Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3711_Библиотеки_им_академика_М_И_Перельмана

These patients presented to the emergency room with a var­ied complex of signs and symptoms and thus are best illus­trated by brief descriptions of each of their situations (Table35.1).

diac activity, and an opacied thorax, the determination for an immediate thoracotomy was readily decided. Unfortunately, four holes (two in the heart and two in the aorta) were the nding. After suture of the cardiac perfora­tions and control of the aorta, we were unable to successfully resuscitate the child despite large volume blood and electro­lyte uid administration. The 3-year-old child, with penetra­tion of the heart and aorta both anteriorly and posteriorly by the 2–3-mm metallic straight spindle, already had the spindle removed prior to arrival at the hospital. Diagnostic x-rays and contrast studies were consistent with penetration of both the heart and the aorta. A bloody pleural effusion was pres­ent, but the patient was stable hemodynamically, on serial chest x-rays and on laboratory studies. Thus, close observa­tion was successfully elected by the parents as the treatment of choice.

Automobiles, diving into a pool with little water, or a motorcycle accident may all be causes of accidental thoracic aortic trauma. The blunt trauma patient with an aortic contu­sion, laceration, or transaction usually will have other trau­matic injuries involving the long bones, spine and spinal cord, heart, and abdominal contents. Patient #4 had extensive vascular (two aortic lesions), thoracic, and abdominal inju­ries including the left renal artery torn off the aorta and the bladder torn off the urethra. In this patient, rapid ER diagnos­tic CT and x-ray studies were followed by emergency repair of the aorta, long bones, diaphragm, splenectomy, renal artery saphenous vein bypass, and urethral reanastomosis. Following 3months of intensive care, he was discharged and recovered completely. Two of the patients (#5 and 6) had concomitant spinal cord injury with paralysis and no improvement of their paralysis after aortic repair.

With continued advances in technical and therapeutic interventions, including MRI (magnetic resonance imaging), the treatment of these patients has continued to evolve. Concomitant signicant nonaortic injuries (especially cra­nial, spinal, and hepatic) are now more readily assessed, and their treatment may take preference. Determinations as to the advisability of surgery, or when to perform such, are dis­cussed by the attending physicians (e.g., neurosurgeons, orthopedic, cardiovascular, etc.). Both operative and nonop­erative programs utilizing medication and close observation have been followed [2, 13]. More recently, endovascular therapy utilization for the adult with aortic lesions has increased throughout the world. Thus, Saad reported on the endovascular repair of a traumatic aortic transsection in a 12-year-old [14]. Goldstein then reported on the use of six covered stents in four patients aged 11 to 14years with one death due to intracranial trauma [15]. Two teenagers after correction of their concomitant traumatic lesions had stents placed for their thoracic aortic transections with ultimate recovery, while another female teenager had an iliac limb prosthesis placed as an interim bridge for future correction of an aortic lesion [15–17].