Traumatic Aortic Rupture: Diagnosis and
Management
James S. Gammie, MD, Ashish S. Shah, MD, Brack G. Hattler, MD, PhD,
Robert L. Kormos, MD, Andrew B. Peitzman, MD, Bartley P. Griffith, MD, and
Si M. Pham, MD
Division of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Department of
General and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
Background. Traumatic aortic rupture is a relatively
uncommon lesion that presents the cardiothoracic sur-
geon with unique challenges in diagnosis and manage-
ment. To address controversial aspects of this disease, we
reviewed our experience.
Methods. The study was performed by retrospective
chart review.
Results. Forty-two patients with traumatic thoracic
aortic ruptures were managed between January 1988 and
June 1997. Nine arrived without vital signs and died in
the emergency department. Admission chest radiographs
were normal in 3 patients (12 %) and caused significant
delays in diagnosis. Four of 30 patients admitted with
vital signs had rupture before thoracotomy and died.
Twenty-six underwent aortic repair. In 1 patient repair
was performed with simple aortic cross-clamping,
whereas a second was managed with a Gott shunt. The
T raumatic rupture of the thoracic aorta (TRA) remains
a therapeutic challenge. Parmley and associates [1]
defined the natural history of this disease in a classic
autopsy series from the presurgical era, observing that
80% of patients die at the scene of injury of free rupture
and exsanguination into the chest. When the mediastinal
pleura, adventitia, and sometimes part of the aortic wall
are spared, the victim will have a mediastinal hematoma
of variable size and may survive to reach the hospital. Of
these patients, more than 50% succumb to mediastinal
hemorrhage over the ensuing week [1]. Aggressive diag-
nosis and timely operative intervention provide the op-
portunity to salvage most of these patients.
The most feared complication of operative repair of
TRA is spinal cord ischemia and paraplegia as a result of
thoracic aortic cross-clamping. Despite a vast literature,
controversy continues to surround the optimal method of
spinal cord protection [2–10]. Although there is substan-
tial evidence suggesting that the use of bypass to support
the distal circulation during aortic cross-clamping is the
safest approach [11], many surgeons continue to advocate
the “clamp and sew” technique [12], and more than one
Accepted for publication May 6, 1998.
Address reprint requests to Dr Pham, Division of Cardiothoracic Surgery,
University of Pittsburgh Medical Center, Suite C-700 PUH, 200 Lothrop
St, Pittsburgh, PA 15213 (e-mail: pham@pittsurg.nb.upmc.edu).
© 1998 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
remaining 24 patients had repair with partial left heart
bypass. In 1 patient hypothermic circulatory arrest was
required. Two patients (7.7%) died. There were no cases
of new postoperative paraplegia in the bypass group.
There was no morbidity directly attributable to the
administration of heparin for cardiopulmonary bypass.
Conclusions. In a discrete group of patients with trau-
matic rupture of the aorta, the rupture will become
complete during the first few hours of hospital admis-
sion; aggressive medical treatment with b-blockade and
vasodilators in the interval before the operation is an
essential aspect of management. Active distal circulatory
support with partial left-heart bypass provides the opti-
mal means of preventing spinal cord ischemia during
repair of acute traumatic aortic rupture.
(Ann Thorac Surg 1998;66:1295–300)
© 1998 by The Society of Thoracic Surgeons
third of repairs in North America are done without
bypass [9]. Because of the rarity of this injury, individual
experience in its management is necessarily limited. We
reviewed our experience at a level one trauma center
over the past 9 years to evaluate outcome and to outline
critical technical aspects of bypass management and
aortic repair.
Material and Methods
Between January 1988 and June 1997 we treated 42
patients with blunt injuries to the thoracic aorta. There
were 32 male and 10 female patients. Age ranged from 15
to 83 years, with a mean of 34 years. Three patients
sustained falls, 1 patient was a pedestrian struck by a car,
1 patient was hit by a falling tree, and the remaining 37
patients were involved in motor vehicle crashes.
