Acute traumatic rupture of the thoracic aorta: immediate or delayed surgical repair?

The appropriate management of traumatic aortic rupture is often difficult to determine, particularly if the rupture is associated with severe additional lesions. Between 1986 and 1991, ten consecutive patients with acute traumatic rupture of the thoracic aorta (ATRTA) and concomitant injuries were initially treated medically and submitted to delayed aortic repair. Within the same period no other patient had emergency reconstruction of the thoracic aorta. Diagnosis of ATRTA was established immediately after admission in eight patients. Five patients underwent emergency surgery for severe concomitant injuries. With regard to the aortic lesion, all patients were managed medically and submitted to pharmacological treatment in an attempt to reduce cardiac shear forces. None of the patients developed clinical signs of imminent free rupture while waiting for aortic surgery. In the absence of a significant hemothorax and when no coarctation syndrome is evident, the risk of free aortic rupture is considered to be rather low if the patient reaches the hospital in a stable circulatory condition. Postponement of aortic reconstruction is particularly indicated when severe concomitant lesions preclude safe immediate repair of the aortic tear. Following the patient's recovery from associated major injury, aortic surgery can be performed as a low risk procedure using cardiopulmonary bypass which is recognised as the most effective technique to prevent spinal cord ischemia and to reduce the risk of paraplegia.