Delayed Descending Thoracic Aortic Laceration Caused by a Posterior Rib Fracture Fragment: A Case Report.

INTRODUCTION: Delayed descending thoracic aortic laceration caused by a rib fracture fragment after blunt chest trauma is rare but potentially fatal. Because initial findings may appear limited, diagnosis and definitive treatment can be delayed. We report a case in which rapid progression to massive hemothorax and traumatic cardiac arrest was successfully managed by emergency thoracotomy followed by definitive aortic repair. CASE PRESENTATION: A 78-year-old woman sustained extensive bilateral rib fractures after striking her chest against a tree. She was initially managed conservatively because only a minimal hemothorax was present. Early CT showed a medially displaced posterior left 11th rib fragment adjacent to the descending thoracic aorta. On the following day, she developed worsening chest pain and a rapidly progressive left hemothorax with active contrast extravasation. Bleeding was initially suspected to arise from an intercostal artery, and transcatheter arterial embolization was attempted, but hemostasis was not achieved. Resuscitative endovascular balloon occlusion of the aorta was performed before interhospital transfer; however, she deteriorated to traumatic cardiac arrest during transport. An emergency left anterolateral thoracotomy in the emergency department achieved decompression and temporary hemorrhage control by evacuation of a large clotted hemothorax and intrathoracic gauze packing, allowing transfer to the operating room. Intraoperatively, a focal laceration of the posterior descending thoracic aorta was identified and repaired with pledgeted sutures, and concomitant intercostal arterial bleeding was cauterized. The patient underwent a tracheostomy on POD 10 and was transferred alive for rehabilitation on day 22. CONCLUSIONS: Posterior, medially displaced left rib fractures adjacent to the descending thoracic aorta represent a threatened aorta configuration and warrant particular attention, even when the initial hemothorax is minimal. In such situations, early contrast-enhanced reassessment, close monitoring, and multidisciplinary planning are warranted. If hemothorax rapidly enlarges or the clinical course worsens, clinicians should reconsider aortic injury rather than attributing the bleeding solely to an intercostal source, and timely escalation to definitive operative hemorrhage control may be lifesaving, even after traumatic cardiac arrest.