An autopsy case review of 142 nonpenetrating (blunt) injuries of the aorta

Endovascular Reconstruction Aortic Bifurcation for Aortic Pseudoaneurysm in a Pediatric Trauma Patient

Endovascular treatment options for vascular injury in pediatric patients are quite limited owing to concerns regarding long-term durability and the lack of devices suitable for the pediatric anatomy. However, in rare circumstances, open surgical therapy will not be an option, and patients will require unconventional endovascular solutions for lifesaving or limb-saving therapies. In the present report, we describe an endovascular treatment of a pediatric patient for whom initial surgical management of a blunt abdominal aortic injury had failed, with subsequent development of an aortic pseudoaneurysm. A 10-year-old girl had presented after a high-speed motor vehicle accident with a seatbelt sign. Multiple abdominal injuries were identified, including blunt aortic injury, significant devitalization of the small bowel, colonic perforation with fecal contamination, multiple lumbar spine fractures, and pulmonary contusions. The patient developed bilateral lower extremity ischemia from the aortic injury and had initially undergone open repair. One month later, the patient had developed a pseudoaneurysm of the aorta near the aortic bifurcation. Because of the hostile abdomen and ensuing short gut syndrome, the pseudoaneurysm was managed using endovascular techniques. The limb of an Excluder internal iliac branch endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ) was used as the endograft. The aortic bifurcation was raised and reconstructed using four Viabahn self-expanding stents (W.L. Gore & Associates). The completion angiogram showed complete resolution of the pseudoaneurysm. The follow-up computed tomography angiogram showed widely patent stent grafts with complete resolution of the pseudoaneurysm. Endovascular management of traumatic vascular injuries in pediatric patients is feasible. The likelihood of reintervention in the future is high with patient growth. However, it is a viable option in lifesaving or limb-saving situations in which open repair is high risk.

Trends and Outcomes in Management of Thoracic Aortic Injury in Children, Adolescent, and Mature Pediatric Patients Using Data from the National Trauma Data Bank

BACKGROUND

Thoracic aortic injury (TAI) is rare in the pediatric population. Thoracic endovascular aortic repair (TEVAR) is the recommended standard of care for treatment in the adult population given its association with lower rates of mortality and morbidity than traditional open repairs for treatment of TAI. However, there are unique anatomic challenges in treating pediatric patients with TEVAR which may impact the outcomes and pediatric guidelines. We aimed to compare current management trends and outcomes between different pediatric age groups using data from the National Trauma Data Bank (NTDB).

METHODS

We analyzed the NTDB from 2007 to 2019 using International Classification of Diseases (ICD)-9 and -10 codes to identify patients with a TAI. We excluded patients older than 21 years and any patients who died in the emergency department. The pediatric patients were stratified by age group: children (1-11 years), adolescent (12-17 years), and mature (18-21 years) patients. Patient characteristics compared included injury mechanism and severity, TAI intervention, and outcomes between the 3 groups using bivariate analysis (analysis of variance for parametric and Kruskal-Wallis for nonparametric variables). These characteristics and outcomes were also compared by TAI intervention and injury mechanism. ICD-9 and -10 procedural codes were used to identify patients who underwent TEVAR, open aortic repair (OAR), or both. The modified Poisson regression was performed with relative risk (RR) to evaluate our primary outcome measure-mortality during the trauma admission.

RESULTS

A total of 2,431 pediatric TAI were identified in the NTDB that met the inclusion criteria. This included 134 children (5.5%), 733 adolescent (30.2%), and 1,564 mature (64.3%) patients. Children had significantly lower median Injury Severity Scores (34.1) than the adolescent (38) or mature population (36.1) (P = 0.001). The mechanism of injury differed between age groups. Children had higher rates of blunt trauma (90.3% children, 89.6% adolescent, and 86.8% mature patients) and mature patients had higher rates of penetrating trauma (6% children, 10.1% adolescent, and 12.5% mature patients) (P < 0.001). TAI management also differed significantly between pediatric age groups. Mature patients had significantly higher rates of TEVAR (3% children, 25.2% adolescent, and 29.2% mature patients) and children were most likely to be treated with nonoperative management (NOM) (94% children, 67.9% adolescent, and 64.8% mature patients) (P < 0.001). Patients who were treated with TEVAR were discharge home most frequently (31.8% NOM, 54.1% TEVAR, 44.3% OAR, 22.2% both TEVAR and OAR). Upon modified Poisson regression analysis, patient age was not associated with an increased risk of in-hospital mortality. Intervention with TEVAR (RR: 0.22, 95% CI: 0.15-0.33, P < 0.001) and OAR (RR: 0.58, 95% CI: 0.36-0.93, P = 0.024) were associated with a lower risk of mortality than NOM.

