New this month in Scientific American Vascular and Endovascular Surgery:
- Initial Management of Life-Threatening Trauma
- Injuries to the Chest
- Neurogenic Thoracic Outlet Syndrome
(a) A left anterolateral thoracotomy is performed through the fifth intercostal space. (b) The lung is reflected superiorly for placement of a Satinsky vascular clamp on the descending thoracic aorta. A pericardiotomy is performed with scissors anterior to the phrenic nerve. (c) A so-called butterfly extension across the sternum creates a bilateral anterolateral thoracotomy, providing access to both thoracic cavities and to the pulmonary hila, the heart, and the proximal great vessels.
FREDERICK A. MOORE, MD, FACS
Professor of Surgery, University of Florida, Gainesville, FL
ERNEST E. MOORE, MD, FACS
Chief of Surgery Trauma, Denver Health, Professor and Vice-Chair of Surgery, Bruce M. Rockwell Distinguished Chair of Trauma, University of Colorado, Denver, CO
With the expansion of endovascular techniques in the management of vascular trauma, there has been increasing interest in the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in cases of exsanguinating hemorrhage after trauma. REBOA does not address life-threatening intrathoracic injuries and is not a substitute for emergency department thoracotomy for penetrating chest wounds. Although there has been some controversy over the optimal radiologic imaging technique, newer 64-slice computed tomographic angiographies appear to be as accurate as formal angiograms and are much easier to obtain, with notably fewer complications.
(a) Chest radiograph and (b) illustration demonstrating flail chest.
AMY N. HILDRETH, MD, FACS
Assistant Program Director, Surgical Sciences-Surgery Trauma, Assistant Professor, Surgery, General, Wake Forest School of Medicine, Winston-Salem, NC
J. JASON HOTH, MD, PhD, FACS
Associate Professor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
J. WAYNE MEREDITH, MD, FACS
Director, Surgical Sciences, Wake Forest School of Medicine, Winston-Salem, NC
Chest injuries and rib fractures in particular play a significant role in determining the presence of chronic pain and disability after trauma. Several studies have demonstrated that occult pneumothorax may be observed safely, even in the presence of positive pressure ventilation. In adult patients with posttraumatic empyema, the role of intrapleural fibrinolytic therapy remains controversial.
Anterior view of the right thoracic outlet.
KARL A. ILLIG, MD
Professor of Surgery, Director, Division of Vascular Surgery, Associate Chair, Faculty Development and Mentoring, University of South Florida Morsani College of Medicine, Tampa, FL
Resident, Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
Until quite recently, there have been no guidelines for evaluation, diagnosis, or even terminology for neurogenic thoracic syndrome (NTOS). Recent attempts at standardization have focused on terminology to ensure that vascular surgeons, thoracic surgeons, and neuro-surgeons are all discussing the same entities. It is recommended that for the diagnosis of NTOS to be made, three of the four following primary findings should be present: (1) a history of appropriate symptoms, locally and distally; (2) a characteristic physical examination, with findings both locally and distally; (3) an absence of other diagnoses that could reasonably explain the symptoms; and (4) when performed, a positive response to a scalene test injection. Such symptoms should have been present for least 6 months and be present most of the time and/or truly interfere with the patient’s life.