Stable Penetrating Chest Trauma

Annotation for Point J

When performing operative repair, the ascending aorta, innominate, left common carotid, and origin of the left subclavian can be approached by sternotomy or dedicated clamshell. It is best to open the pericardiumand dissect along the ascending aorta. This allows proximal control with a decreased risk of inadvertently decompressing the injury. Distal control can be obtained by neck or supraclavicular extensions. Injuries to the descending aorta are best approached via left thoracotomy, the level of incision being determined by the site of injury. As described previously, caval occlusion can permit repair of ascending aortic injuries (even through and through). If the patient has no other exsanguinating injuries, cardiopulmonary bypass (including circulatory arrest) can permit repair of injuries that would be otherwise difficult to control. ^25,46 In general, simple suture repair with or without pledgets is sufficient. If repair results in significant narrowing or there is extensive loss of vesselwall, resection and end-toend anastomosis can be performed if there is no tension. Repair with synthetic graft material is required if there is significant tissue loss.¹³ If anticipated, the use of temporary shunts to bypass injuries before entering the hematoma has been described.²⁵ Injuries at the origin of the great vessels are often best approached by side clamping at the origin, division of the vessel, mattress closure of the aortic wall, and then ascending aortic end-to-end graft to the distal vessel. Others prefer to start with an ascending aortic end-to-side graft to the affected vessel and then to ligate the origin at the injury site, but we have seen issues with late embolism from the arterial stump.