CONCLUSIONS

TAI is less prevalent in children compared to adults. TEVAR for TAI is associated with lower risk of in-hospital mortality compared to both NOM and OAR without differences between pediatric subgroups. Further studies should be completed to determine the most appropriate management guidelines.

Current updates in acute traumatic aortic injury: radiologic diagnosis and management

Acute traumatic aortic injuries, which have substantial lethal outcomes at the time of admission, are fatal in 80% to 90% of cases. These injuries are relatively rare and have nonspecific clinical presentations. Radiologists and emergency physicians need to identify the radiological signs of acute traumatic aortic injury and differentiate them from common imaging errors to ensure accurate diagnosis and determine appropriate management protocols. In combination with image-guided interventions, advances in cross-sectional imaging have enabled nonsurgical management of acute traumatic aortic injuries. Timely and precise diagnoses of these injuries following prompt treatment are essential as up to 90% of patients presenting at the hospital can undergo early repair.

Thoracic Trauma: Aortic Injuries

Thoracic aortic injuries caused by high impact trauma are life-threatening and require emergent diagnosis and management. With improvement in the acute care services, an increasing number of such injuries are being managed such that patients survive to undergo definitive therapies. A high index of clinical suspicion is required to order appropriate imaging. Computed tomography angiography is used to classify the injuries and guide treatment strategy. While low-grade injuries might be managed conservatively, high-grade injuries require urgent surgical or endovascular intervention. Over the past decade, endovascular repair of the thoracic aorta with or without a surgical bypass has become the preferred treatment with reduced mortality and morbidity. Rapid advancements in the stent graft technology have reduced the anatomic barriers to endovascular therapy and increased the confidence of the operators. Detailed planning prior to the procedure, understanding of the anatomy, correct choice of hardware, and adherence to technical protocol are essential for a successful endovascular procedure. These patients are often young and the limited data on the long-term outcome of aortic stent grafts make a case for a robust follow-up protocol.

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management

Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ^©RSNA, 2020.

Finite Element Analysis of the Mechanism of Traumatic Aortic Rupture (TAR)

As many as 80% of patients with TAR die on the spot while out of those reaching a hospital, 30% would die within 24 hours. Thus, it is essential to better understand and prevent this injury. The exact mechanics of TAR are unknown. Although most researchers approve it as a common-sense deceleration injury, the exact detailed mechanism of TRA still remains unidentified. In this work, a deceleration mechanism of TAR was carried out using finite element analysis (FEA). The FE analysis aimed to predict internal kinematics of the aorta and assist to comprehend the mechanism of aorta injury. The model contains the heart, lungs, thoracic aorta vessel, and rib cage. High-resolution computerized tomography (HR CT scan) was used to provide pictures that were reconstructed by MIMICS software. ANSYS FE simulation was carried out to investigate the behavior of the aorta in the thoracic interior after deceleration occurred during a car crash. The finite element analysis indicated that maximum stress and strain applied to the aorta were from 5.4819e5 to 2.614e6 Pa and 0.21048 to 0.62676, respectively, in the Y-direction when the initial velocity increased from 10 to 25 m/s. Furthermore, in the X-direction when the velocity changed from 15 to 25 m/s, the stress and strain values increased from 5.17771e5 to 2.3128e6 and from 0.22445 to 0.618, respectively.

Blunt thoracic aortic injury - concepts and management

BACKGROUND

Blunt thoracic aortic injury, a life-threatening concern, remains the second most common cause of mortality among all non-penetrating traumatic injuries, second only to intracranial hemorrhage. Kinetic forces from the rapid deceleration are the impetus for the injury mechanism and are graded accordingly. Given the prevalence of trauma as a public health problem, contemporary management considerations are important.

