Traumatic aortic injury: computerized tomographic findings at presentation and after conservative therapy

Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury

BACKGROUND

Society for Vascular Surgery (SVS) grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury.

METHODS

A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

RESULTS

Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% confidence interval [CI] 6.7%-14.9%) for all-cause mortality, 2.9% (95% CI 1.1%-5.7%) for aorta-related mortality, and 3.3% (95% CI 1.4%-6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8).

CONCLUSIONS

Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data support nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.

Non-Operative Management of Polytraumatized Patients: Body Imaging beyond CT

In the transition from the operative to the conservative approach for the polytraumatized patients who undergo blunt trauma, diagnostic imaging has assumed a pivotal role, currently offering various opportunities, particularly in the follow-up of these patients. The choice of the most suitable imaging method in this setting mainly depends on the injury complications we are looking for, the patient conditions (mobilization, cooperation, medications, allergies and age), the biological invasiveness, and the availability of each imaging method. Computed Tomography (CT) represents the “standard” imaging technique in the polytraumatized patient due to the high diagnostic performance when a correct imaging protocol is adopted, despite suffering from invasiveness due to radiation dose and intravenous contrast agent administration. Ultrasound (US) is a readily available technology, cheap, bedside performable and integrable with intravenous contrast agent (Contrast enhanced US—CEUS) to enhance the diagnostic performance, but it may suffer particularly from limited panoramicity and operator dependance. Magnetic Resonance (MR), until now, has been adopted in specific contexts, such as biliopancreatic injuries, but in recent experiences, it showed a great potential in the follow-up of polytraumatized patients; however, its availability may be limited in some context, and there are specific contraindications, such as as claustrophobia and the presence non-MR compatible devices. In this article, the role of each imaging method in the body-imaging follow-up of adult polytraumatized patients will be reviewed, enhancing the value of integrated imaging, as shown in several cases from our experience.

A systematic review and meta-regression analysis of nonoperative management of blunt traumatic thoracic aortic injury in 2897 patients

BACKGROUND

Thoracic endovascular aortic repair has transformed the management of blunt traumatic thoracic aortic injuries (BTTAI). Recent studies have suggested that the nonoperative management (NOM) of BTTAI may be a viable alternative. We investigated the NOM of BTTAI by conducting a systematic review and meta-analysis of the mortality proportions and incidence of complications.

METHODS

We searched PubMed through June 22, 2017, and referenced lists of included studies without language restriction, with the assistance of a trained librarian. We included studies that reported the NOM of BTTAI (≥5 participants). Two authors independently screened titles, abstracts, and performed data extraction. Pooled prevalence of mortality (aortic related, in hospital) were obtained based on binomial distribution with Freeman-Tukey double-arcsine transformation and continuity correction. The random-effects model was used for all analyses to account for variation between studies. Meta-regression was performed to explore sources of heterogeneity, including Injury Severity Score, age, and gender.

RESULTS

We included 35 studies comprising 2897 participants. The pooled prevalence of all-cause in-patient mortality in the overall, grade I, grade II, grade III, and grade IV populations are as follows: 29.0% (95% confidence interval [CI], 19.3%-39.6%; I² = 95%; P < .01), 6.8% (95% CI, 0.6%-19.3%; I² = 52%; P = .03), 0% (95% CI, 0%-2.0%; I² = 0%; P = .81), 29.2% (95% CI, 17%-42.5%; I² = 3%; P = .41), and 87.4% (95% CI, 16.4%-100%; I² = 48%; P = .14), respectively. The combined incidence of aortic-related in-patient mortality in the overall, grade I, grade II, and grade III populations are: 2.4% (95% CI, 0.4%-5.5%; I² = 60%; P < .01), 0.93% (95% CI, 0%-14.2%; I² = 65%; P < .01), 0% (95% CI, 0%-1.8%; I² = 0%; P = .99), and 0.13% (95% CI, 0%-6.4%; I² = 14%; P = .33), respectively. The total proportion of postdischarge aortic-related mortality is 0% (95% CI, 0%-0.5%; I² = 0%; P = .91). Meta-regression showed a decreased risk of in-hospital mortality as age increases (β = .99; 95% CI, 0.98-1.00), an increased risk of in-hospital mortality with a higher Injury Severity Score (β = 1.02; 95% CI, 1.00-1.04), and a decreased risk of in-hospital mortality among male patients (β = .54; 95% CI, 0.3-0.90).

