Role of angiography in the detection of aortic branch vessel injury after blunt thoracic trauma

Full realization of internal mammary artery injury after blunt chest trauma

Due to the substantial and continual increase in the number of motorized vehicles globally, clinicians are faced with an enormous population at risk for suffering internal mammary artery injuries after blunt chest trauma. Nevertheless, very little attention has been paid to this issue by relevant health practitioners. In addition, there is a scarcity of extant research data, as well as societal guidelines, regarding internal mammary artery injury. In cases with undetected internal mammary artery injury, however, the outcome may be catastrophic or fatal. Thus, investigating and reviewing the anatomy, etiology, diagnostic approaches, and treatment strategies for patients with internal mammary artery injury are urgently needed.

Assessment of internal mammary artery injury after blunt chest trauma: a literature review

The occurrence, bleeding, and treatment of internal mammary artery (IMA) injury after blunt chest trauma have not been well described in the literature. We reviewed articles published from July 1977 to February 2014 describing IMA injury after blunt chest trauma in 49 patients. There was a predominant incidence in males and on the left side. Blunt trauma to the IMA can cause anterior mediastinal hematoma, hemothorax, pseudoaneurysm, arteriovenous fistula, and extra-pleural hematoma. Of the 49 patients studied, 20 underwent embolization, 22 underwent surgical operation, 4 were managed by clinical observation, and 3 had undescribed treatment. Different parts and extents of IMA injury, adjacent vein injury, as well as the integrity of the pleura determined differences in bleeding modality. Prompt diagnosis, complete hemostasis, aggressive resuscitation, and multidisciplinary teams are recommended for patients with IMA injury.

Emergent combined repairs for aortic injury and bowel perforation after blunt trauma

Traumatic aortic rupture is frequently associated with multi-system injuries and is often immediately fatal. Although delayed open repair or endovascular repair has been recommended for an acceptable outcome, an emergency operation is mandatory for a life-threatening condition. We present here a challenging case of survival after immediate, combined repairs for acute aortic injury and bowel perforation.

ACR Appropriateness Criteria(®) blunt chest trauma--suspected aortic injury

The purpose of these guidelines is to recommend appropriate imaging for patients with blunt chest trauma. These patients are most often imaged in the emergency room, and thus emergency radiologists play a substantial role in prompt, accurate diagnoses that, in turn, can lead to life-saving interventions. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount.

[Endovascular treatment of traumatic ruptures of the thoracic aorta]

Traumatic rupture of the descending aorta is an acute life-threatening event. The most common cause is deceleration trauma resulting in a sudden stretching of the aortic isthmus as for example in car and motorcycle accidents and falls from a great height. Exemplified by a case report of a multiply injured 57-year-old male the diagnostic pathways, therapy and postoperative complications are presented.

Concomitant aortic valve and internal mammary artery injuries in blunt chest trauma: report of a case

We report a case of concomitant injury to the aortic valve and internal mammary artery (IMA) from nonpenetrating chest trauma. To our knowledge, this is the first such case to be reported. Transcatheter arterial embolization (TAE) following diagnostic angiography offers an effective and minimally invasive treatment for traumatic IMA injuries. Because there might be an asymptomatic interval after traumatic aortic valve injuries, serial physical examinations and repeated echocardiography should be mandatory for patients with de novo heart failure after blunt chest trauma. Transesophageal echocardiography can provide a clearer image of cardiac injuries than transthoracic echocardiography, particularly if there is extensive anterior mediastinal hematoma resulting from IMA trauma.

Vascular injuries after blunt chest trauma: diagnosis and management

Background

Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Methods

A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise.

Discussion

Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

Current management of traumatic rupture of the descending thoracic aorta

Traumatic rupture of the descending thoracic aorta remains a leading cause of death following major blunt trauma. Management has evolved from uniformly performing emergent open repair with clamp and sew technique to include open repair with mechanical circulatory support, medical management and most recently, endovascular repair. This latter approach appears, in the short term, to be associated with perhaps better outcome, but long term data is still accruing. While an attractive option, there are specific anatomic and physiologic factors to be considered in each individual case.

Acute traumatic aortic injury: imaging evaluation and management

Despite recent advances in prehospital care, multidetector computed tomographic (CT) technology, and rapid definitive therapy, trauma to the aorta continues to be a substantial source of morbidity and mortality in patients with blunt trauma. The imaging evaluation of acute aortic injuries has undergone radical change over the past decade, mostly due to the advent of multidetector CT. Regardless of recent technologic advances, imaging of the aorta in the trauma setting remains a multimodality imaging practice, and thus broad knowledge by the radiologist is essential. Likewise, the therapy for acute aortic injuries has changed substantially. Though open surgical repair continues to be the mainstay of therapy, percutaneous endovascular repair is becoming commonplace in many trauma centers. Here, the historical and current status of imaging and therapy of acute traumatic aortic injuries will be reviewed.

The Endovascular Approach to Acute Aortic Trauma

Endovascular repair of the traumatically injured thoracic aorta has emerged as an exceptionally promising modality that is typically quicker than open repair, with a reduced risk of paralysis. There are a specific set of anatomic criteria that need to be applied, which can be rapidly assessed by the CT angiogram. The enthusiasm for endovascular repair must be tempered by recognition of the complications and lack of long-term follow-up, particularly in younger patients. Surgeons who are skilled in open aortic repair must not only be involved, but should take on a leadership role during the planning, deployment, and follow-up of these patients. Familiarity with all of the available devices expands treatment options. As more specific devices become available, and more follow-up is accrued, the role of endovascular stents will continue to grow.

