TRAUMATIC RUPTURE OF THE THORACIC AORTA IN CHILDHOOD WITH SPECIAL REFERENCE TO THE THERAPEUTIC STRATEGY

Acute traumatic tear of the thoracic aorta is extremely rare in childhood. Based upon our own experience with two children, the essential diagnostic and therapeutic measures are discussed with special reference to timing of surgery. Aortic disruption must be suspected in a child who sustains severe blunt chest injury and develops an abnormally wide mediastinum. Definite diagnosis is established by aortography or computed tomography. The appropriate therapeutic approach is determined by the clinical symptomatology and particularly by the severity of concomitant lesions. In the absence of a significant hemothorax and if no difference in pulse amplitude between upper and lower extremities is evident, the risk of free aortic rupture with intrathoracic exsanguination is presumed to be rather low if the patient reaches the hospital alive. In that situation, the continuity of the injured aorta is maintained by the adventitia and surrounding mediastinal structures. Therefore, these patients may derive the best benefit from an initially conservative management including pharmacological intervention to reduce the risk of free aortic rupture. This concept is particularly indicated if aortic disruption is associated with severe concomitant injury such as intraabdominal or intracranial lesions. Such injuries preclude safe aortic repair immediately after establishment of diagnosis. Delay of aortic repair until recovery from associated major injury allows heparinization and the use of a pump oxygenator, which is regarded as the most effective method to prevent spinal cord ischemia and to reduce the risk of paraplegia.