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Trauma associated with the anatomical variation of thoracic great vessels
(Portuguese PDF version)

Ricardo Costa-Val¹, João Batista de Rezende-Neto², Leonardo P. Q. Silva³, Eduardo Vergara Miguel⁴, Tatiana Karina De Puy e Souza⁵

1. PhD student in Surgery, Universidade Federal de Minas Gerais (Brazil). Cardiovascular surgeon, Department of Trauma, Hospital João XXIII/FHEMIG, Belo Horizonte, MG, Brazil.
2. PhD in Surgery, Universidade Federal de Minas Gerais (Brazil). General surgeon, Department of Trauma, Hospital João XXIII/FHEMIG, Belo Horizonte, MG, Brazil.
3. General surgeon, Department of Trauma, Hospital João XXIII/FHEMIG, Belo Horizonte, MG, Brazil.
4. Vascular surgeon, head of the Service of Cardiovascular Trauma at Hospital João XXIII/FHEMIG, Belo Horizonte, MG, Brazil.
5. Undergraduate student in Medicine, Faculdade de Barbacena, Barbacena, MG, Brazil.

Correspondence:
Ricardo Costa Val
Rua Aimorés, 612/1103
CEP 30140-070 - Belo Horizonte - MG, Brazil
Tel.: +55 31 9972.6066/3224.2974
E-mail: costaval@mkm.com.br

J Vasc Br 2004;3(1):55-6

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PART I - CASE REPORT

Male, 21-year-old patient, previously healthy, had a gunshot wound. Clinical records at admittance (according to the Advanced Trauma Life Support - ATLS® - protocol) were: A - free airways, no alterations in cervical spine; B - breathing frequency at 25 bpm (breaths per minute); C - hemodynamically stable, systolic arterial pressure at 150 mmHg, symmetrical peripheral pulses; D - no neurological disabilities, Glasgow Coma Scale = 15; E - entrance wound in the 4th left intercostal space, in the mean axillary line. Results at initial examination: a) chest radiograph: small hemopneumothorax to the left, 4th rib fractured, bullet in superior mediastinum and great deviation of the trachea; b) chest computed tomography: no signs of lesions in subclavian arteries or the descending thoracic aorta, despite the important deviation of the trachea (Figure 1).

Figure 1 - Chest computed tomography; two views evidencing the bullet in superior mediastinum as well as a great deviation of the trachea to the right.

The patient underwent left thoracic drainage and was sent to a room for continuous observation of the trauma. Since the patient had a gunshot wound in the area of superior mediastinum associated with imaging findings at initial examination, the hypothesis of lesion to thoracic great vessels was suggested.

What would you do in such circumstances?

Would you perform surgery considering the possibility of lesions to the thoracic great vessels ?

Would you perform a hemodynamic study (such as aortography) in order to confirm the diagnosis? It is worth mentioning that such a procedure is not available at Hospital João XXIII/FHEMIG; it would require that the patient be transferred temporarily to another hospital.

Would you only monitor the evolution of the case?

Click here for the answer of the diagnostic challenge.