Blunt Trauma of the Aorta, Current Guidelines

Chronic Post-Traumatic Aortic Isthmus Pseudoaneurysm After Conservative Management of Grade II Injury: Why Is Continuous Follow-Up Mandatory?

Background: Grade I-II blunt traumatic aortic injuries (BTAIs) are typically managed conservatively, but their long-term progression is poorly understood. Chronic pseudoaneurysms may develop years after the injury, often remaining asymptomatic and being incidentally diagnosed. Methods: Two cases of post-traumatic aortic pseudoaneurysms, detected 20 and 25 years following conservatively managed BTAIs, are reported. Additionally, a comprehensive review of all post-traumatic pseudoaneurysms reported in the MedLine (PubMed.gov, U.S. National Library of Medicine, National Institute of Health) database between January 1984 and December 2024 was performed. Results: Both our patients underwent successful hybrid procedures, with no complications at the 1- and 4-year follow-ups. Our literature review identified 37 patients across 22 studies, with 32.4% presenting asymptomatically or incidentally diagnosed through routine imaging, between 1 month and 50 years after the initial trauma. In 37.8% of cases, the patients underwent open or endovascular repair. Conclusions: This case series and literature review emphasize the importance of long-term follow-up for patients with conservatively managed BTAIs, as chronic complications such as aortic pseudoaneurysms can arise decades later. Continuous surveillance is critical to ensure early detection and management.

Two cases of complex traumatic aortic dissection combined with multiple organ injuries

Traumatic aortic injury (TAI) is an acute, critical, and severe disease, and then combined with multiple organ damage, it is even more dangerous. TAI progresses very rapidly, with a pre-hospital mortality rate of 57%-80%, and even when arriving at the hospital, more than one-third of the patients die within 4 h, and it is the 2nd leading cause of death in individuals aged 4-34 years. In addition, the incidence of TAI combined with injury was 81.4%. Therefore, early diagnosis, expeditious surgery, and timely and effective multidisciplinary cooperation are essential for successful rescue. The authors report 2 patients with acute traumatic aortic dissection combined with multiple organ injuries and treated with emergency endovascular surgery to discuss their clinical characteristics and treatment experience, and to provide experience in the diagnosis and treatment of such patients.

Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience

BACKGROUND

Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings.  Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay.

RESULTS

A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05).

CONCLUSION

Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.

Surgeon-Modified Fenestrated Stent-grafts for Zone 2 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injury: Early and Midterm Results

AIM

Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery.

MATERIALS AND METHODS

Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period.

RESULTS

The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I.

CONCLUSION

TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA.

CLINICAL IMPACT

Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.

Delayed Repair of Aortic Dissection in a Trauma Patient With Occult Esophageal Rupture

Aortic dissection and esophageal rupture are life-threatening conditions in trauma patients. The combination complicates treatment. Here, we report a case of traumatic aortic dissection with occult esophageal rupture that was treated successfully with a staged operative strategy: primary esophageal repair followed by delayed aortic arch and aortic valve repair.

Blunt Thoracic Aortic Injury and Contemporary Management Strategy

Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.

Cone-beam computed tomography for trauma

Radiographic imaging is critical in helping guide treatment of critically injured patients. Cone-beam computed tomography is an axial imaging technique available from fixed imaging systems found in hybrid operating rooms. It can be used to provide focused studies of specific anatomical regions, where patients cannot undergo conventional multidetector computed tomography. This includes non-contrast-enhanced evaluation of the intracranial contents and vascular imaging throughout the body. There are a number of advantages and disadvantages to cone-beam computed tomography, but these are not widely discussed within the trauma literature. This narrative review article presents the initial practical experience of this novel imaging modality. LEVEL OF EVIDENCE: Review article, level III.

Endovascular treatment of traumatic dissection of the thoracic aorta - series of 16 cases

Background

Aortic injuries caused by blunt chest traumas have high pre-hospital and emergency mortality. The endovascular approach is one option for treatment of these injuries, but many outcomes related to this approach remain unknown.

Objectives

The aim of this study is to describe a specialist trauma center’s experience with endovascular treatment of cases like these.

Methods

This is a descriptive study based on review of the electronic medical records of patients who had suffered from blunt thoracic aorta trauma and were seen at a hospital specializing in trauma cases in the city of Curitiba (Paraná, Brazil).

Results

Sixteen patients were included in the study. All patients were traffic accident victims and 75% of the accidents were the result of vehicle collisions. Aortic lesions ranged from grade I to IV and the majority had grade II lesions (50%). All patients underwent endovascular treatment with endografts, an average of 71 hours after the trauma. Two patients died, both from causes unrelated to their aortic injuries. During follow-up, only two patients presented complications (endoleak and progression of the dissection).

