Keywords
shrapnel wound
aortic arch
ascending aorta
thermal coagulation
thrombosis
pericardial tamponade
combat trauma
How to Cite
Abstract
Introduction. Combat-related injuries of the aorta are predominantly fatal, especially in the absence of immediate cardiothoracic surgical intervention during the early stages of evacuation. Injuries of the aortic arch and ascending aorta are usually accompanied by massive hemorrhage and rapid death on the battlefield; therefore, reports of survival are extremely rare. In most published cases, survival is associated with the specific caliber, shape, and trajectory of the projectile, as well as with pathophysiological mechanisms that can temporarily restrict bleeding.
Aim. To present an exclusive clinical case of survival after a through-and-through shrapnel injury of the aortic arch and ascending aorta resulting from mine-explosive trauma.
Materials and methods. A comprehensive clinical and instrumental analysis was carried out in a serviceman with a mine-explosive injury. Diagnostic workup included chest radiography, dynamic contrast-enhanced computed tomography, echocardiography, intraoperative observations, and the conclusions of a multidisciplinary team consultation.
Case Data. The patient sustained a through-and-through shrapnel wound of segment A of the aortic arch with an exit into the ascending aorta and pericardial cavity. The metallic fragment, approximately 3 mm in diameter, had a spherical shape and demonstrated features of high-temperature impact, resulting in thermal coagulation of the vascular wall defect margins. Coagulated thrombi partially sealed the entry and exit sites, while a large hemopericardium produced cardiac tamponade, effectively limiting further blood loss. This unique combination of factors stabilized the patient’s condition and created favorable conditions for delayed surgical intervention during the subacute phase, following conservative therapy and dynamic imaging surveillance.
Conclusions. This case represents an exceptionally rare example of survival after a transfixing shrapnel injury of the aortic arch and ascending aorta — injuries that are typically incompatible with life. The conjunction of favorable factors, including the small diameter of the fragment, its high temperature with coagulative effect, rapid thrombus formation at the wound sites, and the presence of pericardial tamponade, ensured an unusual clinical course and allowed for planned surgical correction. This clinical example highlights the importance of comprehensive analysis of injury mechanisms and may serve as a valuable reference for optimizing treatment strategies in similar combat-related vascular traumas.
References
Tsymbaliuk, V. I. (Ed.). (2021). Atlas of combat surgical trauma (experience of anti-terrorist operation/joint forces operation).Kharkiv: Kolegium. (in Ukrainian).
Lazoryshynets, V. V., Homenko, I. P., Korda, M. M., et al. (2019).Combat trauma of the heart, thoracic aorta and main vessels of the limbs: A manual.Tsymbaliuk, V. I. (Ed.). Ternopil: TNMU. (in Ukrainian).
Homenko, I. P., Lurin, I. A., Usenko, O. Yu., et al. (2021).Gunshot wounds of soft tissues (experience of anti-terrorist operation/joint forces operation).Tsymbaliuk, V. I. (Ed.). Kharkiv: Kolegium. (in Ukrainian).
Lurin, I. A., Khoroshun, E. M., Humeniuk, K. V., et al. (2023).Treatment of wounded with combat chest injuries: A collective monograph.Tsymbaliuk, V. I. (Ed.). Ternopil: TNMU. (in Ukrainian).
Humeniuk, K. V., Homenko, I. P., Lurin, I. A., et al. (2022).Treatment of the wounded with combat injuries of the abdomen (according to the experience of anti-terrorist operation/joint forces operation): A monograph.Tsymbaliuk, V. I. (Ed.). Kherson: Oldi+. (in Ukrainian).
Humeniuk, K. V. (Ed.). (2023).Khirurhichna taktyka pry poranenniakh sertsia ta sudyn hrudnoi porozhnyny: metod. rekomendatsii.Kyiv. (in Ukrainian).