Means are reported with standard deviations. Compar-
ison of continuous variables was with Student’s t test.
Results
Multiple injuries were the rule: injury severity scores
ranged from 26 to 59, with a mean of 40 6 9 (an injury
severity score of 40 predicts a mortality of 41%). Nine
patients arrived without vital signs. Eight of them under-
0003-4975/98/$19.00
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1296 GAMMIE ET AL Ann Thorac Surg
TRAUMATIC AORTIC RUPTURE 1998;66:1295–1300

Table 1. Clinical Characteristics of Patients With Free Rupture Early After Admission
Time to
Patient Admission SBP Max SBP Location Arresta Medical
No. Clinical History (mm Hg) (mm Hg) CXR of Arrest (min) Therapy

1 74-yo man, fall; 9 L fluid before 68 117 Hemothorax Operating room 75 No

arrival, L CT in ED: .2 L blood
2 77-yo man, fall; 2 L blood from 82 114 Hemothorax CAT scan 45 No
L CT before arrival, 10 units
PRBCs before arrival
3 75-yo man, MVA 74 144 Wide Angiography suite 65 No
4 47-yo man, MVA 134 230 Wide Operating room 130 No
a
Time from admission to arrest.
CAT 5 computed tomographic; CT 5 chest tube; CXR 5 chest radiograph; ED 5 emergency department; L 5 left; Max 5 maximum;
MVA 5 motor vehicle accident; SBP 5 systolic blood pressure; yo 5 year-old.

went emergency thoracotomy in the emergency de-
partment and 1 had bilateral chest tubes placed; none
survived. Families of 3 elderly patients with multiple
injuries and substantial comorbidities declined operative
intervention.
Four of 30 patients (13%) admitted with vital signs
progressed to complete aortic rupture within 2.5 hours of
admission, before repair could be completed (Table 1).
Three of 4 were hypotensive on arrival and probably had
active leaks (2 had hemothoraces on radiographs). A
fourth patient was normotensive (134/80 mm Hg) on
admission and was resuscitated with 4 L of crystalloid
and 2 units of packed red blood cells. Sustained hyper-
tension persisted over the first 2 hours in the hospital
(maximum systolic blood pressure 5 240 mm Hg), until
he suddenly became hypotensive during angiography.
Despite urgent transfer to the operating room, free rup-
ture of the aorta was visualized at thoracotomy and he
died. The remaining 26 patients underwent operative
repair of their thoracic aortic tears and form the sub-
stance of this report.
Time from hospital admission to repair ranged from 25
minutes to 127 hours, with a median of 5 hours. Four
patients had delays of more than 24 hours to repair. In 3
patients, normal admission chest radiographs were re-
sponsible for the delays, whereas the fourth patient had
repair postponed because of concern of anticoagulation
in the setting of a traumatic brain injury. Diagnosis in all
cases except 1 was confirmed with aortography. One
patient was taken to the operating room within 25 min-
utes of arrival on the basis of a highly suggestive chest
radiograph and transesophageal echocardiogram. Eight
patients (8/26 5 31%) were evaluated with transesopha-
geal echocardiography, which in all but one instance
clearly demonstrated a tear.
Three patients had normal chest radiographs on ad-
mission. Two of these films were available for retrospec-
tive review by a trauma radiologist and were confirmed
to be normal. Two of these patients had development of
Interval mediastinal widening developed 29 and 123
hours after admission in 2 of these patients, whereas the
remaining patient was noted to have a new pulse deficit
in his left arm 27 hours after arrival. In each case,
aortography confirmed the presence of a TRA.
