Skip to main content
SpringerLink
Log in

Traumatische thorakale Aortenruptur

Präklinische Beurteilung, Diagnostik und Therapieoptionen

Traumatic thoracic aorta rupture

Preclinical assessment, diagnosis and treatment options

  • Notfallmedizin
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Zusammenfassung

Die traumatische thorakale Aortenruptur stellt eine lebensbedrohliche Verletzung der Aorta dar, die als Begleitverletzung nach stumpfem Thoraxtrauma oder im Rahmen eines Polytraumas vorkommen kann. In Abhängigkeit vom Ausmaß der Zerreißung der Aortenwand ist diese Gefäßverletzung mit einer hohen primären Letalität und einem relevanten sekundären Rupturrisiko im weiteren Verlauf verbunden. Bei der präklinischen Beurteilung können der linksthorakale Schmerz, ein abgeschwächtes linksseitiges Atemgeräusch mit zunehmender Dyspnoe und Tachykardie sowie ein abgeschwächter Puls an den unteren Extremitäten entsprechend einer Pseudokoarktation Hinweise für eine thorakale Aortenruptur geben. Die präklinische Therapie besteht in der Stabilisierung der Vitalfunktionen und der Behandlung des möglichen Schockzustands. Während die offene operative Therapie der traumatischen Aortenruptur bisher vorwiegend durch Direktnaht oder Gefäßinterponat mit kurzer Abklemmung der thorakalen Aorta oder extrakorporaler Zirkulation durchgeführt wurde, gewinnt die endovaskuläre thorakale Stentgraft-Implantation zunehmend an Bedeutung. Die bisher publizierten Ergebnisse zur endovaskulären Therapie der traumatischen Aortenruptur und auch eigene Erfahrungen weisen darauf hin, dass die Einführung der thorakalen Stentgraft-Implantation zu einem Verfahrenswechsel mit der Möglichkeit der frühzeitigen Primärversorgung der lebensbedrohlichen Verletzung ohne zusätzlichen Thoraxeingriff geführt hat. Regelmäßige Kontrolluntersuchungen sind erforderlich, um mögliche Dislokationen der Stentgrafts oder Leckagen zu erkennen und notwendige endovaskuläre oder offen chirurgische Sekundäreingriffe durchführen zu können.

Abstract

Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3

Literatur

  1. Amabile P, Collart F, Gariboldi V et al. (2004) Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 40(5): 873–879

    Article  PubMed  Google Scholar 

  2. Andrassy J, Weidenhagen R, Meimarakis G et al. (2006) Stent versus open surgery for acute and chronic traumatic injury of the thoracic aorta: a single-center experience. J Trauma 60: 765–771; discussion 771–772

    PubMed  Google Scholar 

  3. ASE/SCA (1999) Guidelines for performing a comprehensive intraoperative multiplane transoesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for intraoperative echocardiography and the Society of Cardiovascular Anaesthesiologists Task Force for certification in perioperative transoesophageal echocardiography. Anesth Analg 89: 870–884

    Article  Google Scholar 

  4. Attar S, Cardarelli MG, Downing SW et al. (1999) Traumatic aortic rupture: recent outcome with regard to neurologic deficit. Ann Thorac Surg 67: 959–964; discussion 964–965

    Article  PubMed  CAS  Google Scholar 

  5. Bardenheuer M, Carlson J, Tebbe U et al. (1999) Das stumpfe Thoraxtrauma: präklinisches und frühes klinisches Management. Notfall Rettungsmed 1: 117–131

    Article  Google Scholar 

  6. Bardenheuer M, Obertacke U, Waydhas C et al. (2000) Epidemiologie des Schwerverletzten. Notfall Rettungsmed 5: 309–317

    Article  Google Scholar 

  7. Bennett DE, Cherry JK (1967) The natural history of traumatic aneurysms of the aorta. Surgery 61: 516–523

    PubMed  CAS  Google Scholar 

  8. Boeckler D, Kotelis D, Kohlhof P et al. (2007) Spinal cord ischemia after endovascular repair of the descending thoracic aorta in a sheep model. Eur J Vasc Endovasc Surg 34: 461–469

    Article  Google Scholar 

  9. Bokhari F, Brakenridge S, Nagy K et al. (2002) Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma 53: 1135–1138

    PubMed  Google Scholar 

  10. Bracken MB, Shepard MJ, Collins WF et al. (1990) A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 322: 1405–1411

