Abstract
Blunt thoracic aortic injury (BTAI) resulting from cardiopulmonary resuscitation (CPR) is rarely reported and most reports are of aortic rupture. Clinical reports have also documented aortic dissection and intramural hematomas with sequential imaging showing the development of these aortic injuries after the administration of CPR, suggesting that non-transmural aortic injury may also result from CPR. We report partial separation of an aortic intimal atheromatous plaque as a component injury in a case with multiple complications of manual CPR. A 74-year-old male presented to the emergency room (ER) with a 2-day history of chest pain. While in the ER, he suffered witnessed cardiac arrest and resuscitative attempts were pursued for 60 min prior to declaring death. At autopsy, there were numerous injuries attributable to CPR, including bilateral rib fractures, sternal fracture, retrosternal and mediastinal hemorrhage, epicardial ecchymoses, and ruptured pericardium. There was a perforated inferior wall myocardial infarct with a large left hemothorax. There was partial separation/laceration of an intimal atheromatous plaque on the anterior wall of the ascending aorta proximal to the origin of the brachiocephalic artery, forming a triangular flap, without associated intramedial dissection or hematoma. There was no thrombus formation, effectively excluding existence of the laceration prior to circulatory arrest. This aortic injury provides pathologic confirmation of non-transmural BTAI definitively sustained during manual CPR. Pathologists and clinicians alike should be cognizant of the possibility of BTAI resulting from CPR, which may manifest the full range of severity from intimal tear through aortic rupture.
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Hashimoto Y, Moriya F, Furumiya J (2007) Forensic aspects of complications resulting from cardiopulmonary resuscitation. Leg Med (Tokyo) 9(2):94–99
Krischer JP, Fine EG, Davis JH, Nagel EL (1987) Complications of cardiac resuscitation. Chest 92(2):287–291
Olds K, Byard R, Langlois NEI (2015) Injuries associated with resuscitation—an overview. J Forensic Leg Med 33:39–43
Kralj E, Podbregar M, Kejžar N, Balažic J (2015) Frequency and number of resuscitation related rib and sternum fractures are higher than generally considered. Resuscitation 93:136–141
Smekal D, Johansson J, Huzevka T, Rubertsson S (2009) No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device—a pilot study. Resuscitation 80(10):1104–1107
Smekal D, Lindgren E, Sandler H, Johansson J, Rubertsson S (2014) CPR-related injuries after manual or mechanical chest compressions with the LUCAS™ device: a multicentre study of victims after unsuccessful resuscitation. Resuscitation 85(12):1708–1712
Frink RJ, Rose JP (1997) Cardiopulmonary resuscitation and direct cardiac injury: evidence of fractured coronary arteries and HIS bundle hemorrhage. J Invasive Cardiol 9(9):578–585
Rabl W, Baubin M, Broinger G, Scheithauer R (1996) Serious complications from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med 109(2):84–89
Kitzman DW, Scholz DG, Hagen PT, Ilstrup DM, Edwards WD (1988) Age-related changes in normal human hearts during the first 10 decades of life. Part II (Maturity): a quantitative anatomic study of 765 specimens from subjects 20 to 99 years old. Mayo Clin Proc 63(2):137–146
Edwards WD (1996) Pathology of myocardial infarction and reperfusion. In: Gersh BJ, Rahimtola SH (eds) Acute myocardial infarction. Chapman & Hall, Boston, pp 16–50
Klintschar M, Darok M, Radner H (1998) Massive injury to the heart after attempted active compression-decompression cardiopulmonary resuscitation. Int J Legal Med 111(2):93–96
Okuda T, Takanari H, Shiotani S, Hayakawa H, Ohno Y, Fowler D (2015) Pericardial tear as a consequence of cardiopulmonary resuscitation (CPR) involving chest compression: a report of two postmortem cases of acute type A aortic dissection with hemopericardium. Leg Med (Tokyo) 17(3):201–204
Baldwin JJ, Edwards JE (1976) Clinical conference: rupture of right ventricle complicating closed chest cardiac massage. Circulation 53(3):562–564