All injuries with the exception of two were located in
the descending thoracic aorta at the level of the ligamen-
tum arteriosum, just distal to the takeoff of the left
subclavian artery. One tear extended proximally to the
transverse aorta and necessitated placement of an inter-
position graft to reconstruct the origin of the left subcla-
vian artery. Another patient had two tears: one at the
ligamentum arteriosum and a second on the underside of
the aortic arch. All repairs were performed via a left
posterolateral thoracotomy. Interposition grafts were
used in all patients but 1, in whom a primary repair was
done. Ten patients underwent laparotomy and 4 patients
underwent orthopedic procedures in addition to thora-
cotomy.
In 1 patient early in the series repair was performed
with the “clamp and sew” technique, whereas a passive
(aorta to aorta) heparin-bonded (Gott) shunt was used in
another. Since then all patients have had distal circula-
tory support with partial left-heart bypass as an adjunct
to aortic repair. Fourteen patients were managed with left
atrial to distal (distal aorta or femoral artery) bypass, and
10 were managed with venoarterial bypass (pulmonary
artery to distal bypass in 9, femoral venous to femoral
artery bypass in 1). Heparin requirements for each of
these strategies are listed in Table 2. The heparin dose
was higher for the venoarterial bypass group (mean, 316
units/kg) versus the left atrial to distal group (mean, 73
units/kg). In general, patients given heparin for cardio-
pulmonary bypass had some form of assessment of their
intracranial status before the operation. Among 24 pa-
Table 2. Method of Distal Circulatory Support
No. of Heparin Dose
Method Patients (units/kg, mean [range])
LA to distal 14 73 (0 –125)
Venoarterial bypass
PA to distal 9 316 (50 – 480)
Femoral to femoral 1 300
Gott shunt (Ao to Ao) 1 0
Clamp and sew 1 0
Ao 5 aorta; distal 5 distal aorta or femoral artery; LA 5 left atrial;
PA 5 pulmonary artery.
Ann Thorac Surg
1998;66:1295–1300
tients placed on bypass, 14 had negative head computed
tomographic scans before the operation. Of the remain-
ing 10 patients, 1 had a small subdural hematoma and
was given minimal-dose heparin for partial left-heart
bypass, 5 had nonfocal neurologic examinations with a
Glasgow coma scale score of 15, 2 had Glasgow coma
scale scores less than 15 in association with a nonfocal
examination, and 2 were not fully assessed.
Comparison of the low-dose heparin group (left atrial
to distal bypass) and the full-dose heparin group (veno-
arterial bypass) revealed no differences in outcome as
assessed by duration of mechanical ventilation (median,
9 versus 4; p 5 0.9), hospital length of stay (19 versus 13
days; p 5 0.8), or mortality (there was one death in each
group).
Median cross-clamp time was 49 minutes. Median
cardiopulmonary bypass time was 54 minutes. Femoral
artery mean arterial pressure during bypass ranged from
40 to 88 mm Hg, with a mean of 65 6 12 mm Hg. Proximal
mean arterial pressure during bypass ranged from 52 to
115 mm Hg, with a mean of 82 6 18 mm Hg. Gradients
(proximal 2 femoral mean arterial pressures) ranged
from 26 to 53 mm Hg, with a mean of 117 6 24 mm Hg.
Bypass circuit flows ranged from 0.9 to 2.4 L/m2 per
minute, with a mean of 1.4 6 0.4 L/m2 per minute.
Overall hospital mortality for patients undergoing re-
pair was 2 of 26 (7.7%). One death occurred in a 58-year-
old woman involved in a motor vehicle accident. Associ-
ated injuries included multiple rib fractures and a
malleolar fracture. Aortic repair was performed using
venoarterial (pulmonary artery to aorta) bypass. Cross-
clamping of the aorta precipitated hemodynamic deteri-
oration with bradycardic arrest. Postoperatively she suf-
fered two additional cardiac arrests and died on
postoperative day 7 of multiple organ failure. Autopsy
revealed significant two-vessel coronary artery disease
and a small myocardial contusion. The second death was
in a 30-year-old man who underwent repair using left
atrial to distal aortic bypass. At the time of cross-
clamping, massive bleeding occurred from a second,
previously unrecognized, tear in the underside of the
aortic arch. Before control could be secured, he exsangui-
nated.
