(Chest. 2000;117:1508-1510.)
© 2000
American College of Chest Physicians
Aortic Rupture and Concomitant Transection of the Left Bronchus After Blunt Chest Trauma*
Miralem Pasic, MD, PhD;
Ralf Ewert, MD;
Marcus Engel, MD;
Norbert Franz;
Peter Bergs, MD;
Hermann Kuppe, MD, PhD and
Roland Hetzer, MD, PhD
*
From the Deutsches Herzzentrum Berlin, Berlin, Germany. Manuscript received June 9, 1999; revision accepted October 10, 1999.
Correspondence to: Miralem Pasic, MD, PhD, Deutsches Herzzentrum Berlin, Klinik für Herz-, Thorax- and Gefässchirurgie, Augustenburger Platz 1, D-13353 Berlin, Germany; e-mail: pasic{at}dhzb.de
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Abstract
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We report a patient with traumatic aortic rupture and
preoperatively unrecognized complete disruption of the bronchus for the
left lower lobe. Preoperative state was complicated by inadequate
oxygenation due to total atelectasis of the unventilated collapsed left
lower lobe with consequent significant shunting of the unoxygenated
blood. The patient had no massive pneumothorax because the intact
peribronchial tissue and pleura covered the injured place, preventing
important air leakage. The suspicion of possible concomitant
tracheobronchial injury and early diagnostic bronchoscopy are important
in patients with aortic rupture after blunt chest trauma.
Key Words: aortic rupture • bronchial rupture
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Introduction
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Aortic
trauma is often obscured by the presence of other serious injuries.
However, if the diagnosis is made, it can overshadow the presence of
other severe but rare injuries. We report a patient with traumatic
aortic rupture and preoperatively unrecognized complete disruption of
the bronchus to the left lower lobe, a possibly catastrophic
complication.
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Case Report
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A 34-year-old man was transferred to our institution because of
rupture of the descending thoracic aorta after a fall from the sixth
floor (about 20 m height) onto the ground in an alcoholic state.
He had been intubated and placed on mechanical ventilation because of
head trauma and unconsciousness. Bilateral chest tubes were inserted in
order to drain small hemothoraces with apical pneumothoraces, and
multiple fractures of both legs were stabilized using external
fixation. The other concomitant injuries were bilateral serial rib
fractures and fractures of both clavicles, scapula, humerus, and
pelvis. Despite these injuries, the patient maintained stable
respiratory status and an adequate blood pressure. A chest
roentgenogram performed after admission at our institution revealed
full expansion of the lungs without pneumothoraces. While the patient
was being prepared to be transferred into the operating room, the blood
gas analysis worsened abruptly, with a PO2
value of 50 mm Hg. A new chest roentgenogram showed a small left-sided
apical pneumothorax, and an additional chest tube was inserted
immediately, with consequent minimal air leak and full expansion of the
lungs. However, ventilation became increasingly difficult and
insufficient, and peripheral oxygen saturation values dropped to 70%
despite administration of 100% oxygen. Repeated tracheal toilette was
not followed by improvement of oxygenation. His hemodynamic state
worsened progressively with tachycardia and hypotension. Because of
worsening of the cardiopulmonary status, the patient was immediately
transported to the operating room. Although a standard endotracheal
tube was replaced with a double-lumen tube, there was no improvement in
the respiratory and hemodynamic state. This situation demanded an
emergency thoracotomy. When turning the patient to the right lateral
decubitus position for the left thoracotomy, the peripheral pulse
oximetry revealed an abrupt improvement of peripheral oxygen saturation
from 70 to 100% and ventilation became increasingly normal.
Immediately taken blood gas analyses showed a
PO2 value of 300 mm Hg and oxygen saturation of
100% that allowed reduction of the inspired oxygen from 100 to 50%.
Thereafter, the surgical procedure was straightforward. A left
posterolateral thoracotomy incision was made, the left lung was
deflated, and some liquid blood was evacuated from the left pleural
space. Acute aortic disruption was found at the posteromedial half of
the aortic circumference, distal to the origin of the left subclavian
artery, with a localized mediastinal hematoma and an extravasation of
blood into the periaortic area. The rupture involved all layers of the
aortic wall, but the mediastinal pleura remained intact. An 18-mm
Dacron gelatine-impregnated prosthesis was interposed in the proximal
part of the descending thoracic aorta in a standard manner using
inclusion technique and normothermic femorofemoral partial
cardiopulmonary bypass. Then, the left lung was inflated and
ventilation of the left lung was started and some air leak was noted.
The exact site of the leakage could not be identified immediately.
After visual inspection and palpation, it was noted that the bronchus
to the left lower lobe was injured. There was no overt communication of
the airway injury with the pleural space because intact peribronchial
tissue and pleura prevented the development of a larger air leakage.
Opening of the visceral pleura revealed unexpectedly a major bronchial
injury with a significant loss of ventilated air. After close
inspection, it was seen that the bronchus to the left lower lobe was
totally transected and the lobe hung on the lobar vessels (Fig 1)
.
End-to-end anastomosis of the disrupted bronchus was performed with
absorbable polydioxanone 5-0 suture, using continuous suture for the
pars membranacea and interrupted sutures for the cartilaginous part.