Conclusions

The endovascular method is a viable alternative for treatment of blunt trauma thoracic aortic injuries. Randomized and controlled studies are needed to provide evidence to support indication of this method to treat this type of injury.

Hemothorax resulting from an initially masked aortic perforation caused by penetration of the sharp edge of a fractured rib: A case report

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Rare aortic injury from a rib fracture, which is not found in primary evaluation.

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Hemothorax with great vessel injury can be fatal and should be detected using computed tomography.

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Some great vessel injuries cannot be detected through contrast-enhanced chest computed tomography.

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Great vessel injury should be considered in hemothorax with multiple rib fractures.

Introduction

There are multiple causes of hemothorax in blunt chest trauma. However, a traumatic hemothorax with an uncertain cause is potentially life-threatening without treatment, because an undetected and hidden great vessel injury can remain unknown. Delayed diagnosis can lead to death.

Presentation of case

A 77-year-old man was transferred to a local hospital, after experiencing a 3-m fall. Contrast CT of the chest revealed a left clavicle fracture, multiple left rib fractures and hemopneumothorax, but no obvious signs of great vessel injury, such as aortic injury. His condition was stable, owing to the chest tube thoracostomy with 800 ml blood output and intravenous fluid. The patient was then transferred to our hospital for further treatment. However, his condition rapidly deteriorated in the ambulance on the way to our hospital, and he needed a blood transfusion. On arrival, he was in shock, with his vital signs compromised due to blood loss. Emergency open thoracotomy was performed to explore the bleeding point and stop hemorrhaging. Intraoperative findings revealed sharp edges of the fractured fourth and fifth left ribs to be protruding into the chest cavity toward the descending aorta and causing an aortic pinhole injury. Ruptured aorta was repaired with a pledget-armed sutures and the sharp fractured ribs were resected. The patient was discharged, uneventfully, 35 days after the operation.

Conclusion

This case suggests that even if great vessel injury is not detected on contrast CT at admission, it should always be considered especially in a hemothorax case with multiple rib fractures.

Emergency percutaneous thoracic endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single center experience

PURPOSE

To analyze the efficacy and outcome of percutaneous thoracic endovascular aortic repair (TEVAR) in patients with traumatic blunt aortic injury in our single-center.

METHODS

From January 2014 to December 2018, a total of 89 patients with traumatic blunt aortic injuries were treated with emergency TEVAR in our center. Their clinical data such as demographics, operative details and postprocedure outcomes were analyzed retrospectively in this study using SPSS 20 software. Continuous variables were expressed as mean and standard deviation or median and interquartile range. Categorical variables are expressed as the numbers and percentages of patients.

RESULTS

The median age of the patients was 37 years, and 76 (85.4%) were males. All the patients were involved in violent accidents and combined with associated injuries. Two patients died while awaiting the operations and 87 patients underwent emergency percutaneous TEVAR, with a 100% technique success. The mean time interval from admission to operating room was (90.1 ± 18.7) min, and the mean procedure time was (54.6 ± 11.9) min. Eighty (92.0%) patients were operated on under local anesthesia, while other 7 (8.0%) patients were under general anesthesia. Two cases underwent open repair of the femoral arteries because of the pseudoaneurysm formation of the access vessels. A total of 98 aortic covered stent grafts were deployed, of which 11 patients used two stent grafts (all in dissection cases). The length of the stent was (177.5 ± 24.6) mm. The horizontal diameter of aorta arch at the proximal left subclavian artery ostium was (24.9 ± 2.4) mm, the proximal diameter of the covered stent was (30.5 ± 2.6) mm, and the oversize rate of proximal site was (22.7 ± 4.0)%. The proximal landing zone length was (14.1 ± 5.5) mm. The left subclavian artery ostium was completely covered in 5 patients and partially covered in 32 patients. No blood flow reconstruction was performed. The overall aortic-related mortality was 2.25% (2/89). Among 87 patients, the median follow-up time was 24 months. Postoperative computed tomography angiography scans demonstrated no residual pseudoaneurysm, hematoma or endoleak. One patient complained of mild left upper limb weakness during follow-up due to left subclavian artery occlusion. Neither late death, nor neurological or other complications occurred.

CONCLUSION

Emergency percutaneous endovascular repair is a less invasive and effective approach for the treatment of traumatic blunt aortic injuries. Long-term results remain to be further followed.