Two patients suffered paraplegia. One was a 28-year-
old man with multiple injuries including a ruptured
spleen and a liver laceration necessitating splenectomy
and hepatorrhaphy. He also sustained a closed head
injury with a subdural hematoma and multiple rib and
extremity fractures. Initial diagnosis of his thoracic aortic
injury was delayed as a result of a normal admission
chest radiograph. A widened mediastinum developed 5
days after admission. He was repaired without hepa-
rinization with the use of a Gott (aorta to aorta) shunt.
Lower extremity paralysis was noted postoperatively in
the intensive care unit, and somatosensory evoked po-
tentials confirmed a spinal cord lesion. The second pa-
tient was a 19-year-old man injured in a motor vehicle
accident who also had a normal admission chest radio-
graph. Suspicion of an aortic tear was raised when a
marked pulse deficit developed in the left arm 27 hours
GAMMIE ET AL 1297
TRAUMATIC AORTIC RUPTURE
Table 3. False-Negative Admission Chest Radiograph Rates
Normal
Radiographs/Total
Author Year (%)
Hilgenberg et al [3] 1992 3/48 (6.2)
Higgins et al [14] 1992 0/19 (0)
Walls et al [5] 1993 4/27 (14.8)
Read et al [6] 1993 3/16 (8)
Hunt et al [2] 1996 6/144 (4)
Fabian et al [9] 1997 19/259 (7)
Gammie et al (present study) 1998 3/26 (12)
after admission. Aortography confirmed the tear at the
aortic isthmus. He was noted on arrival to the operating
room to be without femoral pulses and to have developed
paraplegia. Aortic repair was performed with left atrial to
femoral bypass. Postoperative somatosensory evoked po-
tentials identified a lesion at the level of the spinal cord.
Median intensive care unit length of stay was 7 days,
with a range of 2 to 35 days. Total hospital stays ranged
from 7 to 51 days, with a median of 16 days. There were
26 complications in 15 patients: prolonged respiratory
failure (vent . 4 days), 10; pneumonia, 7; pancreatitis, 4;
vocal cord paresis, 1; acute renal failure (temporary
hemodialysis), 1; missed duodenal injury, 1; candidemia,
1; and cortical blindness, 1.
Comment
This report details a recent clinical experience with
traumatic rupture of the thoracic aorta. This is an uncom-
mon injury: among an average of 1,600 blunt trauma
admissions per year at our center during the study
period, 4.4 TRAs were diagnosed and 3.2 were repaired.
A recent survey of 50 trauma centers in North America
documented an average of 2.2 cases of TRA per center
per year [9]. The relatively infrequent occurrence of this
entity means that few surgeons are able to accrue large
personal experiences. We have reviewed our experience
to emphasize critical aspects of diagnosis, medical man-
agement, techniques of distal circulatory support, and
operative repair.
Three of 26 patients (12%) in this series had normal
admission chest radiographs, even when reviewed retro-
spectively. These-false negative radiographs caused sig-
nificant delays in treatment of the underlying thoracic
injury. These patients had 30-, 33-, and 127-hour intervals
from injury to repair, in comparison with a median time
to repair of 5 hours for the entire series. Delays in
treatment in 1 case almost certainly and in another likely
contributed to paraplegia. Woodring and King [13] re-
ported two normal chest radiographs in a series of 32
patients with known thoracic aortic transections, for a
false-negative rate of 6%. Other recent surgical series [3,
5, 6, 14] have reported false-negative rates between 0%
and 15% (Table 3).