MAIN BODY

Blunt thoracic aortic injury may be fatal if not diagnosed and treated expeditiously. Endovascular options allow safe and effective management of these dangerous injuries. This paper describes the overview of blunt thoracic aortic trauma, the epidemiology, presentation, diagnosis, and treatment options with a focus on endovascular management.

CONCLUSION

Blunt thoracic aortic injury requires a high index of suspicion based on mechanism of injury in the trauma population. Endovascular options have become the mainstay of blunt thoracic aortic injury treatment whenever feasible with satisfactory results and long-term outcomes.

Ascending aorta disruption after thoracic blunt trauma

Blunt traumatic aortic injury is the second leading cause of death after motor vehicle accidents. The most frequent localisation of aortic lesion is the isthmus, especially in those who survived the accident. Here we report a case of blunt traumatic aortic injury with unusual localisation and modality. A 31 years old man sustained a motorcycle accident, being run over by a car. Computed tomography scan showed an atypical ascending aorta lesion, confirmed by intraoperative finding. The patient underwent emergency ascending aorta replacement with Dacron tubular graft. The patient was discharged uneventfully on 35th postoperative day, after multiple maxillofacial surgeries for concomitant injuries.

[Rupture of the descending thoracic aorta following sudden traumatic deceleration injury]

La rupture aigue post traumatique de l’aorte thoracique constitue la seconde cause de mortalité chez les accidentés de la route; 80% des patients décèdent sur les lieux de l’accident. L’atteinte de sa portion descendante en dehors de l’isthme est rare et évaluée à moins de 3%. Nous rapportons le cas d’un homme de 60 ans, victime d’un accident de la voie publique (AVP) dont le mécanisme était un motocycliste heurté par une voiture avec points d’impacts au niveau du membre supérieur droit et thoracique. Cet AVP a occasionné une fracture des deux os de l’avant bras et une rupture de l’aorte thoracique descendante (ATD). Le traitement a consisté en premier temps à une suture de la brèche aortique complétée par la mise en place d’une prothèse synthétique circonférentielle avec anastomose aorto-aortique et en 2^ème temps à la mise en place d’une plaque vissée de l’avant bras. L’évolution était bonne et le malade fut transféré au Service de Chirurgie Vasculaire.

[Acute post-trauma dissection of the descending thoracic aorta]

BACKGROUND

Traumatic injury to the descending thoracic aorta other than the isthmus is rare, and little known. Acute post-trauma rupture may occur in a context of multiple or rarely unique localizations.

CASE REPORT

We report the case of a young man who was the victim of multiple injuries with an isolated rupture of the descending thoracic aorta. Early diagnosis and adapted endovascular treatment led to favorable outcome.

CONCLUSION

In 90% of cases, acute post-trauma rupture of the aorta in a single localization involve the isthmus. Rupture of the descending aorta is more exceptional but must not be missed. The pathophysiological mechanism and appropriate management are discussed in light of a review of the literature.

Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy

PURPOSE

Blunt aortic injuries (BAI) have historically been considered an indication for emergent surgical intervention. Nevertheless, the observation that the outcome of the concomitant traumatic injuries has a major impact on prognosis and the rise of thoracic endovascular aortic repair (TEVAR) as an effective therapy for BAI have significantly changed in recent years the treatment algorithm of this condition. Our objective was to identify findings associated with the aortic injury which would be the best predictor of prognosis, with the objective of guiding the decision-making process for selecting the optimal timing of aortic repair.

METHODS

We reviewed blunt aortic injuries from 3 Level I Trauma Centers from July 2008 to December 2016. We analyzed overall and BAI-related 30-day mortality in relation to: hemodynamics, timing of treatment, TEVAR vs open repair, and aortic injury grade as defined by the Society for Vascular Surgery. Based on computed tomographic angiography (CT scan) imaging, we selected the radiologic aortic findings most indicative of high mortality risk, which we defined as "Radiographic Severe Injury" (RSI): (1) total/partial aortic transection, (2) active contrast extravasation, or (3) the association of 2 of more of the following: contained contrast extravasation > 10 mm, periaortic hematoma, and/or mediastinal hematoma with thickness > 10 mm, or significant left pleural effusion.