There was no air leakage from the anastomosis, and no additional
covering of the anastomosis with pleural or muscle flap was attempted.
After femoral decannulation, the chest was closed in a standard way
after placing two chest tubes. Intraoperative bronchoscopy showed a
normal anastomotic relationship, and postoperative esophagoscopy
excluded esophageal lesions. After a prolonged postoperative course,
the patient was discharged in a good general condition.
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Figure 1. Artistic view of the combined aortic rupture
(arrowhead) and bronchial injury of the bronchus for the left lower
lobe (arrow). The bronchial defect was identified by palpation and
visible pleural bubbles in the interlobar fisura. The bronchial
disruption encompassed complete diagonal transection of three bronchial
rings.
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Discussion
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The reported case emphasizes the importance of a suspicion of
concomitant tracheobronchial injury in patients with aortic rupture
after blunt chest trauma. Early recognition of tracheobronchial
disruption is essential because if overlooked, it may have severe,
life-threatening consequences.1
The clinical presentations
of a bronchial injury may be overt or subtle, and usually present when
they are least expected and are a challenge to manage.2
In
a patient with massive air leak, the use of double-lumen endobronchial
tube or selective endobronchial intubation may be needed to achieve
adequate pulmonary ventilation.3
Our patient had no
massive pneumothorax because the intact peribronchial tissue and pleura
covered the injured place, preventing important air leakage. Thus, the
cause of inadequate oxygenation in this patient was total atelectasis
of the unventilated collapsed left lower lobe with consequent
significant shunting of the unoxygenated blood. The suspicion of
possible concomitant tracheobronchial injury and early diagnostic
bronchoscopy are important in patients with aortic rupture after blunt
chest trauma.
The possible causes of bronchial disruption after blunt injury are
presumably similar to that of aortic rupture. Traumatic aortic rupture
results most commonly from sudden high-speed deceleration or less
frequently from chest compression. The typical point of injury is
located in the most proximal descending thoracic aorta, at the site of
insertion of the ligamentum arteriosum, just distal to the origin of
the left subclavian artery, where a highly mobile region of the aorta
is placed between two fixed aortic segments. The aortic arch is
anchored with the neck vessels including the left subclavian artery,
and the descending thoracic aorta is fixed to the thorax by the
ligamentum arteriosum and by the intercostal arteries. The mobile part
of the aorta—the distal part of the aortic arch and the most proximal
part of the descending thoracic aorta—is only loosely fixed to the
chest wall by the parietal pleura. With the abrupt deceleration of the
thorax, as in our patients when the body crashed against the ground,
the fixed portions decelerate with the chest but the loosely fixed part
of the aorta continues to move forward until they finally decelerate.
Aortic rupture occurs at the interface between these two parts. The
similar principle can be applied for the transection of the bronchus,
in which complete rupture occurs at the transition region between the
fixed and nonfixed part of the tracheobronchial tree. The trachea and
the proximal part of the bronchi are fixed, and sudden deceleration
results in movement of the left lower bronchus around its fixed points
of attachment. This movement may lead to shearing forces that may cause
disruption.
We report on an exceedingly rare4
5
combination of
injuries with traumatic aortic disruption and concomitant left lower
bronchial transection. The complete disruption of the bronchus—a
possibly catastrophic complication—was not recognized preoperatively.
Therefore, in a patient with traumatic aortic injury and similar
clinical presentation of abrupt deterioration of pulmonary function
without a clinicaly identifiable cause, we recommend emergency
bronchoscopy to exclude a concomitant injury of the tracheobronchial
tree. After blunt chest trauma, early diagnosis of possibly associated
vascular, tracheobronchial, and esophageal injuries should be
performed, because all these lesions may be caused by the same
mechanism. Therefore, we suggest that patients with traumatic aortic
injury should routinely undergo screening to exclude concomitant
lesions of the tracheobronchial tree and esophagus regardless of the
presence or absence of pulmonary symptomatology or signs of esophageal
trauma. Bronchoscopy and esophagoscopy may be performed in the
operating room prior to chest closure in these patients. Awareness of
the possibility of these rare concurrent injuries could
contribute to timely diagnosis and treatment.
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References
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Rossbach, MM, Johnson, SB, Gomez, MA, et al (1998) Management of major tracheobronchial injuries: a 28-year experience. Ann Thorac Surg 65,182-186[Abstract/Free Full Text]
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Devitt, JH, Boulanger, BR (1996) Lower airway injuries and anaesthesia. Can J Anaesth 43,148-159[Abstract/Free Full Text]
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Bishop, MJ, Benson, MS, Pierson, DJ (1987) Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome. Chest 91,400-402[Abstract/Free Full Text]
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Sadow SH, Murray CA III, Wilson RF, et al. Traumatic rupture of ascending aorta and left main bronchus. Ann Thorac Surg; 1988; 45:682–683
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Marzelle, J, Nottin, R, Dartevelle, Ph, et al (1989) Combined ascending aortic rupture and left main bronchus disruption from blunt chest trauma. Ann Thorac Surg 47,769-771[Abstract]
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Abstract
Introduction