Our experience is at odds with the radiology literature,
which suggests that a normal chest radiograph is strong
1298 GAMMIE ET AL Ann Thorac Surg
TRAUMATIC AORTIC RUPTURE 1998;66:1295–1300

evidence for the absence of an underlying aortic injury. Table 4. Summary of Morbidity and Mortality With Partial
Mirvis and colleagues [15] reviewed the admission chest Left Heart Bypass
radiographs of 205 patients with blunt trauma undergo- Author Year Patients Paraplegia Mortality
ing aortography, 41 of whom were found to have aortic
tears. They concluded that a normal interpretation of an Benckart et al [23] 1989 21 0 3
erect chest radiograph has a negative predictive value of Hess et al [7] 1989 16 0 1
98%. Marnocha and Maglinte [16] concluded that a nor- Higgins et al [14] 1992 10 0 0
mal aortic arch combined with the absence of tracheal Read et al [6] 1993 16 0 2
and nasogastric tube deviation ruled out an aortic injury. Walls et al [5] 1993 8 0 1
Our series, in accordance with previous reports in the Forbes and Ashbaugh 1994 21 0 4
surgical literature, demonstrates a surprisingly high in- [8]
cidence (12%) of normal admission chest radiographs in Nicolosi et al [24] 1996 18 0 ...
patients with TRA. A high level of suspicion is necessary Fabian et al [9] 1997 43 2 7
to avoid the catastrophic results of a missed aortic injury. Gammie et al 1998 24 0 2
(present study)
Although some reports have suggested that medical
therapy and deliberate delayed operative therapy is Total 177 2 (1.1%) 20 (11.3%)
acceptable management of a TRA [17], 4 of 30 patients
(13%) in this series admitted with vital signs had rupture
within 2.5 hours of arrival and died. Of these 4 patients distal flow, and clinical data confirmed high rates of
experiencing free rupture during initial diagnostic and paraplegia. Mattox and colleagues [21] and others advo-
resuscitative measures, it is clear that at least 2 had cated simple cross-clamping of the aorta and repair of the
substantial leaks before arrival. Three of 4 were hypoten- injury without distal circulatory support. The “clamp and
sive at the time of admission. The 1 patient with sus- sew” technique emphasizes speed of repair, with many
tained hypertension during the first 2 hours after admis- authors demonstrating a benefit to cross-clamp times
sion likely would have benefited from pharmacologic less than 30 minutes [19]. Olivier and associates [22]
blood pressure control. Few patients in our series re- introduced the technique of left atrial to femoral bypass
ceived medical therapy (b-blockade, antihypertensives), with the centrifugal pump in 1984 and began the current
in accord with practice across North America: Fabian and trend favoring this technique for mechanical distal circu-
associates [9] documented that only 17% of patients with latory support.
TRA received medical therapy. Our experience suggests A recent metaanalysis of articles reporting outcomes of
that the threat of completion of rupture of a thoracic treatment of traumatic thoracic aortic tears in more than
aortic injury in the early hours after admission is real, 1,000 patients provides strong support for the use of
and institution of aggressive blood pressure control dur- mechanical partial left heart bypass during repair of TRA
ing expeditious evaluation should not be overlooked. [11]. Overall paraplegia rates were 19.2% for simple
b-Blockade, possibly in combination with vasodilators cross-clamping, 11.1% for passive (Gott) shunting, and
and analgesics, should be given to all hemodynamically 2.3% for active augmentation of distal perfusion. These
stable patients undergoing evaluation for a possible TRA. data also emphasized the rapid increase in the incidence
The presence of hypotension not readily explained by of paraplegia that occurs with cross-clamp times in
identified injuries should increase concern for imminent excess of 30 minutes when the “clamp and sew” tech-
rupture. nique is used. Our experience with paraplegia after
All patients except 2 in this series were supported repair performed with active distal circulatory support is
intraoperatively with partial left-heart bypass. The opti- similar to recent series reporting minimal neurologic
mal method of preventing spinal cord injury in the morbidity with partial left-heart bypass. In 177 patients
patient with TRA has been a source of considerable undergoing repair of TRA with distal circulatory support,
debate in the literature [3–10]. The approach to intraop- the incidence of paraplegia was only 1.1% (Table 4).