RESULTS

Of a total of 76 consecutive patients, 50 (66%) underwent immediate repair, 24 (31%) delayed aortic repair, and 2 (3%) died prior to repair. 58 patients (76%) had TEVAR, while 16 (24%) had open repair. Overall mortality was 18% and BAI-related mortality was 13%. In BAI-related mortalities, 70% of patients had RSI. Patients with high risk of overall mortality had hypotension and tachycardia (SBP < 100, HR ≥ 100), high ISS, and required vasopressors. Factors only associated with BAI-related mortality included RSI.

CONCLUSION

CT scan findings suggestive of RSI are predictive of mortality associated with BAI. Radiologic assessment of the severity of the aortic injury with characterization for the presence of RSI may represent the key factors to determine the optimal timing of treatment of the aortic injury and guide the overall treatment strategy.

LEVEL OF EVIDENCE

IV.

Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges

Blunt thoracic aortic injuries are rare occurrences but carry an increased risk of mortality. Over the last two decades, however, major advances in diagnostic imaging, staging, and treatment have significantly improved outcomes. Modern imaging paved the way for a new staging system based on the anatomical layers of the aortic wall. This staging system, in turn, allowed for refinement of treatment, which now includes nonoperative management with anti-impulse therapy, endovascular intervention, and, if needed, open surgical repair. As is the case with any other rapidly evolving therapy, however, new challenges and controversies arise. The resolution of these challenges will rely on a broad, international, and multidisciplinary effort. (This is a review article based on the invited lecture of the 46th Annual Meeting of Japanese Society for Vascular Surgery.)

Is endovascular repair the first choice for all blunt aortic injury? A real-world assessment

Blunt thoracic aortic injury (BTAI) represents an infrequently encountered but lethal traumatic injury. Minimal aortic injuries are appropriately treated by medical management, while more severe injuries require endovascular or open repair. Rapidly evolving endovascular technology has largely supplanted open repair as first line operative intervention, however, the complexity of the severely injured blunt trauma patient can complicate management decisions. The development and implementation of an optimal consensus grading system and treatment algorithm for the management of BTAI is necessary and will require multi-institutional study.

Cross-sectional imaging of thoracic traumatic aortic injury

Aortic injury remains a major contributor to morbidity and mortality from acute thoracic trauma. While such injuries were once nearly uniformly fatal, the advent of cross-sectional imaging in recent years has facilitated rapid diagnosis and triage, greatly improving outcomes. In fact, cross-sectional imaging is now the diagnostic test of choice for traumatic aortic injury (TAI), specifically computed tomography angiography (CTA) in the acute setting and CTA or magnetic resonance angiography (MRA) in follow-up. In this review, we present an up-to-date discussion of acute traumatic thoracic aortic injury with a focus on optimal and emerging CT/MR techniques, imaging findings of TAI, and potential pitfalls.

The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma

BACKGROUND

Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma.

METHODS

We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury.

RESULTS

There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6-16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88).

CONCLUSIONS

Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.

Ascending aorta, aortic arch and supra-aortic vessels rupture in blunt thoracic trauma

Surgical strategy and long-term outcomes of patients with rupture of the ascending aorta, aortic arch and supra-aortic vessels following blunt thoracic trauma have been rarely reported. We reviewed our institutional experience between 1995 and 2016. We identified 2 patients with an innominate artery ruptures, 2 with an aortic arch ruptures and 1 with an ascending aorta rupture; all were induced by the posterior displacement of the anterior chest wall. All patients underwent open surgical repair. Cardiopulmonary bypass with antegrade cerebral perfusion was required in 2 cases. All patients were alive at the end of the follow-up (median 18 months; from 3 to 180 months) including 1 patient with cortical blindness.

Acute aortic syndromes and aortic emergencies

Acute aortic syndrome (AAS) and emergencies are relatively uncommon but are considered as life threatening, potentially fatal conditions. Different forms of aortic emergencies/AAS are often clinically indiscernible. Prompt and accurate diagnosis of these entities significantly influences prognosis and guides therapy. We aim to elucidate the pertinent role that radiology plays in the management of acute aortic diseases, with contrast-enhanced computed tomography angiography (CTA) being the most rapid and robust imaging technique.

