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Injuries of the abdominal aorta due to blunt trauma are rare. So far, 33 cases have been reported in the English literature and false aneurysm formation after such injuries is even rarer. In this article, a case of false aneurysm of the abdominal aorta after blunt trauma in an acrobat which was successfully managed is reported, and the English literature for similar cases reviewed.
Sixteen patients bearing aneurysms of the abdominal aorta were studied by means of a 0.5 T MR unit. Spin-echo T1-weighted sequences and gradient-echo refocusing sequences were performed. All patients were previously submitted to US; in 8 cases angio CT was performed, and in 6 patients angiography of the abdominal aorta. A comparative analysis with the US findings showed a high correlation coefficient for the maximum diameters (R = 0.93) while site and size evaluations were not accurate. A very high correlation coefficient for the maximum diameters (0.97) was found at the comparative analysis with CT findings, while in two cases an erroneous suprarenal location was described. Angiographic examination provided valuable information about renal and iliac involvement, but the maximum diameters could not be accurately assessed. Spin-echo MRI allowed good evaluation of the maximum size, of location and extent of the aneurysm, as well as of iliac involvement; this technique, however, was useless in the characterization of the thrombus. Gradient-echo refocusing sequences have proven very useful for the identification of endoluminal contours and for the correct evaluation of the thrombus. Spin-echo sequences, on the contrary, accurately assessed only 7 cases, whereas the diagnosis was uncertain in the remaining 4 patients.
In this paper, we present two cases of dissecting aneurysm in the infrarenal abdominal aorta and a review of this type of lesion. DeBakey's classification has found wide acceptance since it combines both anatomical description and a basis for management. However, there is another type of the aneurysm, omitted in this classification, which involves the infrarenal segment of the abdominal aorta, the intimal tear being distal to the renal arteries. Its clinical manifestation, therefore, differs from dissecting aneurysm of the thoracic aorta. The incidence of dissecting aneurysm in the lower abdominal aorta in the literature is 2-14%. Sixteen cases of atraumatic dissecting aneurysm in the abdominal aorta, including our two, have been reported in Japan. Radioimaging techniques such as ultrasound, computerized tomography with contrast enhancement and conventional angiography, allow diagnosis of dissecting aneurysm. Computerized tomography with contrast enhancement has led to more frequent preoperative diagnosis of dissecting aneurysm in the abdominal aorta. However, precise visualization of the intimal defect together with the site of entry is a prerequisite of operation. Angiography remains the most suitable method of achieving this end. Although both abdominal and thoracic aortic dissection share a common management in respect to hypotensive therapy, we believe that surgical intervention is required, especially in dissection of the abdominal aorta, with prosthetic replacement of the infrarenal segment and obliteration of any proximal or distal false lumen.
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Thirty-five patients had surgery for injuries of the aorta at the Los Angeles County-USC Medical Center over a 4 1/2 year period. There were 27 survivors. The principles of management were to operate without delay if there was evidence of continued bleeding after initial fluid replacement as occurred in 11 patients. For the 24 patients who became stable after initial resuscitation, a more deliberate plan of management was used. Blood pressure was carefully monitored and controlled to avoid hypertension. Priorities for associated injuries were established and in several cases, they took treatment precedence over the aortic injury. Delay was sometimes necessary to utilize the more experienced personnel. In no instance did a stabilized patient hemorrhage during the delay. The most common injury seen was a blunt disruption of the proximal descending aorta. The details of the operative technique for this injury have been reported herein, along with a justification for not using either pump bypass or shunt to perfuse the distal aorta during the period of aortic cross-clamping.
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Haemodynamic monitoring, anaesthetic technique and perioperative management were reported for a series of 317 consecutive patients who underwent graft replacement of descending thoracic or thoracoabdominal aortic aneurysms at the Baylor College of Medicine, Houston (Texas) between january 1979 and june 1982. The surgical technique used was aortic clamping without shunt. The anaesthetic technique combined high dose fentanyl (50-100 micrograms X kg-1), oxygen ventilation, pancuronium bromide and vascular filing. The patients were monitored by Swan-Ganz catheters. The systemic blood pressure increased by 8% during the clamping of the aorta in spite of the use of sodium nitroprussiate, whereas the systemic vascular resistances did not increase significantly. The cardiac output increased by 19%, whereas the heart rate remained stable. After unclamping, the systemic blood pressure did not decrease significantly, whereas the systemic vascular resistances fell by 20%; the cardiac output increased by 64%, whereas the heart rate remained stable. The 30-day mortality was 10% (32 patients). Four of them died during surgery. The postoperative morbidity included 33 cases of paraplegia and paraparesis, 31 cases of renal insufficiency and 28 cases of postoperative pulmonary complications. The prevention of the consequences of aortic clamping and the management of the hypoxaemia occurring during one lung anaesthesia are discussed.
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