The effect of changing presentation and management on the outcome of blunt rupture of the thoracic aorta

BACKGROUND

The management of traumatic aortic rupture has evolved from emergency surgery for all to incorporating nonoperative and endovascular approaches. In addition, the greater emphasis on restraint systems over the past decade might result in lower immediate mortality.

METHODS

We reviewed our contemporary experience with reference to a previous report from the same institution to determine whether there has been improvement in outcome related to these factors.

RESULTS

In 1990, a review of 104 patients admitted to our center over a 15-year period (1975-1990) noted an overall mortality of 65%. Forty-two patients died before they could reach the operating room, including 15 who were declared dead on arrival and 27 who died before reaching the operating room. All patients underwent angiography, followed by immediate operation. The mortality rate of those who reached the operating room was 34%, and paralysis-paraplegia occurred in 26% of survivors. A review of 53 patients admitted between January 1, 2000, and April 2005 documented an overall mortality of 26% and a paralysis rate of 4.5% in operative survivors. Only 3 patients died during initial evaluation, 2 who were in arrest on arrival. Eight patients were managed nonoperatively, and 13 were managed by means of deliberate delay before intervention to improve physiologic status. Finally, 19 patients were managed with endografts.

CONCLUSION

The improved outcome over the decade since the initial experience reflects both a reduced severity of injury attributable to restraint systems and a more flexible approach to the acute management, which can modify the effect of associated injuries.

Occult mediastinal great vessel trauma: the value of aortography performed during angiographic screening for blunt cervical vascular trauma

PURPOSE

To determine the value of aortography in the assessment of occult aortic and great vessel injuries when routinely performed during screening angiography for blunt cerebrovascular injury (BCVI).

METHODS

One hundred and one consecutive patients who received both aortography and screening four-vessel angiography over 4 years were identified retrospectively. Angiograms for these patients were evaluated, and the incidence of occult mediastinal vascular injury was determined.

RESULTS

Of the 101 patients, 6 (6%) had angiographically documented traumatic aortic injuries. Of these 6 patients, one injury (17%) was unsuspected prior to angiography. Four of the 6 (67%) also had BCVI. One additional patient also had an injury to a branch of the subclavian artery.

CONCLUSION

Routine aortography during screening angiography for BCVI is not warranted due to the low incidence (1%) of occult mediastinal arterial injury. However, in the setting of a BCVI screening study and no CT scan of the chest, aortography may be advantageous.

Review of branch aortic injuries in blunt chest trauma

OBJECTIVES

To review the incidence, mechanisms of injury, diagnosis and treatment of injuries to the major branches of the thoracic aorta within the thoracic cavity following blunt trauma.

METHODS

Medline, Embase and Cochrane were searched using appropriate key word and MeSH headings. Full text articles were retrieved where there was any information relating to the mechanism of injury, incidence of injury, diagnosis, treatment or outcome in patients with injuries to the brachiocephalic, subclavian or carotid arteries within the thoracic cavity following blunt chest trauma.

RESULTS

The reported incidence of these injuries varied widely, most injuries were related to rapid deceleration injuries or falls. Diagnosis depends on a high level of clinic suspicion and appropriate investigations include helical CT scanning and arteriography. Treatment options have expanded in recent years with the use of endovascular stents; however, the optimal treatment remains uncertain.

CONCLUSIONS

Aortic branch injuries must be actively excluded in patients with suspicious mechanisms of injury. Guidelines determining appropriate investigative pathways and methods of treatment should be developed at all trauma centres.

The Trend of Using Computed Tomography in the Detection of Acute Thoracic Aortic and Branch Vessel Injury after Blunt Thoracic Trauma: Single-Center Experience Over 13 Years

BACKGROUND

The purpose of this study was to review the trend of using chest computed tomography (CT) and aortography in evaluating patients with blunt thoracic trauma.

METHODS

A total of 85 patients who had blunt aortic injury diagnosed by chest CT, aortography, or both were included in this study.

RESULTS

Aortography was the dominant modality before 1998, and the use of chest CT has increased to 50% of patients with aortic injuries as of 2001. Isolated aortic, branch vessel, or combined injuries were found in 71 (84%), 11 (13%), and 3 (4%) patients, respectively. All 14 patients with branch vessel injuries were diagnosed by aortography. Ninety-eight percent of patients with aortography were true-positives, and 20% of patients with chest CT had indirect signs of aortic injury.

CONCLUSION

Our institution has increased the use of chest CT to evaluate blunt thoracic trauma. Patients with indirect signs of aortic injuries shown on chest CT require further evaluation. In our experience, angiography remains the optimal diagnostic modality for evaluating aortic branch vessel injuries.

Multislice CT in thoracic trauma

The introduction of CT imaging in the 1970s revolutionized all aspects of medical care, perhaps nowhere more so than in the evaluation of acutely injured patients. Just as single-slice helical scanning was a great advance over conventional CT, the capabilities of MSCT are proving to be dramatically superior to single-slice methods. Improved contrast bolus imaging, thinner slices, and isotropic voxels should enable the trauma radiologist to identify both major organ system disruption and subtle injuries more promptly. Multiplanar and three-dimensional reconstructions, a forte of MSCT, facilitate rapid communication of disease states with surgeons and others involved in the care of injured patients. In many centers, whole-body CT is beginning to supplant plain films of the chest and spine in the evaluation of severe trauma victims; the cost-effectiveness of such methods is still under evaluation.