A 34-year-old man was transferred to our institution because of
rupture of the descending thoracic aorta after a fall from the sixth
floor (about 20 m height) onto the ground in an alcoholic state.
He had been intubated and placed on mechanical ventilation because of
head trauma and unconsciousness. Bilateral chest tubes were inserted in
order to drain small hemothoraces with apical pneumothoraces, and
multiple fractures of both legs were stabilized using external
fixation. The other concomitant injuries were bilateral serial rib
fractures and fractures of both clavicles, scapula, humerus, and
pelvis. Despite these injuries, the patient maintained stable
respiratory status and an adequate blood pressure. A chest
roentgenogram performed after admission at our institution revealed
full expansion of the lungs without pneumothoraces. While the patient
was being prepared to be transferred into the operating room, the blood
gas analysis worsened abruptly, with a Po2
value of 50 mm Hg. A new chest roentgenogram showed a small left-sided
apical pneumothorax, and an additional chest tube was inserted
immediately, with consequent minimal air leak and full expansion of the
lungs. However, ventilation became increasingly difficult and
insufficient, and peripheral oxygen saturation values dropped to 70%
despite administration of 100% oxygen. Repeated tracheal toilette was
not followed by improvement of oxygenation. His hemodynamic state
worsened progressively with tachycardia and hypotension. Because of
worsening of the cardiopulmonary status, the patient was immediately
transported to the operating room. Although a standard endotracheal
tube was replaced with a double-lumen tube, there was no improvement in
the respiratory and hemodynamic state. This situation demanded an
emergency thoracotomy. When turning the patient to the right lateral
decubitus position for the left thoracotomy, the peripheral pulse
oximetry revealed an abrupt improvement of peripheral oxygen saturation
from 70 to 100% and ventilation became increasingly normal.
Immediately taken blood gas analyses showed a
Po2 value of 300 mm Hg and oxygen saturation of
100% that allowed reduction of the inspired oxygen from 100 to 50%.
Thereafter, the surgical procedure was straightforward. A left
posterolateral thoracotomy incision was made, the left lung was
deflated, and some liquid blood was evacuated from the left pleural
space. Acute aortic disruption was found at the posteromedial half of
the aortic circumference, distal to the origin of the left subclavian
artery, with a localized mediastinal hematoma and an extravasation of
blood into the periaortic area. The rupture involved all layers of the
aortic wall, but the mediastinal pleura remained intact. An 18-mm
Dacron gelatine-impregnated prosthesis was interposed in the proximal
part of the descending thoracic aorta in a standard manner using
inclusion technique and normothermic femorofemoral partial
cardiopulmonary bypass. Then, the left lung was inflated and
ventilation of the left lung was started and some air leak was noted.
The exact site of the leakage could not be identified immediately.
After visual inspection and palpation, it was noted that the bronchus
to the left lower lobe was injured. There was no overt communication of
the airway injury with the pleural space because intact peribronchial
tissue and pleura prevented the development of a larger air leakage.
Opening of the visceral pleura revealed unexpectedly a major bronchial
injury with a significant loss of ventilated air. After close
inspection, it was seen that the bronchus to the left lower lobe was
totally transected and the lobe hung on the lobar vessels (Fig 1).
End-to-end anastomosis of the disrupted bronchus was performed with
absorbable polydioxanone 5-0 suture, using continuous suture for the
pars membranacea and interrupted sutures for the cartilaginous part.
There was no air leakage from the anastomosis, and no additional
covering of the anastomosis with pleural or muscle flap was attempted.
After femoral decannulation, the chest was closed in a standard way
after placing two chest tubes. Intraoperative bronchoscopy showed a
normal anastomotic relationship, and postoperative esophagoscopy
excluded esophageal lesions. After a prolonged postoperative course,
the patient was discharged in a good general condition.