Bodily K, Fischer RP (1979) Aortic rupture and right ventricular rupture induced by closed chest cardiac massage. Minn Med 62(4):225–227
Fagnoul D, Herpain A, Vincent J, De Backer D (2013) Aortic luminal thrombus and intramural hematoma after cardiopulmonary resuscitation. Rev Bras Ter Intensiva 25(4):345–347
Juan Y, Saboo S, Desai N, Khandelwal K, Khandelwal A (2014) Aortic intramural hematoma and hepatic artery pseudoaneurysm: unusual complication following resuscitation. Am J Emerg Med 32(1):107–4
Kopp R, Axt R, Klein A, Weidenhagen R, Schmucker R, Czerner S et al (2008) Endovascular treatment of an intramural aortic haematoma following cardiopulmonary resuscitation for myocardial ischemia with ventricular fibrillation. Resuscitation 77(3):410–414
Dorsa FB, Tunick PA, Culliford A, Kronzon I (1992) Pseudoaneurysm of the thoracic aorta due to cardiopulmonary resuscitation: diagnosis by transesophageal echocardiography. Am Heart J 123(5):1398–1400
Patterson RH, Burns WA, Jannotta FS (1973) Rupture of the thoracic aorta: complication of resuscitation. JAMA 226(2):197
Nelson DA, Ashley PF (1965) Rupture of the aorta during closed-chest cardiac massage. JAMA 193:681–683
Englund E, Kongstad P (2006) Active compression-decompression CPR necessitates follow-up post mortem. Resuscitation 68(1):161–162
Oren-Grinberg A, Shahul S, Sarge T (2011) Dissection of the thoracic aorta following cardiopulmonary resuscitation. Critical Ultrasound Journal 3(1):25–27
Univers J, Stevens S, Daley B (2015) Aortic dissection after cardiopulmonary resuscitation. Am Surg 81(5):E218–E219
Yang E, Jeong W, Lee J, Kim S (2014) Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation. Am J Emerg Med 32(11):1437–2
Baubin M, Sumann G, Rabl W, Eibl G, Wenzel V, Mair P (1999) Increased frequency of thorax injuries with ACD-CPR. Resuscitation 41(1):33–38
Boland L, Satterlee P, Hokanson J, Strauss C, Yost D (2015) Chest compression injuries detected via routine post-arrest care in patients who survive to admission after out-of-hospital cardiac arrest. Prehosp Emerg Care 19(1):23–30
Azizzadeh A, Shalhub S (2014) Vascular Trauma (Ch 157). In: Cronenwett JL, Johnston KW (ed) Rutherford’s Vascular Surgery, 8th edn. Elsevier, pp 2451–65.
Erbel R, Aboyans V, Boileau C, Bossone E, Di Bartolomeo R, Eggebrecht H et al (2014) 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 35(41):2873–2926
Lee WA, Matsumura J, Mitchell RS, Farber M, Greenberg R, Azizzadeh A et al (2011) Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 53(1):187–192
Silver MD (1997) The healed and sealed aortic intimomedial tear. Cardiovasc Pathol 6(6):315–320
Murray CA, Edwards JE (1973) Spontaneous laceration of ascending aorta. Circulation 47(4):848–858
Kidane B, Abramowitz D, Harris J, DeRose G, Forbes T (2012) Natural history of minimal aortic injury following blunt thoracic aortic trauma. Can J Surg 55(6):377–381
Osgood M, Heck J, Rellinger E, Doran S, Garrard CL, Guzman R et al (2014) Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg 59(2):334–341
Gunn MLD, Lehnert B, Lungren R, Narparla C, Mitsumori L, Gross J et al (2014) Minimal aortic injury of the thoracic aorta: imaging appearances and outcome. Emerg Radiol 21(3):227–233
Mosquera V, Marini M, Gulías D, Cao I, Muñiz J, Herrera Noreña J et al (2012) Minimal traumatic aortic injuries: meaning and natural history. Interact Cardiovasc Thorac Surg 14(6):773–778
Takada A, Saito K, Kobayashi M (2003) Cardiopulmonary resuscitation does not cause left ventricular rupture of the heart with acute myocardial infarction: a pathological analysis of 77 autopsy cases. Leg Med (Tokyo) 5(1):27–33
Mitsui H, Uchida H, Teramoto S (1994) Correlation between the layer of an intimal tear and the progression of aortic dissection. Acta Med Okayama 48(2):93–99
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Williams, A.S., Castonguay, M. & Murray, S.K. Aortic intimal separation resulting from manual cardiopulmonary resuscitation—completing the spectrum of blunt thoracic aortic injury complicating CPR. Int J Legal Med 130, 1581–1585 (2016). https://doi.org/10.1007/s00414-016-1377-5
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DOI: https://doi.org/10.1007/s00414-016-1377-5