    PubMed  CAS  Google Scholar 

  11. Bracken MB, Shepard MJ, Holford TR et al. (1997) Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 277: 1597–1604

    Article  PubMed  CAS  Google Scholar 

  12. Christ F, Lackner CK (2004) Präklinische Versorgung des Patienten mit Schock. Internist 45: 267–276

    Article  PubMed  CAS  Google Scholar 

  13. Dake MD, Miller DC, Semba CP et al. (1994) Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 331: 1729–1734

    Article  PubMed  CAS  Google Scholar 

  14. Degoute CS (2007) Controlled hypotension: a guide to drug choice. Drugs 67: 1053–1076

    Article  PubMed  CAS  Google Scholar 

  15. Dunser MW, Mayr AJ, Ulmer H et al. (2003) Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation 107: 2313–2319

    Article  PubMed  CAS  Google Scholar 

  16. Dyer DS, Moore EE, Ilke DN et al. (2000) Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients. J Trauma 48: 673–682; discussion 682–683

    PubMed  CAS  Google Scholar 

  17. Fildes JJ, Betlej TM, Manglano R et al. (1995) Limiting cardiac evaluation in patients with suspected myocardial contusion. Am Surg 61: 832–835

    PubMed  CAS  Google Scholar 

  18. Finkelmeier BA, Mentzer RM Jr, Kaiser DL et al. (1982) Chronic traumatic thoracic aneurysm. Influence of operative treatment on natural history: an analysis of reported cases, 1950–1980. J Thorac Cardiovasc Surg 84: 257–266

    PubMed  CAS  Google Scholar 

  19. Frykberg ER, Crump JM, Dennis JW et al. (1991) Nonoperative observation of clinically occult arterial injuries: a prospective evaluation. Surgery 109: 85–96

    PubMed  CAS  Google Scholar 

  20. Galandiuk S, Raque G, Appel S et al. (1993) The two-edged sword of large-dose steroids for spinal cord trauma. Ann Surg 218: 419–425; discussion 425–427

    Article  PubMed  CAS  Google Scholar 

  21. Gilham MJ, Parr MJA (2002) Resuscitation for major trauma. Curr Opin Anaesthesiol 15: 167–172

    Article  Google Scholar 

  22. Hemilla MR, Arabi S, Rowe SA et al. (2004) Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair? J Trauma 56: 13–23

    Article  Google Scholar 

  23. Ho RT, Blackmore CC, Bloch RD et al. (2002) Can we rely on mediastinal widening on chest radiography to identify subjects with aortic injury? Emerg Radiol 9: 183–187

    PubMed  Google Scholar 

  24. Horton TG, Cohn SM, Heid MP et al. (2000) Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury. J Trauma 48: 1008–1013

    PubMed  CAS  Google Scholar 

  25. Ishimaru S, Kawaguchi S, Koizumi N et al. (1998) Preliminary report on prediction of spinal cord ischemia in endovascular stent graft repair of thoracic aortic aneurysm by retrievable stent graft. J Thorac Cardiovasc Surg 115: 811–818

    Article  PubMed  CAS  Google Scholar 

  26. Jahromi AS, Kazemi K, Safar HA et al. (2001) Traumatic rupture of the thoracic aorta: cohort study and systematic review. J Vasc Surg 34: 1029–1034

    Article  PubMed  CAS  Google Scholar 

  27. Jellinger K (1966) Zur Orthologie and Pathologie der Rückenmarksdurchblutung. Springer, Wien, S 55–59

  28. Jauch KW, Heber G (1993) Gefäßverletzungen. In: Heberer G, Köle W, Tscherne H (Hrsg) Chirurgie und angrenzende Gebiete. Springer, Berlin Heidelberg New York

  29. Kahn RA, Moskowitz DM, Marin M et al. (2002) Anesthetic considerations for endovascular aortic repair. Mt Sinai J Med 69: 57–67

    PubMed  Google Scholar 

  30. Kahn RA, Moskowitz DM, Marin ML et al. (2000) Safety and efficacy of high-dose adenosine-induced asystole during endovascular AAA repair. J Endovasc Ther 7: 292–296

    Article  PubMed  CAS  Google Scholar 

  31. Kentner R, Safar P, Prueckner S et al. (2005) Titrated hypertonic/hyperoncotic solution for hypotensive fluid resuscitation during uncontrolled hemorrhagic shock in rats. Resuscitation 65: 87–95