erative protection of the spinal cord during repair of TRA Paraplegia did not develop in any patient in our series
has evolved. Initial reports of repair on full cardiopulmo- arriving in the operating room in hemodynamically sta-
nary bypass emphasized prohibitive rates of hemor- ble condition and without evidence of preexisting neu-
rhagic complications. Mortality was attributed to uncon- rologic compromise. Despite the compelling weight of
trolled bleeding as a sequela of obligatory systemic published evidence supporting the role of distal circula-
heparinization for cardiopulmonary bypass. However, in tory support in minimizing the devastating complication
many of these reports investigation of intraabdominal of paraplegia after TRA, support for the “clamp and sew”
injuries was deferred until aortic repair was completed, technique remains strong [12]. In general, these authors
with predictable adverse consequences. Gott [18] intro- acknowledge the importance of the 30-minute ceiling
duced the 9-mm heparin-bonded shunt with inflow from and express confidence in their ability to complete the
either the proximal aorta or left ventricular apex and repair in less than this time. Fabian and associates’ [9]
outflow to the descending thoracic aorta or the femoral survey of North American trauma centers documented a
artery, as a means of supporting the spinal cord and cross-clamp time in excess of 30 minutes in 67% of cases.
viscera [19]. Experimental work by Molina and associates Since the mid 1980s, our approach to distal perfusion
[20] suggested that the Gott shunt provided inadequate during repair of traumatic transections of the aorta has
Ann Thorac Surg
1998;66:1295–1300
almost exclusively been one of partial left-heart bypass
(see Table 2). We carry out partial left-heart bypass in
one of two ways. Left atrial to femoral artery (or descend-
ing aorta) bypass is usually established with minimal
heparin (5,000 units) and consists of a simple circuit with
only a centrifugal pump. Recently we have cannulated
the posterior surface of the inferior left pulmonary vein
with a 24F cannula in lieu of the atrial appendage. This
has provided flow of 2 to 3 L/min and is an effective
nonpharmacologic means of controlling blood pressure
in proximal and distal circulations. In contrast, venoarte-
rial bypass requires full systemic heparinization and a
complete cardiopulmonary bypass circuit, including an
oxygenator, heat exchanger, and cardiotomy. For veno-
arterial bypass, we generally cannulate the pulmonary
artery with a 32F right-angle cannula (TF-032-L-90; Re-
search Medical Inc, Midvale, UT) directed toward the
right ventricle for inflow and the femoral artery or
descending aorta for outflow. The pulmonary artery is a
reasonable option for inflow when venoarterial bypass is
used because it is easily accessible via a left thoracotomy
and offers adequate inflow and ease of cannulation. An
excellent (and perhaps superior) alternative for inflow for
venoarterial bypass is venous cannulation of the femoral
vein (femorofemoral bypass).
Venoarterial bypass offers several advantages over left
atrial to femoral bypass. These include the ability to cool
to 34°C (which may enhance spinal cord protection) and
later rewarm the patient (of particular importance in the
coagulopathic trauma population). An oxygenator in the
circuit avoids difficulties in maintaining adequate oxy-
genation of the patient during single-lung ventilation. In
our experience, intubation with a double-lumen tube is
not always possible (eg, massive orofacial injuries) and
the presence of venoarterial bypass permits discontinu-
ation of ventilation to achieve critical exposure. Venoar-
terial bypass also affords the surgeon the option to
perform hypothermic circulatory arrest should a complex
aortic tear be encountered, as was necessary in 1 patient
in this series. By using venoarterial bypass, the perfu-
sionist can rapidly add volume to the circuit, a capability
not present with the left atrial to femoral circuit without
adjunctive rapid infusion systems. Cross-clamping of the
aorta predictably leads to proximal hypertension, distal
hypotension, and a markedly increased left ventricular
afterload that may necessitate the concomitant adminis-
tration of vasodilators, inotropic agents, and the admin-
istration of volume in the patient on left atrial to femoral
bypass. Administration of vasodilators during aortic
cross-clamping can initiate a deleterious steal of perfu-
sion from the spinal cord. Venoarterial bypass mitigates
these concerns by permitting complete unloading of the
left ventricle and affording a means of rapidly replenish-
ing volume. Arterial pressures are maintained at desired
levels by simply adding or removing blood from the
circuit. Finally, shed blood can be returned to the bypass
circuit, and venoarterial bypass offers superior support to
a failing heart.
