One incision, complete access: Median sternotomy and aortic occlusion in penetrating chest trauma

BACKGROUND: We set out to evaluate outcomes of an innovative surgical approach that combines the use of a resuscitative median sternotomy and a descending aortic occlusion open (Ordoñez Maneuver) and/or endovascular for hemodynamically unstable patients suffering from penetrating chest trauma. METHODS: We conducted a retrospective observational study at a Level I trauma center from 2018 to 2024. Eighty-two patients (older than 18 years) with severe penetrating chest trauma (Injury Severity Score, >15) who underwent an emergency median sternotomy with or without aortic occlusion were included. The primary outcome was mortality. RESULTS: A total of 82 patients (93% male; median age, 27 years) underwent median sternotomy. The median Injury Severity Score was 25 with estimated blood loss of 3 L. Forty-eight patients (59%) underwent aortic occlusion: 23 (28%) via open cross-clamping and 25 (30%) via resuscitative endovascular balloon occlusion of the aorta. The median aortic occlusion time was 30 minutes. Thoracic vessel injuries occurred in 66% of patients, cardiac injuries in 29%, and lung injuries in 71%. Overall mortality was 27%. The expected mortality in the resuscitative median sternotomy (RMS) cohort was 34.15% (28 expected deaths), compared with 26.8% observed mortality (22 observed deaths; p = 0.32). Among the survivors, the median intensive care unit length of stay was 4 days, and the median hospital length of stay was 8 days. CONCLUSION: A resuscitative median sternotomy in combination with an aortic occlusion (open and/or endovascular) is a feasible and versatile option for hemodynamically unstable patients with penetrating chest trauma. This approach offers access to both hemithoraces and mediastinal structures through a single incision without higher than expected mortality. Further validation from future prospective, comparative studies are necessary before broader recommendations can be made. ( J Trauma Acute Care Surg . 2026;100: 810-817. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.