Posttraumatic Coarctation of the Aorta

Diagnostic Clues

JOHN S. GRIFFIN, MD*

JOHN L. OCHSNER, MD

P. JEFFREY BOWER, MD

New Orleans, Louisiana

From the Department of internal Medicine, Section on Cardiology, and the Department of Surgery, Ochsner Clinic and Ochsner Foundation Hospital, New Orleans, La. Man- uscript received July 3, 1972; revised manu- script received August 15, 1972, accepted September 8, 1972.

*Present address: 4800 Texas Blvd., Tex- arkana, Texas 75501.

Address for reprints: John S. Griffin, MD, Alton Ochsner Medical Foundation, 1514 Jefferson Highway, New Orleans, La. 70121.

A patient with posttraumatic rupture of the aorta presented without the typical findings of mediastinal widening on chest roentgenogram, shock or hemothorax. The findings of acquired coarctation, that is, reduced volume of the femoral pulses and blood pressure difference bet\kreen the arms and legs, led td early performance of retrograde aortography and successful corrective surgery. The need for atten- tion to these subtle clues of aortic rupture is stressed.

Early surgical intervention can save lives in patients with traumatic rupture of the aorta, and prompt recognition is the key to satisfacto- ry treatment. Although cases of posttraumatic rupture of the aorta with typical presenting findings are easily diagnosed, less apparent presentations are missed with tragic consequences. This report em- phasizes the diagnostic significance of subtle evidence of acquired coarctation in a patient seen after an automobile-motorcycle acci- dent.

Case Report

A 16 year old boy was transferred to the Ochsner Foundation Hospital for treatment 2 to 3 hours after injury in an automobile-motorcycle accident. He did not appear to be seriously injured, but was taken to his local hospi- tal for observation and treatment. Pertinent physical findings at that time were swelling and ecchymoses of the anterior chest wall, tenderness of the sternochondral junctions and abrasions and lacerations of the hands and left leg. A systolic murmur was heard below the left clavicle. Blood pressure was 128/70 mm Hg in the right arm and 118/75 in the left arm. The boy’s physician was alarmed by the presence of a murmur and referred him to our institution for further treatment.

On admission he seemed moderately distressed. Blood pressure was 140/ 75 mm Hg in the right arm and 130/90 in the left leg. Pulse rate was lOO/ min and regular. Femoral pulsations were diminished in volume but were not delayed in time. The jugular venous pressure was normal. The heart sounds were normal. A grade 2/6 long systolic murmur and a faint decre- scendo diastolic murmur were heard in the pulmonic area. The remaining tests of the physical examination were within normal limits.

The chest roentgenograms (Fig. 1) were normal, in both posteroanterior and lateral views. The electrocardiogram was within normal limits. The he- moglobin was 11.3 g/100 ml; the white blood cell count was 12,4OO/mms with a slight leftward shift; the lactic dehydrogenase level was 390 interna- tional units (normal 90 to 200 units) and serum glutamic oxaloacetic trans- aminase was 95 units (normal 20 to 50 units). Urinalysis, blood urea nitro- gen and serum electrolytes were within normal limits.

The physical findings were consistent with acquired coarctation of the aorta. An aortogram was indicated in spite of the normal-appearing chest X-ray films. Percutaneous retrograde aortography demonstrated a tear in the aorta just distal to the left subclavian artery. There was subintimal fill- ing beyond the tear that narrowed the lumen of the aorta to 1 cm-an ac- quired coarctation (Fig. 2).

Immediate operative repair was necessary. A posterolateral incision was made in the fourth intercostal space, and a pulsating hematoma could be

March 1973 The American Journal of CARDIOLOGY Volume 31 391

POSTTRAUMATIC COARCTATION OF AORTA-GRIFFIN ET AL.