Recycling and Reinforcing Intimomedial Flap of the Infrarenal Aorta Using Anterior Longitudinal Ligament in Patients With Acute Trauma With Bowel Injuries

We present a patient with blunt abdominal trauma with severe acute right limb ischemia and clinical signs of diffuse peritonitis. Computed tomography angiography showed circumferential dissection of the infrarenal aorta with occlusion of the right common iliac artery. We opted for simultaneous abdomen exploration and open repair of injured aorta. Critical weakening of the aortic wall with imminent rupture was identified intraoperatively. Aortotomy cranially from bifurcation showed circumferential intimomedial dissection. The fixation of fragile intimomedial flap of aortic dissection was achieved with reinforcement using an anterior longitudinal ligament. The long aortoiliac arteriotomy was repaired using a great saphenous vein patch. Patient had uneventful postoperative course and was discharged after 7 days. In patients with abdominal polytrauma with peritonitis, and no available endovascular tools, open surgery for circumferential aortic dissection is possible and successful. Described reinforcement of the posterior aortic wall to the anterior longitudinal ligament should be added to the armamentarium of aortic injury treatment.

Open Versus Endovascular or Hybrid Thoracic Aortic Aneurysm Repair

Thoracic aortic aneurysms are associated with significant morbidity and mortality. There are multiple underlying etiologies, including genetic abnormalities, that have important implications in their natural history. The variable histologic, anatomic, and clinical presentations necessitate careful consideration of available treatment options. Surgical repair of these aneurysms has been the mainstay of treatment; however, these approaches can carry a relatively high risk of morbidity and mortality. Endovascular approaches have now become first-line therapy for descending thoracic aneurysms, and with advancements in graft technology, endovascular approaches are being increasingly employed for hybrid repairs of the aortic arch and even the ascending aorta. However, to date, clinical outcomes from randomized trials and long-term follow-up are limited. As technology continues to advance, there is the potential for further integration of surgical and endovascular treatments so that patients have the best opportunity for a favorable outcome.

[Probable post-traumatic aneurism of ascending thoracic aorta: about a case]

Thoracic aortic aneurysms are relatively rare. Etiologies are dominated by atherosclerosis, elastic tissue dystrophies and trauma. We report the case of a 50-year old patient with a personal history of severe chest trauma occurring at age 25 years during parachute training. He presented with neurosensory signs of arterial hypertension. Chest X-ray showed aneurysmal dilatation of the thoracic aorta. Transthoracic echocardiography, CT angiography and MRI objectified ascending aortic aneurysm. The assessment of extent and etiological research were negative. The anatomopathological examination of surgical specimen showed nonspecific lesions.

Thoracic trauma: principles of early management

Thoracic trauma remains an important cause of early and late mortality in the injured patient. This review provides an overview of the emergency room management of thoracic trauma, amplifying the approach and principles of Advanced Trauma Life Support. The presentation, pathophysiology, diagnosis and treatment of the 12 most significant thoracic injuries are described. Focusing on emergency room management, and using the concept of the ‘lethal six’ and ‘hidden six,’ appropriate management strategies are detailed.

Role of Transesophageal Echocardiography in Blunt Chest Trauma

Patients who suffer blunt chest trauma are at risk for injury to the heart, and the thoracic aorta and its branch vessels. Unrecognized injury to the heart or aorta may lead to life threatening complications. Therefore, the physician caring for the trauma patient must be able to accurately and rapidly diagnose cardiac and thoracic aortic injury. Transesophageal echocardiography is an ideal tool to diagnose cardiac and aortic injury in the patient with blunt chest trauma because it provides high quality images of the heart and thoracic aorta and can safely and rapidly be performed in the emergency department, operating suite or intensive care unit. To utilize transesophageal echocardiography most effectively, the echocardiographer must be familiar with the indications, limitations, and piffalls of transesophageal echocardiography in patients with blunt chesttrauma. This review describes the role of transesophageal echocardiography in evaluating the patient with blunt chest trauma for cardiac, thoracic aortic, and mediastinal injury.

