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© 2004 European Association of Cardio-Thoracic Surgery
Transection of left common carotid artery with arch extension after blunt chest traumaDepartment of Thoracic and Cardio-Vascular Surgery, Robert Debré Hospital, Reims, France * Corresponding author. Address: Service de Chirurgie Thoracique et Cardiovasculaire, Centre Hospitalier Régional et Universitaire, avenue du Général Koenig, 51092, Reims Cedex, France. Tel.: +33-3 2678-7105; fax: +33-3 2678-3273. (E-mail: sru{at}club-internet.fr). Received March 22, 2004; received in revised form June 23, 2004; accepted July 5, 2004
We report the case of a 63-year-old man, admitted after a traffic accident. Clinical examination found chest trauma, mandibular and long bone fractures but there was no cerebral ischemic signs. The chest X-ray showed a widening of the mediastinum; therefore an aortography demonstrated a false aneurysm, an intimal flap of the left common carotid artery (LCCA) and a middle aortic arch disruption. Surgical reconstruction was accomplished by inserting Dacron prosthesis from the ascending aorta to the LCCA. The aortic arch wound was reconstructed by an autologous pericardial patch. In light of this surgical case, we discuss early methods of diagnosis and details of medical, surgical or endovascular treatments.
Blunt injuries to cerebrovascular arteries must be considered in any patient after deceleration injury [1]. Innominate artery is the most frequently injured vessel, followed by subclavian arteries. Carotid injuries are infrequently reported [2]. Rapid diagnosis and successful outcome justified aggressive approach for management of suspected aortic and cerebrovascular vessels injuries. We report a case of left common carotid artery (LCCA) rupture with aortic arch disruption.
A 63-year-old man was admitted after road accident. He was conscious but amnesic in regard to the accident. Initial clinical examination revealed chest wall trauma, mandibular fracture and limb bone fractures. Chest radiography revealed a widened mediastinum, extrapleural hematoma, bilateral pulmonary contusion, and multiple rib fractures. CT scan confirmed left extrapleural and mediastinal haematomas with pulmonary contusion signs. Aortography demonstrated a LCCA false aneurysm with a proximal aortic arch intimal dissection (Fig. 1). Deceleration was the most important mechanism of arterial injuries.
Surgery was performed through a midline sternotomy prolonged to the right side of the neck (Fig. 2). After heparinization, cardiopulmonary bypass was instituted between the right atrium and the right femoral artery with a second arterial canula in the right common carotid artery for brain protection. Aorta was cross-clamped between left common carotid and subclavian arteries. Left common carotid and right subclavian arteries were also cross-clamped and cold blood cardioplegia was performed by aorta. During cooling to 25°C, arch vessels were approached after mobilisation of innominate vein. Circumferential subadventitial transection of LCCA ostium with extension to proximal aortic arch was confirmed. Dacron* prosthesis bypass from the ascending aorta to the LCCA and repair of wound aortic arch with autologous pericardial patch were performed (Fig. 2). Despite heparin treatment, no ischemic or hemorrhagic event was noted during postoperative course. Patient was discharged 22 days after surgery without neurological complications.
Avulsion of LCCA is uncommon after blunt chest trauma. In 1994, Pretre et al. reported 14 cerebrovascular arterial injuries: subclavian arteries in 11, innominate arteries in two and right carotid artery only in one case. Diagnosis is often delayed because of frequent severe injuries association or, in some case, of absence of neurological signs [2]. These uncommon injuries should be suspected in presence of head injury with Glasgow score<8, chest injury or neurological signs [3,4]. Early clinical and radiological diagnosis is the key to successful management. CT scan or RMI, are interesting for aortic injuries detection but limited for supra-aortic arteries injuries. Duplex ultrasound can confirm diagnosis but cannot be useful for screening all patients with acute blunt chest trauma [3]. Aortic and cerebrovascular arteries arteriography is the ‘gold standard’ exam with good sensibility and specificity [5]. Some authors realise systematically four-vessel angiograms for patients with possible cerebrovascular artery injuries [6]. Severity of the supra-aortic arterial vessels lesions was graded on arteriographic findings. Five different grades have been describing [7].
In fact, to repair isolated vascular lesion, extracorporeal circulation and heparinization can be often avoided, but cardiopulmonary bypass is needed to control and repair complexes injuries of supra-aortic arteries especially with arch extension. Our patient presented a LCCA grade V lesion with aortic arch extension. For this reason, we have chosen the surgical approach with hypothermic extracorporeal circulation (25°C) with right carotid artery perfusion. We have used hypothermia to improve brain protection during LCCA clamping and no circulatory arrest was needed. We performed a bypass with 8mm Dacron* graft between the ascending aorta and the LCCA because of anastomotic stricture risk after direct anastomosis. Aortic repair has been realised with an autologous patch of pericardium without any biochemical treatment. Some authors report that glutaraldehyde can avoid patch retraction but for this patient we have not used this treatment. Large aortic lesions need a partial or complete arch replacement with branched Dacron graft under circulatory arrest and cerebral perfusion. After surgery, all authors report that anticoagulation is highly efficient and reduce neurological morbidity [2,5,6,8] and global mortality despite an increase of hemorrhagic signs and need of blood transfusion for patients with multiple injuries [2,7,8]. Walh use only antiplatelet treatment after surgery without heparin and found same neurological and mortality results without need of blood transfusion [10]. In conclusion, we report the case of disruption of the aortic arch with rupture of the LCCA after blunt chest trauma successfully treated by surgical approach and with uneventful clinical course.
Author: Dr. Hitoshi Hirose, The Cleveland Clinic Foundation, Department of Thoracic and Cardiovascular Surgery, Metro Health Drive, Cleveland OH 4410, USA. Date: 14-Oct-2004 Message: Injuries to the great vessels of the aorta after blunt chest trauma is uncommon. Detection of mediastinal hematoma is the key to the diagnosis. A large mediastinal hematoma may be diagnosed on the chest x-ray. However, smaller mediastinal hematoma may be diagnosed by CT scan. However, the specific diagnosis of the injury of the vessel and the extension of the injury should be accessed by angiography.Figure AFigure B
Response Author: Dr. Rubin Sylvain, Department of Thoracic and Cardio-vascular Surgery, Robert Debre Hospital, Reims, France Date: 24-Oct-2004 Message: I agree with you for small and partial injury. But with new generation CT scan (16 or 32), we are able to identify very small arterial lesions, less than 2 or 3 mm. However, angiography can be helpful in some difficult cases. For us, this invasive investigation must be used as a second intention if the CT scan shows a real mediastinal hematoma without any lesions.
doi:10.1016/j.icvts.2004.07.006
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Abstract
1. Introduction
