Diagnosis
The diagnosis of aortic rupture is not easy to make. However, if a rupture is suspected, action must be taken very quickly, as the death rate is very high, depending on the size and location of the rupture. A rupture or dilatation of the aorta can be diagnosed by ultrasound, especially by swallowing ultrasound, CT and MRI. X-rays can give indications of a tear, but are not suitable for diagnosis.
First aid for aortic rupture
A surgical intervention is indispensable in the case of an acute aortic rupture. Therefore, if an aortic rupture is suspected, the emergency call (112) should be made immediately, as the patient must be taken to a cardiothoracic surgery clinic/centre as soon as possible. However, the diagnosis of an aortic tear is difficult without technical aids (e.g. ultrasound), since almost all tears are spontaneous rather than traumatic.
Until the emergency doctor arrives, it is necessary to place the patient in the stable lateral position in the event of unconsciousness, and in the shock position in the event of shock. Ensure sufficient warmth or a warming underlay, i.e. if possible cover the patient and do not lay him on a cold stone floor but on a carpet. The patient should be calmed down and sufficient oxygen should be provided (e.g. an oxygen probe should be applied if one is available due to previous illnesses of the patient).
Pulse and respiration should also be checked regularly until help arrives. If the circulation has already stopped, the patient must be resuscitated immediately (heart–lung resuscitation). Since only an operation can help to stop the bleeding, the emergency doctor can only treat symptoms before reaching the hospital. Symptoms such as severe chest/back pain, shortness of breath, unconsciousness, blood pressure differences in arms and legs, severe drop in blood pressure up to shock and complete circulatory failure may be present. The most important thing is to relieve these symptoms while keeping the circulation stable and relieving pain.
Therapy
Depending on the location and size of the aortic tear, there are various therapeutic options. The rupture can be treated by surgery with a vascular prosthesis, or by using a stent, which is inserted with the help of catheters. In addition, the blood pressure is brought up to about 110/60 with the help of medication and closely monitored.
The severe pain can be controlled with the help of opiates. There are two different surgical techniques for the surgical treatment of an aortic tear. The first technique is open, conventional treatment.
Here, the left thoracic cavity (thorax) is opened (so-called left-lateral thoracotomy) if the aortic tear is at the level of the thoracic aorta. If the aortic tear lies more in the region of the abdominal aorta, a longitudinal incision is usually made in the middle of the abdomen or, more rarely, a flank or transverse abdominal incision. The injured part of the aorta is exposed and either replaced with a prosthesis or closed with a direct suture.
This prosthesis can be a so-called tube or Y prosthesis made of plastic and closes the injured part of the aorta. A Y prosthesis consists of three connected tubes (Y-shape) and is chosen if connected vessels such as the pelvic arteries are also injured and have to be splinted. Otherwise the simpler tubular prosthesis is chosen.
This type of operation is a great risk, especially for polytraumatic patients, i.e. patients with serious and life-threatening concomitant injuries. The operation takes a very long time and is performed under general anesthesia. In addition, only one half of the lung is ventilated during the operation, and connection to a heart–lung machine may also be necessary.
The second technique is endovascular stenting (TEVAR = Thoracic Endovascular Aortiv Repair). In this case, computer tomographically supported angiography (imaging of the aorta with the help of imaging techniques) is performed first. During this examination the aorta can be assessed.
The appropriate size for a stent is selected. A stent is an expandable tube, which can be made of either metal or plastic mesh. Such a stent is inserted into the aorta.
This is done arterially via the arteria femoralis, i.e. the artery on the thigh. Under angiographic control, the stent is advanced via the femoral artery to the aorta and positioned at the site of the tear. The stent is now positioned over the aortic tear.
Over time, the endothelium (wall of the aorta) of the aorta can overgrow the stent and the closure of the tear and the preserved rag of the aorta are secured. Such an operation can also be performed under spinal or local anaesthesia and does not require general anaesthesia as in open surgery. An acute aortic tear is followed by a longer intensive medical treatment and monitoring.
In some cases, the affected person must be kept in an artificial coma so that the body has time to heal. The exact duration of healing cannot be determined, as this varies individually according to the person affected and the type of rupture and therapy. However, complete healing can take several months. During this time, the affected person is not physically able to take full strain.