Case report: Open replacement of incomplete semi-circular traumatic ruptures of the ascending and descending aorta

An incomplete traumatic rupture of the ascending aorta is a rare but life-threatening condition. Hence, the assessment of the extent of the injury prior to therapy is crucial. We report a case of a 50-year-old male with traumatic aortic rupture who underwent emergency surgery after the evaluation of computed tomography scan (CT-scan). The surgical treatment involved replacement of the ascending aorta and stent implantation in descending aorta due to its covered rupture.

Angiographic Description of Blunt Traumatic Injuries to the Thoracic Aorta with Specific Relevance to Endograft Repair

Purpose:

To describe the precise anatomical location and extent of injury (based on angiography) in a series of patients with blunt thoracic aortic injury (BTAI) and evaluate the findings relative to the potential for endograft repair.

Methods:

Thoracic aortograms from 50 trauma patients (37 men; mean age 37 years, range 13–87) with BTAI were retrospectively reviewed. Parameters important for endograft repair were recorded, including the length of the pseudoaneurysm, the distance between the origin of the most distal arch vessel and the pseudoaneurysm, the diameter of the aorta both above and below the pseudoaneurysm, and finally, the curvature of the aorta in the vicinity of the pseudoaneurysm.

Results:

The mean distance from the left subclavian artery to the superior aspect of the injury measured 5.8 mm along the lesser curve and 14.9 mm along the greater curve. The mean length of the injury was 17.0 mm and 26.0 mm along the lesser and greater curves, respectively. The mean aortic diameter adjacent to the injury measured 19.3 mm. The mean degree of curvature of the aorta over the length of the injury was 27.2°, with a mean radius of curvature of 32.6 mm at the superior aspect of the injury and 39.3 mm inferiorly.

Conclusions:

In most cases of BTAI, the location of the injury will necessitate covering the origin of the left subclavian artery if endovascular repair is to be performed. The curvature of the aorta in the region predisposed to these injuries requires that the endograft be very flexible and/or precurved.

Traumatic injuries of the thoracic aorta: The role of imaging in diagnosis and treatment

Traumatic injury of the thoracic aorta remains the leading cause of death in multiple trauma patients and it requires urgent management. Computed tomography has a key diagnostic role and allows the clinician to choose an appropriate treatment strategy. The development of new classifications, based on a better understanding of the mechanisms of these injuries, has clarified the indications for treatment. Advances in techniques, especially in endovascular management, have contributed to improving prognosis for patients. Interventional radiology, which usually consists of endovascular placement of a covered stent, now constitutes the gold standard treatment in these injuries. Due to the potentially grave prognosis of these patients, it is crucial to know how to detect these injuries and to describe the imaging signs of serious damage.

Laceration of the Aorta: An Autopsy Series

Of 145 autopsies on subjects of impact trauma, 35 had lacerations of the aorta located as follows: proximal aorta ( 5 ), isthmus (22), and descending aorta ( 11 ) (three subjects had lacerations of the isthmus and the descending aorta). Four of the five lacerations of the proximal aorta ruptured into the pericardial sac. All lacerations at the isthmus were full thickness. Five were double, parallel, adjacent lacerations, of which only one was circumferential. Three of the 22 also had intimal tears of the descending aorta. One of the 22 lacerations was tamponaded and did not rupture into a body cavity. In eight, rupture and bleeding occurred into both pleural cavities, whereas 12 had rupture only into the left pleural cavity. Fourteen of the 22 had evidence of transient tamponade in the form of a mediastinal hematoma. Of the 11 subjects with lacerations of the descending aorta, one had only intimal tears. The other ten had full thickness lacerations that were located throughout the descending aorta. Four of the ten had more than one aortic laceration. Six of the total 11 had a vertebral dislocation. Three of the ten also had a laceration at the isthmus. Severe wounds of the head and thoracoabdominal viscera other than the aorta were common. Most subjects died at the scene.

Novel to this study are the explicit descriptions of 1) aortic lacerations involving less than the circumference of the aorta, 2) aortic lacerations that are double, and 3) the tendency for double lacerations to be less than circumferential.

