Delayed Traumatic Aortic Rupture into the Esophagus

A 45-year-old man was brought to our emergency department with acute chest pain that had awakened him from sleep. The pain was sharp in character and was accompanied by cold sweating. Seven days earlier, he had sustained a steering-wheel injury while driving at the speed of 120 km/hr. At another hospital, he underwent a series of examinations, including chest radiography and laboratory tests. No abnormal results were found, and he was discharged from the hospital 8 hours later with the diagnosis of chest wall contusion. He was able to perform daily activities, but continued to experience anterior chest discomfort and mild dysphagia after the accident.

Upon arrival at our hospital, the patient was alert and oriented but looked acutely ill. He was experiencing chest pain and was drooling due to dysphagia. The patient's blood pressure was 90/60 mmHg, his pulse rate was 110 beats/min, and his respiratory rate was 20 breaths/min. A hemogram showed a decreased hemoglobin level (10.1 g/dL). There was no blood or material of coffee-ground appearance noted from the nasogastric tube. An initial chest radiograph disclosed widening of the mediastinum, and an esophagogram revealed narrowing in the upper third of the esophagus with partial obstruction of the contrast medium (Fig. 1). A computed tomographic (CT) scan of the chest showed what appeared to be an aortic rupture (Fig. 2), intramural hematoma of the esophagus, and left atrial compression by the hematoma (Fig. 3). Transthoracic echocardiography (TTE), performed to evaluate the heart valves and myocardial injuries, revealed that the left atrium was compressed by a mass.

Fig. 1 Esophagogram shows the contrast material stasis in the upper esophagus. The arrow indicates the nasogastric tube.

Fig. 2 Chest computed tomographic scan shows an intimal flap (arrowhead) in the descending aorta, intramural hematoma (star) of the esophagus, and left pleural effusion. The arrow indicates the nasogastric tube.

Fig. 3 Chest computed tomographic scan shows the left atrium (LA) compressed by intramural hematoma (star) of the esophagus. The arrow indicates the nasogastric tube.

The patient became apneic and went into cardiac arrest while being prepared for surgery. He was resuscitated and taken to surgery for a suspected aortic rupture. After opening the chest by means of a left thoracotomy, we evacuated 3,000 mL of bloody pleural effusion and found a pseudoaneurysm around the aortic isthmus, just distal to the left subclavian artery. We also found a hematoma, along the esophagus, that was especially large at the middle third portion of the esophagus. With use of simple cross-clamping of the aorta, we entered the pseudoaneurysm and found that the aorta was transected, with a 5-cm gap at the isthmus (Fig. 4). Aortic continuity was restored by interposition of a short segment of 18-mm Dacron graft (Fig. 5). Although continuous direct cardiac massage was performed during the procedure, the patient died on the operating table.

Fig. 4 Photograph reveals complete transection of the descending aorta with a 5-cm gap (between the 2 arrows).

Fig. 5 Photograph shows part of the descending aorta replaced by a segment of 18-mm Dacron graft.

Comment

Traumatic rupture of the thoracic aorta after blunt thoracic injury is the cause of death in about 15% of all traffic fatalities. ¹ With improved emergency transport, 20% to 30% of patients who sustain blunt trauma of the thoracic aorta survive until they reach the hospital. However, the mortality rate in these patients is very high. In modern centers, the use of transesophageal echocardiography (TEE) or spiral CT scanning is standard for diagnosing rupture of the thoracic aorta secondary to severe blunt chest trauma, ² and the 2 techniques are similar in regard to diagnostic accuracy. ³ Transesophageal echocardiography can also provide details about the extent and degree of injury to the heart and aorta. ³ Our patient presented with acute onset of severe dysphagia and shock 7 days after the initial trauma. We suspected that a large intramural hematoma of the esophagus secondary to isthmus rupture might have occurred as a delayed reaction to the automobile accident. Therefore, we arranged for the use of TTE rather than TEE, to avoid further esophageal trauma that might lead to free esophageal rupture.

Delayed rupture of the thoracic aorta into the esophagus after blunt thoracic trauma is very rare. To our knowledge, ours is the 1st report of a radiographic investigation in a patient who presented with dysphagia due to traumatic aortic rupture into the esophagus. This case highlights the devastating course of traumatic aortic rupture. If a patient in such a situation is to survive, he or she must be diagnosed early and undergo surgery as soon as the diagnosis is established.