Lazoryshynets, V. V., Vitovskyi, R. M., Rudenko, M. L., Ioffe, N. O., & Vitovskyi, A. R. (2023). Poranennia sertsia fleshetoiu: osoblyvosti klinichnykh proiaviv, diahnostyky ta khirurhichnoho likuvannia.Ukrainskyi zhurnal sertsevo-sudynnoi khirurhii,4(31), 100–105. (in Ukrainian). DOI : https://doi.org/10.30702/ujcvs/23.31(04)/LV069-100105
Ariaka, H., Aizawa, K., Nishizaki, K., Minakawa, M., Kimura, N., & Adachi, H. (2022). An unusual occurrence of penetrating aortic arch injury by a ball-point pen: A case report and review of the literature.Journal of Cardiothoracic Surgery, 17(1), 233.https://doi.org/10.1186/s13019-022-02057-5.
Tanenbaum, M. T., Matecki, M., Sarin, S., Kartiko, S., Ayubi, F., & Lala, S. (2024). Gunshot wound causing thoracic aortic injury with bullet embolization to the common femoral artery.Journal of Vascular Surgery Cases, Innovations and Techniques, 10(6), 101588.https://doi.org/10.1016/j.jvscit.2024.101588
Lakhotia, S., Prakash, S., Singh, D. K., Kumar, A., & Panigrahi, D. (2012). Penetrating injury of ascending aorta with arrow in situ.Annals of Thoracic Surgery, 93(4), e85–e87.https://doi.org/10.1016/j.athoracsur.2011.11.029
Kawall, T., Pereira, B. A., Oliveira, T. G., & Fernandes, F. F. (2020). Case report and concise review of cardiac gunshot injury.American Journal of Case Reports, 21,e925327. https://doi.org/10.12659/AJCR.925327.
Moreno, C., Moore, E. E., Majure, J. A., & Hopeman, A. R. (1986). Pericardial tamponade: A critical determinant for survival following penetrating cardiac wounds.Journal of Trauma, 26(8), 821–825. Doi.:10.1097/00005373-198609000-00007
Naseer, A., Hussain, Z., Ali, M., Shabbir, A., & Ahmad, M. (2023). A cardiac injury and pericardial tamponade following a stab wound to the chest: A case report.Annals of Medicine and Surgery, 84, 104885.https://doi.org/10.1097/MS9.0000000000000637
Weinheimer, R. (2000). Properties of selected high explosives. InProceedings of the 27th International Pyrotechnics Seminar(pp. 609–627). Grand Junction, CO.
Ghebreamlak, S. M. (2022).Thermal initiation of energetic materials caused by hot fragments(Master’s thesis). Stockholm: KTH Royal Institute of Technology. Retrieved from https://www.diva-portal.org/smash/get/diva2:1751412/FULLTEXT01.pdf
Zhou, M., Wu, C., An, F., Liao, S., Yuan, X., Xue, D., & Liu, J. (2020). Acceleration characteristics of discrete fragments generated from explosively-driven cylindrical metal shells.Materials, 13(9), 2066.https://doi.org/10.3390/ma13092066.
Shuker, S. T. (2015). Thermal shell fragment craniofacial injury: Biophysics, pathophysiology, and management.Journal of Craniofacial Surgery, 26(1), 55-59.https://doi.org/10.1097/SCS.0000000000001180
Alkatout, I., Schollmeyer, T., Hawaldar, N. A., Sharma, N., & Mettler, L. (2012). Principles and safety measures of electrosurgery.JSLS, 16(1), 130–139.https://doi.org/10.4293/108680812X13291597716348.
Flynn, M. (2009). Vessel-sealing devices: Update on technology.OBG Management, 21(9), 44–51.
Morikawa, T., Hamamoto, S., Gonda, M., Taguchi, K., Unno, R., Torii, K., … Yasui, T. (2024). Evaluation of thermal effects of surgical energy devices: ex vivo study.Scientific Reports, 14(1), 27365.https://doi.org/10.1038/s41598-024-78624-8
Bianchi, F., Colombo, A., Pinter, A., & Grasso, G. (2022). Thermophysical and mechanical properties of biological tissues as a function of temperature: A systematic literature review. International Journal of Hyperthermia, 39(1), 645–663.https://doi.org/10.1080/02656736.2022.2076350
Chen, X., Li, Y., Wang, J., & Zhang, H. (2024). An extensive evaluation of laser tissue welding and sealing devices. Biomaterials Advances, 159, 213525.https://doi.org/10.1016/j.bioadv.2024.213525
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.