title: Anatomical considerations in the surgical management of blunt thoracic aortic injury.
abstract: OBJECTIVE
  Blunt aortic injury (BAI) involving the thoracic aorta is usually described as occurring at the isthmus. We hypothesized that injuries 1 cm or less from the inferior border of the left subclavian artery (LSCA) are associated with an increased mortality rate compared with injuries that are more distal.
  
  
  METHODS
  A retrospective review of patients admitted with the diagnosis of BAI was performed. Injuries were divided into two groups: group I, injuries that were 1 cm or less from the junction of the LSCA and the thoracic aorta; group II, injuries that were more than 1 cm from the LSCA. Primary outcome measures included cross-clamp time, rupture, and death.
  
  
  RESULTS
  In a 14-year period, 122 patients were admitted with BAI. The anatomy relative to the LSCA could be determined in 91 patients who underwent operative repair. Forty-two injuries (46%) were classified as group I, and 49 injuries were classified as group II. Group I injuries were characterized by an increased mortality rate (18/42 or 43% in group I vs 11/49 or 22% in group II, P = .04), intraoperative rupture rate (7/42 or 17% in group I vs 1/49 or 2% in group II, P = .003), and cross-clamp time (39.5 +/- 21.9 minutes in group I vs 28.4 +/- 13 minutes in group II, P = .04). Three ruptures occurred while proximal control was being obtained.
  
  
  CONCLUSIONS
  Increased technical difficulty and risk of rupture characterize injuries that occur proximally in the descending thoracic aorta, 1 cm from the LSCA. These injuries may be better managed by instituting bypass before attempting to obtain proximal control and by routinely clamping proximal to the LSCA.
authors.affiliation: Division of Thoracic Surgery, Harborview Medical Center, Seattle, WA 98104, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: Carter
authors.forename: M
authors.initials: M
authors.lastname: Meissner
authors.forename: E
authors.initials: E
authors.lastname: Bulger
authors.forename: S
authors.initials: S
authors.lastname: Demirer
authors.forename: S
authors.initials: S
authors.lastname: Brundage
authors.forename: G
authors.initials: G
authors.lastname: Jurkovich
authors.forename: J
authors.initials: J
authors.lastname: Borsa
authors.forename: M S
authors.initials: MS
authors.lastname: Mulligan
authors.forename: R
authors.initials: R
authors.lastname: Karmy-Jones
mesh_terms: D000704:Analysis of Variance; D000714:Anastomosis, Surgical / Q000009:adverse effects* / Q000379:methods; D001013:Aorta, Thoracic / Q000033:anatomy & histology* / Q000293:injuries* / Q000601:surgery; D001019:Aortic Rupture / Q000209:etiology; D002423:Cause of Death; D003250:Constriction; D004210:Dissection / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D010264:Paraplegia / Q000209:etiology; D061226:Recurrent Laryngeal Nerve Injuries; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D013348:Subclavian Artery / Q000033:anatomy & histology* / Q000293:injuries / Q000601:surgery; D016019:Survival Analysis; D013997:Time Factors; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014861:Washington / Q000453:epidemiology; D014949:Wounds, Nonpenetrating / Q000145:classification / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*