    Article  PubMed  Google Scholar 

  32. Kipfer B, Leupi F, Schuepbach P et al. (1992) Acute traumatic aortic aneurysm: the Duke experience from 1970 to 1990. J Vasc Surg 15: 331–334

    Article  Google Scholar 

  33. Kouchoukos NT, Dougenis D (1997) Surgery of the thoracic aorta. N Engl J Med 336: 1876–1888

    Article  PubMed  CAS  Google Scholar 

  34. Kreimeier U, Messmer K (2002) Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions. Acta Anaesthesiol Scand 46: 625–638

    Article  PubMed  CAS  Google Scholar 

  35. Kühne CA, Ruchholtz S, Voggenreiter G et al. (2005) Traumatische Aortenverletzungen bei polytraumatisierten Patienten. Unfallchirurg 109: 279–287

    Article  Google Scholar 

  36. Lee JT, White RA (2004) Current status of thoracic aortic endograft repair. Surg Clin North Am 84: 1295–1318, vi–vii

    Article  PubMed  Google Scholar 

  37. Leurs LJ, Bell R, Degrieck Y et al. (2004) Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg 40: 670–679; discussion 679–680

    Article  PubMed  Google Scholar 

  38. Levine WC, Lee JJ, Black JH et al. (2005) Thoracoabdominal aneurysm repair: anesthetic management. Int Anesthesiol Clin 43: 39–60

    Article  PubMed  Google Scholar 

  39. Ma OJ, Mateer JR (1997) Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Ann Emerg Med 29: 312–315; discussion 315–316

    Article  PubMed  CAS  Google Scholar 

  40. Margreiter J, Hormann C, Mair P (2000) Possible uses of transesophageal echocardiography in perioperative monitoring. Anaesthesist 49: 74–92

    Article  PubMed  CAS  Google Scholar 

  41. Mattox KL, Holzman M, Pickard LR et al. (1985) Clamp/repair: a safe technique for treatment of blunt injury to the descending thoracic aorta. Ann Thorac Surg 40: 456–463

    PubMed  CAS  Google Scholar 

  42. Morishita K, Kurimoto Y, Kawaharada N et al. (2004) Descending thoracic aortic rupture: role of endovascular stent-grafting. Ann Thor Surg 78: 1630–1634

    Article  Google Scholar 

  43. Nienaber CA, Kische S, Rehders TC et al. (2007) Rapid pacing for better placing: comparison of techniques for precise deployment of endografts in the thoracic aorta. J Endovasc Ther 14: 506–512

    Article  PubMed  Google Scholar 

  44. Orend KH, Zarbis N, Schelzig H et al. (2007) Endovascular treatment (EVT) of acute traumatic lesions of the descending thoracic aorta – 7 years’ experience. Eur J Vasc Endovasc Surg 34: 666–672

    Article  PubMed  CAS  Google Scholar 

  45. Ott MC, Stewart TC, Lawlor DK et al. (2004) Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 56: 565–570

    PubMed  Google Scholar 

  46. Parmley LF, Mattingly TW, Manion WC et al. (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17: 1086–1101

    PubMed  CAS  Google Scholar 

  47. Parodi JC, Ferreira LM (2002) Ten-year experience with endovascular therapy in aortic aneurysms. J Am Coll Surg 194 [Suppl 1]: S58–S66

    Google Scholar 

  48. Pornratanarangsi S, Webster MW, Alison P et al. (2006) Rapid ventricular pacing to lower blood pressure during endograft deployment in the thoracic aorta. Ann Thorac Surg 81: e21–e23

    Article  PubMed  Google Scholar 

  49. Qian T, Campagnolo D, Kirshblum S (2000) High-dose methylprednisolone may do more harm for spinal cord injury. Med Hypotheses 55: 452–453

    Article  PubMed  CAS  Google Scholar 

  50. Richter M, Krettek C, Otte D et al. (2001) Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study. J Trauma 51: 10–16

    PubMed  CAS  Google Scholar 

  51. Rousseau H, Dambrin C, Marcheix B et al. (2005) Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair. J Thorac Cardiovasc Surg 129: 1050–1055

    Article  PubMed  CAS  Google Scholar 

  52. Safi HJ, Hess KR, Randel M et al. (1996) Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II. J Vasc Surg 23: 223–228

    Article  PubMed  CAS  Google Scholar 

  53. Sayed S, Thompson MM (2005) Endovascular repair of the descending thoracic aorta: evidence for the change in clinical practice. Vascular 13: 148–157

