TRAUMATIC AORTIC RUPTURE - 20-YEAR METAANALYSIS OF MORTALITY AND RISK OF PARAPLEGIA

A metaanalysis of articles concerning the surgical management of acute traumatic rupture of the descending thoracic aorta published in the English-language literature between 1972 and July 1992 was performed. The overall mortality of 1,742 patients who arrived at the hospital alive was 32.0%, one-third died before surgical repair was started. Paraplegia was noted preoperatively in 2.6% of these hospitalized patients, and paraplegia complicated the surgical repair in 9.9% of 1,492 patients who reached the operating room in a relatively stable condition. Patients then were analyzed according to the surgical intervention used. Simple aortic cross-clamping (n = 443) was associated with a hospital mortality of 16.0% and incidence of paraplegia of 19.2%, despite lower average mean cross-clamp times (32 minutes; p < 0.01 versus passive or active methods of providing distal perfusion). In a subset of 290 patients in whom individual data were available, the cumulative risk of paraplegia was shown to increase substantially if the duration of aortic cross-clamping exceeded 30 minutes, but only when distal perfusion was not augmented (p < 0.00001). ''passive'' perfusion shunts (n = 424) Were associated with a mortality of 12.3%, and the incidence of paraplegia decreased to 11.1% (p < 0.001). However, shunts inserted from the apex of the left ventricle had a contradictory high 26.1% incidence of paraplegia compared with shunts from the ascending aorta (8.2%; p < 0.02). ''Active'' augmentation of distal perfusion (n = 561) had the lowest incidence of new postoperative paraplegia at 2.3% (p < 0.00001), although further subdivision of this group showed that using cardiopulmonary bypass with full systemic heparinization was associated with a higher mortality of 18.2%, in contrast to heparinless methods of providing distal perfusion (11.9%; p < 0.01). The crossclamp time needed to repair an aortic rupture exceeded 30 minutes in the majority of reported cases (international average, 41 minutes). Hence, we recommend using heparinless partial bypass during repair of hemodynamically stable patients with traumatic rupture of the descending thoracic aorta.