Recent Clinical Experience With Left Heart Bypass Using a Centrifugal Pump for Repair of Traumatic Aortic Transection

Discussion continues regarding the optimal management of blunt injury to the thoracic aorta after trauma. With an estimated annual incidence of 7500 to 8000 cases in the United States, most surgeons with training in thoracic surgery and trauma will become involved with this injury at some point in their career. 1 The controversies surrounding the management of aortic transections are well known. Experimental data have clearly demonstrated that occlusion of the descending thoracic aorta for >30 minutes will result in spinal cord ischemia and paralysis. 2,3 This concept was confirmed in a clinical series published in 1981. 4 It has also been demonstrated that distal aortic perfusion in the form of a passive shunt effectively reduces this problem. 5 A recent prospective study, conducted by Fabian et al and sponsored by the American Association for the Surgery of Trauma, evaluated the management of blunt aortic injury in major trauma centers in the United States and Canada and found that the incidence of postoperative paraplegia was 8.7%. 6 This number is supported by a large retrospective multiinstitutional study that reported an overall postoperative paraplegia rate of 10.5% 7 and a large metaanalysis of existing English literature that demonstrated a paraplegia rate of 9.9%. 8 The concept of using a centrifugal pump without heparin for repair of these injuries was introduced in 1984. 9 In our initial experience, we had no instances of postoperative paraplegia, and we subsequently adopted this technique as our preferred method for managing this problem. Left atrial to femoral artery (LA-FA) bypass has been consistently shown in the literature to reduce or prevent postoperative paraplegia in patients with thoracic aortic trauma. 7–21 Despite this, 35% of cases in major trauma centers today are performed without distal aortic perfusion. 6 The purpose of this report is to review our overall experience with left heart bypass as an adjunct to the surgical management of traumatic descending aortic injuries to define the indications, results, and possible limitations of this technique.