Contemporary Thoracic Aortic and Abdominal Injuries: An Emergency Strategy.

To the Editor: Topcu and colleagues [1] interestingly bring attention to the management of contemporary injury of the thoracic aorta and spleen. On the basis of our experience, we would like to consider some basic points. In each case of severe thoracoabdominal trauma, it is essential to perform a hemodynamic monitoring and contrast-enhanced computed tomography (CT) angiography to detect a condition of circulatory instability, and to obtain a complete imaging of the thorax, abdomen, and vessels. The most common injuries of the thoracic aorta involve isthmus. In addition, high-grade lesions (III and IV) are preferentially treated with an endovascular technique [2]. Usually, treatment priority is given to the aortic isthmus injuries, possibly considering an endovascular procedure [3]. Subsequently, the other concomitant injuries, especially abdominal ones, must be treated adequately. This strategy was applied successfully in our last consecutive 5 cases of injuries of the aortic isthmus of grade IV, with an associated spleen rupture (3 cases) and a liver laceration (2 cases), obtaining a complete recovery without important complications. On the contrary, a prompt emergency laparotomy becomes necessary when an endovascular treatment is not possible, and the subsequent cardiovascular surgery requires a cardiopulmonary bypass and a prolonged full heparinization, with the risk of increased or recurrent abdominal hemorrhage [1]. Interestingly, we applied an equivalent strategy in three cases of injuries of the left subclavian artery, with secondary hemothorax and associated blunt abdominal trauma [4]. CT allowed a precise diagnosis of the vascular injury. A prompt endovascular treatment was successful, and the subsequent laparotomy for spleen rupture followed without difficulties. When this strategy is not possible, direct surgery of the injured supraaortic branch is indicated. In cases of polytrauma involving contemporaneously the thoracic aorta or its supraaortic branches and the abdomen, and an associated massive hemoperitoneum and hemodynamic instability, a prompt laparotomy becomes necessary. It must be performed under careful hemodynamic control, avoiding increase or recurrence of the thoracic hemorrhage after resolution of the circulatory hypotension. We believe that these challenging clinical situations merit further study and contributions.