The principal disadvantage of venoarterial (pulmonary
arterial to femoral) bypass is the requirement for full
GAMMIE ET AL 1299
TRAUMATIC AORTIC RUPTURE
heparinization. Although long-standing dogma held that
heparinization in this population of patients was highly
undesirable, Pate and associates [10] have recently
pointed out that there are few data to support this belief.
In our experience, most patients were assessed for intra-
cranial and intraabdominal injury before administration
of heparin for bypass. We did not observe bleeding
complications resulting from heparinization in any pa-
tient in this series. In addition, comparison of the low-
dose (left atrial to femoral) and full-dose (venoarterial)
heparin treatment groups revealed no relationship be-
tween heparin dose and outcome.
Technical aspects of safe repair include a generous
fourth intercostal space thoracotomy for optimal expo-
sure and repair of thoracic aortic injuries. Double-lumen
intubation should be performed when feasible to permit
single-lung ventilation and provide wide exposure. Prox-
imal control of the aortic arch should be between the left
carotid and subclavian arteries, with separate control of
the subclavian artery. Bypass is established and dissec-
tion commenced. Once the aorta has been clamped, the
extent of the tear is assessed, and the distal clamp is
repositioned as close as possible to the injury to allow
maximal perfusion of the intercostal vessels from the
distal pump flow. The adventitia surrounding the injury
is typically distorted by hematoma and invariably has
retracted. It is critically important to incorporate gener-
ous amounts of adventitia within the suture line.
In conclusion, traumatic rupture of the aorta is an
uncommon injury that requires aggressive diagnosis and
treatment. Our review has emphasized several important
aspects of the management of this disease. A TRA can be
present despite a normal chest radiograph, and the
resulting delays in treatment can lead to significant
morbidity. Progression of TRA to complete rupture can
occur within hours of hospital admission. Judicious ad-
ministration of a b-blocker and vasodilators to patients
with a suspected TRA should begin in the emergency
department and continue to operation. Distal circulatory
support is critical for effective spinal cord protection.
Administration of heparin for bypass, in our experience,
was not associated with significant morbidity. Manage-
ment options for bypass include left atrial to distal and
venoarterial bypass. The decision as to which to use
should be tailored to the specific clinical situation.
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J. Kent Trinkle, MD 1934 –1998
It is with great sadness that we report the death of Dr
Kent Trinkle, member of the Editorial Board of The
Annals of Thoracic Surgery for 15 years, and Associate
Editor for 8 years, first in charge of Book Reviews, and
later the Section on Collective and Current Reviews. In
addition to his duties as Chief of the Division of Cardio-
thoracic Surgery at the University of Texas Health Sci-
ence Center in San Antonio, plus his numerous other
commitments at the local, state, and national level, Kent
was always a faithful supporter of our journal. He de-
© 1998 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
Ann Thorac Surg
1998;66:1295–1300
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voted a great deal of time and effort to improving The
Annals, and for this we are grateful beyond measure. We
shall miss him as an Editorial Board member, but much
more as a superb human being. I invite you to read the
homilies about Dr Trinkle written by his two long-time
associates, Dr Fred Grover and Dr John Calhoon, in the
Transitions Section of the CTSNet.
Tom Ferguson
Editor, The Annals of Thoracic Surgery
Ann Thorac Surg 1998;66:1300 • 0003-4975/98/$19.00