    Article  PubMed  Google Scholar 

  54. Scharrer-Pamler R, Kotsis T, Kapfer X et al. (2003) Complications after endovascular treatment of thoracic aortic aneurysms. J Endovasc Ther 10: 711–718

    Article  PubMed  Google Scholar 

  55. Schumacher H, Bockler D, Allenberg JR (2004) Surgical management of thoracic aortic lesions. Aneurysm, dissection and traumatic rupture. Chirurg 75: 937–958

    Article  PubMed  CAS  Google Scholar 

  56. Stadlbauer KH, Wagner-Berger HG, Raedler C et al. (2003) Vasopressin, but not fluid resuscitation, enhances survival in a liver trauma model with uncontrolled and otherwise lethal hemorrhagic shock in pigs. Anesthesiology 98: 699–704

    Article  PubMed  CAS  Google Scholar 

  57. Stelter WJ, Becker HM, Heberer G (1983) Ruptures and traumatic aneurysms of the aorta. Chirurg 54: 135–142

    PubMed  CAS  Google Scholar 

  58. Sunder-Plassmann L, Orend KH (2005) Stentgrafting of the thoracic aorta-complications. J Cardiovasc Surg 46: 121–130

    CAS  Google Scholar 

  59. Svensson LG, Hess KR, Coselli JS et al. (1994) Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations. J Vasc Surg 20: 255–262

    PubMed  CAS  Google Scholar 

  60. Svensson LG, Hess KR, D’Agostino RS et al. (1998) Reduction of neurologic injury after high-risk thoracoabdominal aortic operation. Ann Thorac Surg 66: 132–138

    Article  PubMed  CAS  Google Scholar 

  61. Toro K, Hubay M, Sotonyi P et al. (2005) Fatal traffic injuries among pedestrians, bicyclists and motor vehicle occupants. Forensic Sci Int 151: 151–156

    Article  PubMed  CAS  Google Scholar 

  62. Trupka A, Waydhas C, Nast-Kolb D et al. (1995) Effect of early intubation on the reduction of post-traumatic organ failure. Unfallchirurg 98: 111–117

    PubMed  CAS  Google Scholar 

  63. Vignon P, Boncoeur MP, Francois B et al. (2001) Comparison of multiplane transesophageal echocardiography and contrast-enhanced helical CT in the diagnosis of blunt traumatic cardiovascular injuries. Anesthesiology 94: 615–622; discussion 615A

    Article  PubMed  CAS  Google Scholar 

  64. Oppell UO von, Dunne TT, Groot MK de et al. (1994) Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 58: 585–593

    Google Scholar 

  65. Tengg-Kobligk H von, Bockler D, Jose TM et al. (2007) Feeding arteries of the spinal cord at CT angiography before and after thoracic aortic endografting. J Endovasc Ther 14: 639–649

    Article  Google Scholar 

  66. Walcher F (2003) Präklinische Sonographie. Notfall Rettungsmed 7: 476–487

    Article  Google Scholar 

  67. Waydhas C, Sauerland S (2003) Thoraxtrauma und Thoraxdrainage: Diagnostik und Therapie – Ein systematisches Review. Notfall Rettungsmed 6: 627–639

    Article  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor versichert, dass kein Interessenskonflikt im Zusammenhang mit dem vorliegenden Artikel besteht.

Author information

Authors and Affiliations

  1. Chirurgische Klinik und Poliklinik, Klinikum der LMU München - Großhadern, Marchioninistr. 15, 81377, München, Deutschland

    R. Kopp, J. Andrassy, R. Weidenhagen, G. Meimarakis & K.W. Jauch

  2. Institut für Anästhesiologie, Klinikum der LMU München - Großhadern, München, Deutschland

    S. Czerner & A. Weidenhagen

  3. Institut für Klinische Radiologie, Klinikum der LMU München - Großhadern, München, Deutschland

    M. Reiser

Authors
  1. R. Kopp
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Andrassy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. Czerner
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Weidenhagen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. R. Weidenhagen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. G. Meimarakis
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. M. Reiser
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. K.W. Jauch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to R. Kopp.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kopp, R., Andrassy, J., Czerner, S. et al. Traumatische thorakale Aortenruptur. Anaesthesist 57, 782–793 (2008). https://doi.org/10.1007/s00101-008-1375-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-008-1375-1

Schlüsselwörter

Keywords

Search

Navigation