Traumatic aortic injury: CT findings, mimics, and therapeutic options

OBJECTIVE

Traumatic aortic injury (TAI) is rare, but frequently lethal. However, with prompt diagnosis, patients can undergo life-saving open or endovascular repair. Unfortunately, because these injuries are relatively rare, subtle forms of these injuries may be missed, and normal variants may mimic TAI leading to misdiagnosis.

CONCLUSIONS

We will discuss computed tomography findings of typical injury patterns of traumatic aortic injuries as well as treatment options, diagnostic pitfalls and injury mimics. These are highlighted with clinical case examples.

“Don Juan-Fracture” as a Hint to Aortic Isthmus Rupture

We report a case of thoracic aortic rupture after blunt trauma in a 23-year-old male patient. The initial investigation found no external injury or bleeding, only a slightly widened mediastinum and a broken left calcaneus. Abdominal lavage was negative, biochemistry was normal, and breathing and oxygenation were not compromised. When changing his position during diagnostics, the patient all of a sudden developed cardiac arrest and typical signs of hypovolemic shock. An immediate sternotomy was done without any further diagnostics on suspicion of aortic isthmus injury. A circular avulsion at the ligamentum arteriosum was found as assumed and repaired under cardiopulmonary bypass. The patient left the hospital for rehabilitation after 12 days in adequate health status. Biodynamics of blunt trauma after high-speed frontal impact and the relationship between calcaneus fracture, called “Don-Juan fracture,” and aortic rupture at the site of ligamentum arteriosum are discussed.

Atypical Presentation of Traumatic Aortic Injury

Background. Blunt thoracic aorta injury (BAI) is second only to head injury as cause of mortality in blunt trauma. While most patients do not survive till arrival at the hospital, for the remainder, prompt diagnosis and treatment greatly improve outcomes. We report an atypical presentation of BAI, highlighting the diagnostic challenges of this condition in the emergency department.Case Presentation. A previously well 25-year-old male presented 15 hours after injury hemodynamically stable with delirium. There were no signs or symptoms suggestive of BAI. Sonography showed small bilateral pleural effusions. Chest radiograph showed a normal mediastinum. Eventually, CT demonstrated a contained distal aortic arch disruption. The patient underwent percutaneous endovascular thoracic aortic repair and recovered well.Conclusion. This catastrophic lesion may present with few reliable signs and symptoms; hence, a high index of suspicion is crucial for early diagnosis and definitive surgical management. This paper discusses the diagnostic utility of clinical features, injury mechanism, and radiographic modalities. Consideration of mechanism of injury, clinical features, and chest radiograph findings should prompt advanced chest imaging.

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study

OBJECTIVE

To report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries.

METHODS

Historic cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011.

RESULTS

The most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years.

CONCLUSIONS

Traumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis.

Blunt traumatic aortic rupture of the proximal ascending aorta repaired by resection and direct anastomosis

Traumatic aortic injury represents 15% of motor vehicle related deaths with death occurring at the scene in 85% of the cases. Aortic disruptions usually occur at the isthmus in a transverse fashion with all three of the aortic layers being involved. Herein, we report the case of a 68-year old man with no prior medical history who was struck by a vehicle while riding his bicycle. The ruptured segment of aorta was resected circumferentially and interrupted horizontal mattress pledgeted prolene sutures were used to ensure full thickness aortic integrity of the proximal and distal aortic segments. The aorta was closed with a single-layer technique using 4/0 prolene suture. There were no postoperative complications and patient was discharged on Day 44. The case here discussed demonstrates a rare presentation of blunt aortic injury. The proximal ascending aorta is an unusual site of transection following blunt trauma with few reports in the literature. We were able to repair the aorta with direct suture, thus avoiding the use of artificial material.

Surgical management of traumatic rupture of aortic isthmus: a 25-year experience

OBJECTIVE

Traumatic rupture of the thoracic aorta is a surgical emergency with a high mortality rate. This condition requires prompt diagnosis and expeditious evaluation to improve patient survival. The aim of this study is to evaluate the outcomes of early and late management of traumatic rupture of aortic isthmus in patients with blunt thoracic trauma.