FIGURE 1. Posteroanterior roentgenogram of chest. There is no

mediastinal widening.

seen at the aortic isthmus. The hematoma was opened, and the aorta was found to be circumferentially torn with only 3 mm of the posterior aortic wall intact. The severed aorta was repaired primarily with 4-O Dacron suture. The patient tolerated the procedure well, and the postop- erative course was uncomplicated. He was discharged on the 14th postoperative day. When last examined, 12 months after the operation, he was symptom-free and had normal pulse and blood pressure in his arms and legs.

Discussion

Posttraumatic rupture of the aorta is a rapidly fatal condition.l.2 Most persons do not survive the accident, and 82 percent of those involved die within 1 hour of the injury.2 If untreated, most of those who survive the first hour will die from uncontrolled hemorrhage within 2 to 4 weeks.lq3,4 A chronic aneu- rysm will develop in a few persons who may live for years.1*3v5

Blunt nonpenetrating trauma of the chest, gener- ally in association with abrupt deceleration of motion, is the major cause of traumatic rupture of the aorta.6 About 70 percent of these cases arise from head-on automobile collisions. The remaining cases have been reported after car-pedestrian and automobile-motor- cycle accidents, airplane crashes, falls, animal kicks and exp1osions.l Some of the common associated major injuries include flail chest, head injuries, long bone fractures, rupture of the spleen, pulmonary contusions, fractures of the sternum, pelvic fractures and lacerations of the liver.132

FIGURE 2. Lateral view of retrograde aortogram. The arrow

points to the area of acquired coarctation caused by aortic tear

and intimal dissection.

Posttraumatic rupture of the aorta invariably oc- curs at the thoracic aorta isthmus.7 As Groves7 has suggested, this is the “junction between the heart and great vessels which are ‘floating’ in the medias- tinum, and the descending thoracic aorta, which is relatively fixed by its intercostal branches and pari- eta1 pleura to the posterior chest wall.” Sudden ac- celeration or deceleration of these floating structures, the heart, lungs and great vessels, could tear the aorta by traction upon its most fixed point, the liga- mentum arteriosum.

Patients who survive the initial injury usually present with shock, bloody pleural effusions, precor- dial systolic murmurs and chest X-ray evidence of widening of the mediastinal shadow.2 However, not all patients present with typical findings; only 50 percent will present with typical widening of the me- diastinum on chest roentgenogram.2,4 Carefully per- formed aortography is essential to proper diagnosis. It has been suggested, therefore, that patients who have received severe blunt trauma to the chest and have sustained multiple chest wall injuries and have pulse deficits and unexplained hypotension should be considered as possible survivors of aortic rupture and should undergo arch aortography for proper di- agnosis.2

References

Ritlenhouse EA. Dillard DH. Winterscheid LC, et al: Traumat- 4. Gustafsson B, Arnesio B: Pseudocoarctation of the aorta fol- ic rupture of the thoracic aorta: a revrew of the literature and lowing traumatic aortic rupture. Nord Med 73:414, 1965 a report of five cases with attention to special problems in 5. Mahaim C, Hahn C: La coarctation acquise, consequence early surgical management. Ann Surg 170:87-100, 1969 lointaine d’un anevrisme posttraumatique. Cardiologia DeMeules JE, Cramer G, Perry JF Jr: Rupture of the aorta (Basel) 48:404. 1966 and great vessels due to blunt thoracic trauma. J Thorac 6. Heberer G: Ruptures and aneurysms of the thoracic aorta Cardiovasc Surg 61:438-442. 1971 after blunt chest trauma. J Cardiovasc Surg 12:115-120. Malm JR, Deterling RA Jr: Traumatic aneurysm of the tho- 1971 racic aorta simulating coarctation: a case report. J Thorac 7. Groves LK: Traumatic aneurysm of the thoracic aorta. New Cardiovasc Surg 40:271-277. 1960 Eng J Med 270:220-224,1964

392 March 1973 The American Journal of CARDIOLOGY Volume 31