Surgical management of hemorrhage from rupture of the aortic arch

Surgical treatment for a ruptured thoracic aortic aneurysm

OBJECTIVE

The treatment for a ruptured thoracic aortic aneurysm remains controversial. This study was undertaken to assess the outcome from surgery.

METHODS

Between 1993 and 1998, we have performed 19 operations for a ruptured thoracic aortic aneurysm. Patients with an impending rupture or a chronic false aneurysm were excluded. There were 11 men and 8 women, with a mean age of 70.5 +/- 6.7 years. The aneurysm was caused by dissection in 8 patients. Of these, 7 were acute (Stanford type A, 6; type B, 1), and the other one was chronic (type B). Aortic rupture occurred into the pericardial cavity (n = 7), into the left lung (n = 6), the mediastinum (n = 3), the pleural cavity (n = 2), or into the esophagus (n = 1). Severely unstable hemodynamics were noted in 12 patients with a rupture into the pericardium, mediastinum, or pleural cavity (Group A). Inotropic support was required in each of these patients. Metabolic acidosis developed all but 1 patient. The 7 patients with a rupture into the lung or esophagus coughed or vomited blood (Group B). The operative approach was anterior (n = 17) or lateral (n = 2). Grafts were placed in the ascending aorta (n = 4), ascending and transverse arch aorta (n = 7), transverse arch aorta (n = 3), or in the descending thoracic aorta (n = 5). Selective cerebral perfusion was used in 13 patients.

RESULTS

There were 5 hospital deaths (26.3%). The postoperative complications included central nervous system dysfunction (n = 3), low cardiac output syndrome or cardiac arrhythmias (n = 3), respiratory failure (n = 4), acute renal failure (n = 1), and local or systemic infections (n = 4). The perioperative event-free rate was 36.8% overall, 25% in Group A, and 57.1% in Group B.

CONCLUSIONS

Patients with unstable hemodynamics require prompt operative intervention. Rupture into the esophagus is associated with a high mortality rate. Rupture in a thoracic aortic aneurysm can be successfully treated with emergency surgery.