1. Blunt Aortic Injury with Concomitant Intra-abdominal Solid Organ Injury: Treatment Priorities Revisited
Santaniello J, et al, The Journal of TRAUMA Injury, Infection, and Critical Care. 2002;53:442–445.

2. Background Blunt aortic injury (BAI):
90% mortality within first 24 hours
Second leading cause of death in blunt trauma
15%~20% BAI patient with concomitant liver/spleen (L/S) injuries
Cardiopulmonary bypass with heparinization for repair of BAI  L/S operation before aortic repair?
Majority of blunt L/S injuries are now treated non-operatively in hemodynamically stable patients
Evaluates safety of acute BAI repair using partial bypass with full heparinization in patients undergoing non-operative management (NOM) for low-grade blunt L/S injuries
Conclusion: NOM of patients with
grade I or II L/S injury who undergo systemic
anticoagulation with heparin for repair
of BAI is safe and associated with
transfusion rates similar to BAI alone. Patients
with low-grade liver or spleen injuries
do not require laparotomy before BAI
repair using partial bypass.

3. Patients and Methods
BAI patient in Presley Regional Trauma Center over a 6-year period
Study group: Patient with concomitant liver or spleen injury (Aorta L/S group)
Control: patient with L/S injury but without BAI (L/S group)

4. Aortic Injury Management
Patient screened by chest & abdominal CT  thoracic aortography
Blood pressure and heart rate controlled pharmacologically to (SBP~100mmHg, HR < 100 bpm)
BAI repaired by partial bypass with full heparinization

5. Solid Organ Injury Management
Diagnosed by CT and graded by American Assoiciation for the Surgery of Trauma organ injury scale
Aorta L/S vs. L/S
Aorta L/S vs. Aorta

6. Results 84 patients with BAI
56 p’t without associated intra-abdominal injury
28 p’t with concomitant liver and/or spleen injury
Aorta L/S group: 20 patients with solid organ injury (Table 1)
L/S group: 894 patients with grade I/II hepatic or splenic injury
Aorta L/S group vs. L/S group (Table 2)
Aorta L/S group vs. Aorta group (Table 3)
Complication rates (Table 4)

7. Results
No difference in resource use (length of stay) or failure of non-operative solid organ injury management
Similar overall complication rate

8. Discussion1
Past: positive peritoneal lavage  laparotomy  aortic repair
Present: recent shift in management of blunt L/S injuries to non-operative management
Aortic repair with involvement of systemic anticoagulation  increase risk of hemorrhage?
Approaches to BAI with blunt L/S injury:
1. Delay repair of aorta until injured intra-abdominal organ has healed  longer hospital stay in increased costs
2. Perform laparotomy with removal or repair of injured solid organ with subsequent repair of aorta  high morbidity and risk of post-splenectomy sepsis syndrome
3. Clamp-and-sew method for aortic repair  cross-clamp time

9. Discussion2
No increase in the rate of NOM failure for solid organ injury when partial bypass with full heparinization were used
Low-grade liver and spleen injury can be anticoagulated acutely with little or no risk of delayed hemorrhage
Conclusion:
An aortic injury in association with low-grade liver or spleen injuries can be repaired acutely using partial bypass with full heparinization safely and effectively
Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass

10. Study Limitations
Retrospective, deals with grade I or II solid organ injury only
The safety of heparinizing patients with higher grades of liver or spleen injuries (III–V) was not studied, and no conclusions can be drawn for those patients
The high incidence of concomitant injuries, specifically, head injury and fractures, was not addressed

11. Thanks for Your Attention!!!

12. Aorta L/S Group

13. Aorta L/S vs. L/S

14. Aorta L/S vs. Aorta

15. Complications
Similar overall complication rates (45% vs. 32%, p = NS)