Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis

Background. Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear. Methods. A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group. Results. One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 ± 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 ± 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 ± 22 versus 36 ± 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 ± 9 versus 32 ± 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms. Conclusions. Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.