic injury is 5-times more common than right-sided injuries.6 Traumatic aortic rupture is a life-threatening consequence of high-impact blunt trauma to chest, and its diagnosis and treatment have always been challenging. It should be suspected in all patients who have sustained injury by a deceleration or acceleration mechanism, especially if physical or radiographic findings are
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
Siddiqi et al.
1077
Figure 3. Operative photograph showing (a) the pseudoaneurysm of the innominate artery, (b) the tear in the innominate artery, and (c) repair of the innominate artery tear with a pericardial patch.
Figure 4. Proposed algorithm for the initial assessment and management of polytrauma patients.
suggestive of mediastinal injury. Diagnosis should be followed by early intervention. Nowadays, there is a preference for endovascular repair over open repair because of lower mortality and fewer blood transfusions. However, there are only a few centers that have endovascular expertise, so open surgical techniques are still common. Surgical techniques include both direct suture repair and interposition of a prosthetic graft, as used in our case. The most dreaded complications of traumatic aortic rupture repair are paraplegia and renal failure, both of which result from ischemia during the repair. Ischemic complications correlate with the time the aorta is clamped. To counter these, various methods of distal perfusion ranging from heparinbonded (Gott) shunts to partial or full cardiac bypass, with and without systemic heparinization, have been used to minimize distal ischemia. Cardarelli and colleagues,7 in a series of 219 patients, found paraplegia was associated with aortic occlusion without lower body perfusion for longer than 30 min. Bhaskar and colleagues,8 in their series of 20 patients, recommended the clamp-and-sew technique without bypass if the crossclamp time is less than 30 min. Most injuries of the innominate artery (approximately 81.8%) occur at its origin from the aorta.
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
1078
Asian Cardiovascular & Thoracic Annals 23(9)
Anatomically, the proximal portion of the innominate artery is tightly fixed to the aortic arch, compared to the distal part which is more mobile and flexible. Abrupt deceleration causes simultaneous extension of the neck and rotation of the head, which creates great tension on the proximal innominate artery and results in proximal innominate artery injury.9 The most common type of innominate artery injury is an intimal tear and pseudoaneurysm formation. The first successful repair of the innominate artery after blunt trauma was reported by Binet and colleagues10 in 1962. In the majority of cases, primary repair or patch closure is possible; otherwise aorto-innominate bypass can be performed if primary repair is not possible. The association of diaphragmatic injury and thoracic aortic rupture are not rare, but injury to the innominate artery following high-impact blunt trauma to the chest and abdomen is uncommon. Chest radiography and high-resolution computed tomography can be useful for confirming the diagnosis. The planning of operative treatment of this injury complex is often very challenging. Consequently, we believe that early recognition, alertness, knowledge of trauma mechanisms, a high-degree of suspicion, and cooperation and coordination between interdisciplinary treating teams are essential for successful management of the patient. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
2. Zisis C, Fragoulis S, Kaskarelis I, Dedeilias P, Bolos K and Bellenis I. Right diaphragm rupture with extended traumatic dissection of the descending aorta. Ann Thorac Surg 2006; 82: e1–e2. 3. Stahel PF, Heyde CE, Ertel W. Current concepts of polytrauma management. Eur J Trauma 2005;31:200–11. Available at: http://link.springer.com/article/10.1007%2 Fs00068-005-2028-6. Accessed April 07, 2014. 4. Reiff DA, McGwin G, Metzger J, Windham ST, Doss M and Rue LW. Identifying injuries and motor vehicle collision characteristics that together are suggestive of diaphragmatic rupture. J Trauma 2002; 53: 1139–1145. 5. Kara E, Kaya Y, Zeybek R, et al. A case of a diaphragmatic rupture complicated with lacerations of the stomach and spleen caused by a violent cough presenting with mediastinal shift. Ann Acad Med Singapore 2004; 33: 649–650. 6. George L, Rehman SU and Khan FA. Diaphragmatic rupture: a complication of violent cough. Chest 2000; 117: 1200–1201. 7. Cardarelli MG, McLaughlin JS, Downing SW, Brown JM, Attar S and Griffith BP. Management of traumatic aortic rupture: 30-year experience. Ann Surg 2002; 236: 465–470. 8. Bhaskar J, Foo J and Sharma AK. Clamp-and-sew technique for traumatic injuries of the aorta: 20-year experience. Asian Cardiovasc Thorac Ann 2010; 18: 161–165. 9. Preˆtre R, Chilcott M, Mu¨rith N and Panos A. Blunt injury to the supra-aortic arteries. Br J Surg 1997; 84: 603–609. 10. Binet JP, Langlois J, Cormier JM and de Saint Florent G. A case of recent traumatic avulsion of the innominate artery at its origin from the aortic arch. Successful surgical repair with deep hypothermia. J Thorac Cardiovasc Surg 1962; 43: 670–676.
References 1. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma 1997; 42: 374–380.
Downloaded from aan.sagepub.com at University of British Columbia Library on November 14, 2015