METHODS

Between February 1980 and June 2005, 64 patients sustained blunt thoracic trauma underwent open surgical repair for traumatic rupture of the aortic isthmus (7 women, 57 men, and mean age 38 ± 14.3 years). Clinical signs of diagnostic principles in our series of patients were: chest pain and dyspnea (48.5 %), hemoptysis (23.5 %), and hypotension (15.5 %). All patients underwent a left posterolateral thoracotomy through the fourth or fifth intercostal space or median sternotomy. Extracorporeal circulation for spinal cord protection was installed in all patients.

RESULTS

Of the 64 patients identified over the 25-year study period, 15 (23.5 %) underwent direct suture, 48 (75 %) underwent interposition graft repair, and 1 (1.5 %) experienced patch aortoplasty repair. The overall hospital mortality rate for the entire patient was 3 % due to multiple organ failure and myocardial infarction. No paraplegia occurred postoperatively. Three patients died during the follow-up period, two from myocardial infarction, and one from acquired immunodeficiency syndrome.

CONCLUSIONS

Traumatic aortic rupture remains a potentially lethal injury and an ongoing therapeutic challenge. Open surgical technique to repair the traumatic rupture of aorta is a safe procedure: postoperative outcome was excellent and the complications observed that were with aortic endoprosthetic stent-grafts were avoided.

Defining acute aortic syndrome after trauma: Are Abbreviated Injury Scale codes a useful surrogate descriptor?

BACKGROUND

The severity and location of injuries resulting from vehicular collisions are normally recorded in Abbreviated Injury Scale (AIS) code; we propose a system to link AIS code to a description of acute aortic syndrome (AAS), thus allowing the hypothesis that aortic injury is progressive with collision kinematics to be tested.

METHODS

Standard AIS codes were matched with a clinical description of AAS. A total of 199 collisions that resulted in aortic injury were extracted from a national automotive collision database and the outcomes mapped onto AAS descriptions. The severity of aortic injury (AIS severity score) and stage of AAS progression were compared with collision kinematics and occupant demographics. Post hoc power analyses were used to estimate maximum effect size.

RESULTS

The general demographic distribution of the sample represented that of the UK population in regard to sex and age. No significant relationship was observed between estimated test speed, collision direction, occupant location or seat belt use and clinical progression of aortic injury (once initiated). Power analysis confirmed that a suitable sample size was used to observe a medium effect in most of the cases. Similarly, no association was observed between injury severity and collision kinematics.

CONCLUSION

There is sufficient information on AIS severity and location codes to map onto the clinical AAS spectrum. It was not possible, with this data set, to consider the influence of collision kinematics on aortic injury initiation. However, it was demonstrated that after initiation, further progression along the AAS pathway was not influenced by collision kinematics. This might be because the injury is not progressive, because the vehicle kinematics studied do not fully represent the kinematics of the occupants, or because an unknown factor, such as stage of cardiac cycle, dominates.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level IV.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.

[Acute traumatic thoracic aortic rupture in double localisation]

PURPOSE

Traumatic thoracic aortic rupture are commonly localised in one site essentially in the aortic isthmus but multiple localisation are not uncommon. The authors reported the case of a young man who had a double localisation of RTA after a violent car accident.

CASE REPORT

A 23-year-old man had a violent car crush involving sudden deceleration. He had multiple injuries essentially: a traumatic thoracic injury with acute posttraumatic aortic rupture in double localization, in the isthmus and in the descending thoracic aorta. He underwent thoracic endovascular aortic repair (TEVAR) with the use of stent graft three weeks after his car accident. The endovascular treatment was successful and no case of perigraft leakage has been detected during a meaning follow-up of five months.

CONCLUSION

The systematic analysis of the whole thoracic aortic vessel is crucial to not misdiagnose eventual multiple aortic rupture.

Stent Grafting for a Distal Thoracic Aortic Injury

Aortic injury following blunt trauma can be potentially devastating, particularly when it occurs in multiply injured patients. This injury normally occurs just distal to the left subclavian artery. Recently, stent grafting has become a mainstay in therapy. Although technical challenges certainly exist in stent grafting aortic injuries in this location, the ability to avoid all complications associated with traditional open repair make stent grafting extremely attractive. We present a case on a 41-year-old man who sustained an aortic injury just proximal to the celiac axis. We used stent grafting to treat this injury with a very favorable result.