Post-traumatic lesions of the aortic isthmus Ann. Ital. Chir., 80, 2, 2009 89 Ann. Ital. Chir., 2009; 80: 89-100 Stefano Maria Giulini°, Stefano Bonardelli* Department of Medical and Surgical Sciences (Direttore: Prof. S.M. Giulini), Università degli Studi – A.O. Spedali Civili, Brescia, Italy ° UO and Chair of Clinical Surgery * USD and Chair of Vascular Surgery Lesions of the isthmus are most often the result of trau- mas of the thoracic aorta: almost always secondary to closed thoracic traumas (road accidents, falls, crushing, and explosions), they are rarely caused by penetrating wounds (knife and fire arm wounds) or are iatrogenic (operatory catheterisms). Suffering from a high, often immediate mortality rate, they are difficult to treat even in the minority of patients who remain alive until they are hospitalised. In these cases, endovascular aortic exclu- sion (T-EVAR) is today a further therapeutic option com- pared with the, by now, classic alternative between at least initially conservative treatment, based mainly on controlled hypotension, and thoracotomic aortic replace- ment which, in emergency or urgency, in any case has a high mortality rate, also due to the associated lesions that are very frequent in these almost always multi-trau- matised patients, and by specific morbidity – particu- larly serious in terms of the risk of cerebral haemorrhage and paraplegia. Incidence In 1557 Andrea Vesalio described the first case of death from post traumatic thoracic aorta lesion (LTA) in a man who had fallen from his horse 1 . If we exclude direct lesions, moreover almost always fatal, the LTA is caused by a sudden deceleration of the thorax due to impact with a fixed obstacle: for this reason the incidence of immediately lethal cases, once modest, grew initially in a way that is directly proportional to the increase in the spread of high speed vehicles, to then decrease in an equally significant manner with the spread of modern car safety systems, introduced and subjected to on-going development on the basis of the definition of phys- iopathological LTA mechanisms, obtained from autoptic studies, data obtained from experimental animal models and finally from increasingly sophisticated computerised simulations. 2-6 . Pervenuto in Redazione Dicembre 2008. Accettato per la pubblicazio- ne Gennaio 2009. Per corrispondenza: Stefano Bonardelli, MD, Via Sabbionina 3, 25075 Nave (Brescia) (E-mail: s.bonardelli@tiscali.it - bonardel@med.unibs.it) Post-traumatic lesions of the aortic isthmus Lesions of the isthmus are the most frequent among post-traumatic lesions of the thoracic aorta (LTA): almost always secondary to closed thoracic traumas (road accidents, falls, crushing, and explosions), they are rarely iatrogenic (operato- ry catheterisms) or caused by penetrating wounds. In the review of the literature concerned in the report, from the analy- sis of 89 bibliographic sources, we note that the etiopathogenesis and the pathophysiology of the LTA still entail a very high immediate mortality, but we also note that, in recent years, remarkable improvements have been made not only in prevention, first-aid, diagnostic definition and in the understanding of the development of the LTA, but above all in therapeutic results. The correct use of the conservative approach, particularly in the immediately post-traumatic phases, the increasingly wide-spread use of endovascular exclusion (T-EVAR), even if not without numerous technical difficulties, and the further improvement of open surgery, currently make it possible to guarantee the individual patient the treat- ment that can offer the best probabilities of success, at least immediately. Final development, and a more complete and rigorous assessment of the medium and long term results of TEVAR will allow the formulation of therapeutic strategies that are even better defined and increasingly simple to implement, on the basis of algorithms, such as the one proposed by the Authors. KEY WORDS: Aortic rupture, Evar, Isthmus, (T-EVAR), Trauma. LEADING ARTICLE