Die traumatische Aortenruptur

Verkehrsunfälle sind für den größten Teil der traumatischen Aortenrupturen verantwortlich, meist zusammen mit weiteren schweren Begleitverletzungen. Die prähospitale Sterblichkeit ist hoch. Bei Verdacht auf eine beteiligte Aortenverletzung, aufgrund eines hohen traumatic aortic injury scores, ist eine Computertomographie durchzuführen. Es erfolgt eine Triage der Verletzungen, und die Versorgungspriorität der Aorta richtet sich nach dem Schweregrad der Aorten- und Begleitverletzungen sowie dem Zustand des Patienten. Bis zur definitiven Versorgung der aortalen Läsion muss der Blutdruck konsequent gesenkt werden. Grad I und II können in Einzelfällen unter enger Kontrolle inital konservativ gemanagt werden. Grad III (gedeckte Ruptur) und Grad IV (freie Ruptur) benötigen eine raschestmögliche Versorgung (interventionell, chirurgisch). In ausgesuchten Fällen kann auch eine verzögerte Versorgung günstig sein.

Als bevorzugte Versorgungsform hat sich die interventionelle Stentgrafttherapie etabliert.

Instabilities in Aortic Length After TEVAR and Reoperation: 12 Years of Follow-Up Imaging

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) remains an important minimally invasive tool for the treatment of descending thoracic aneurysm. The long-term effects of these repairs in reduction of the aneurysmal sac size as well as stability of the stented portion require study. We report the results of 12 years of radiographic follow-up.

METHODS

All patients who underwent TEVAR for descending thoracic aneurysms from January 2005 to December 2017(n = 371) were evaluated for immediate postoperative and follow-up computed tomographic scans suitable for 3-dimensional reconstruction of the aorta (excluding those with an interim reoperation). We found 62 patients who met these criteria (median duration of radiographic follow-up, 1.8 years). Measurements were taken of centerline, greater and lesser curvatures from the most distal patent brachiocephalic vessel to the first uncovered mesenteric vessel, and between proximal and distal edges of the stented portion of the aorta.

RESULTS

All measured segments, except covered length, were significantly increasing in length for centerline, greater and lesser curvatures, with a median increase of 7.6 mm (interquartile range, 1.7-16 mm). Cox regression for mortality and reoperation found no significant correlation between these changes and mortality and a significant correlation between stented segment greater curvature increase and reoperation (adjusted hazard ratio, 1.06; P < .05).

CONCLUSIONS

Increases in the centerline and greater curve length of the aorta were found to be occurring. This appears to be primarily driven by growth in the nonstented segments. However, changes in the outer curve length of the stented segment were associated with a greater risk of reoperation.

Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard

BACKGROUND

Incidence and treatment of blunt thoracic aortic injury (BTAI) has evolved, likely from improved imaging and emergence of endovascular techniques; however, multicenter data demonstrating this are lacking. We examined trends in incidence, management, and outcomes in BTAI.

STUDY DESIGN

The American College of Surgeons National Trauma Databank (2003 to 2013) was used to identify adults with BTAI. Management was categorized as nonoperative repair, open aortic repair (OAR), or thoracic endovascular repair (TEVAR). Outcomes included demographics, management, and outcomes.

RESULTS

There were 3,774 patients. Median age was 46.0 years (interquartile range [IQR] 29.3, 62.0 years), with 70.8% males, and median Injury Severity Score (ISS) of 34.0 (IQR 26.0, 45.0). The number of BTAIs diagnosed over the decade increased 196.8% (p < 0.001), median ISS decreased from 38 to 33 (p < 0.001), and significantly more patients were treated at a level I trauma center (p < 0.001). After FDA approval of TEVAR devices, there was a significant increase in endovascular repair overall (1.0% to 30.6%, p < 0.001) and in those treated operatively (0.0% to 94.9%, p < 0.001), with a marked decrease in OAR. Use of TEVAR was associated with significantly reduced median ICU LOS (9.0 vs 12.0 days, p = 0.048) and mortality (9.3% vs 16.6%; p = 0.015) compared with OAR. In modern BTAI care, TEVAR has nearly completely replaced OAR.

CONCLUSIONS

The diagnosis of BTAI has increased, likely due to more sensitive imaging. Nearly 70% of patients get nonoperative care. Treatment with TEVAR improves outcomes relative to OAR. Part of the proportional increase in TEVAR use may represent overtreatment of lower grade BTAI amenable to medical management, and warrants further investigation.

Atypical Right Pulmonary Artery Dissection Complicating Severe Blunt Chest Trauma

Pulmonary artery dissection is a rare albeit life-threatening event and it mostly occurs as the spontaneous rupture of pulmonary artery aneurysm complicating chronic pulmonary hypertension. Here, we describe a case of blunt traumatic pulmonary artery dissection.