CONCLUSIONS

This study provides, to our knowledge, the most up-to-date pooled estimate of mortality rates after the NOM of BTTAI. However, its interpretation is limited by the paucity of data and substantial quantitative heterogeneity. If patients are to be managed nonoperatively, we would recommend the judicious use of active surveillance in a select group of patients in the short, mid, and long term.

Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature

Objective:

To review the current use of endovascular techniques in trauma.

Summary Background Data:

Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma.

Methods:

The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines.

Results:

Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability.

Conclusions:

The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.

Seat-Belt Abdominal Aortic Injury-Treatment Modalities

Blunt abdominal aortic injuries are extremely rare, diagnosed in less than 0.05% of all trauma admissions. Aortic injury caused by a seat belt during a car accident is often referred as "seat-belt aorta". We present a case of an 18-year-old woman, restrained back passenger involved in a vehicular collision, sustaining vertebral column and multiple rib fractures, mesenterium and colonic injury, and infrarenal aortic contusion with localized dissection and partial thrombosis.

Traumatic abdominal aortic injury: clinical considerations for the diagnostic radiologist

Traumatic abdominal aortic injury (TAAI) is a severe complication of penetrating and blunt trauma with significant morbidity and mortality, particularly if diagnosis is delayed. In patients with life-threatening injuries, accurate and prompt diagnosis of TAAI can be made with computed tomography (CT). Once the diagnosis of TAAI is made, the radiologist should provide an accurate description of the aortic lesion and the extent of injury in order to guide management whether it be non-operative, open aortic repair, or endoluminal stent repair. The purpose of this article is to review the key imaging aspects of TAAI and to discuss how the key CT imaging findings affect clinical management.

Nonoperative Management of Traumatic Aortic Pseudoaneurysms

BACKGROUND

Current blunt thoracic aortic injury (BTAI) guidelines recommend early repair of traumatic pseudoaneurysms (PSAs) due to risk for subsequent aortic rupture. Recent analyses indicate that early repair is required only in the setting of high-risk features, while delayed repair is safe and associated with lower morbidity and mortality in appropriately selected patients. To evaluate the appropriate indications for nonoperative management (NOM) of traumatic PSAs, we performed a systematic review of studies reporting outcomes for this management strategy. We hypothesized that NOM is safe in appropriately selected patients with traumatic aortic PSAs.

METHODS

English language single- and multi-institutional series reporting NOM of traumatic thoracic aortic PSAs were identified by systematic literature search and review. A descriptive analysis was performed of NOM, with stratification by lesion size and patient follow-up. The primary outcomes were late aortic intervention, aortic-related death, and all-cause mortality.

RESULTS

Eighteen studies, which included 937 patients with traumatic PSAs, were analyzed. One hundred ninety-one patients were managed nonoperatively. The primary indication for NOM was prohibitive risk for aortic repair due to severe comorbidities or concurrent injuries. Where reported, PSAs with <50% circumferential involvement accounted for 88% of lesions selected for NOM. Late interventions were required in 4% of patients. Inpatient aortic-related mortality was 2%, and all-cause inpatient mortality was 32%. Although survival at up to 4-7 years was reported, postdischarge follow-up after PSA NOM was limited to <1 year in most studies.

CONCLUSIONS

NOM of traumatic aortic PSAs is a common practice in BTAI series reporting lesion-specific management, and is associated with low rates of treatment failure. These findings suggest that routine early repair may not be required for traumatic PSAs, particularly for lesions limited to <50% of the aortic circumference. Definitive repair can be delayed until patient stability and repair timing can be guided by assessment of lesion stability on follow-up imaging.

Dual-phase CT for the assessment of acute vascular injuries in high-energy blunt trauma: the imaging findings and management implications

Acute vascular injuries are the second most common cause of fatalities in patients with multiple traumatic injuries; thus, prompt identification and management is essential for patient survival. Over the past few years, multidetector CT (MDCT) using dual-phase scanning protocol has become the imaging modality of choice in high-energy deceleration traumas. The objective of this article was to review the role of dual-phase MDCT in the identification and management of acute vascular injuries, particularly in the chest and abdomen following multiple traumatic injuries. In addition, this article will provide examples of MDCT features of acute vascular injuries with correlative surgical and interventional findings.

WSES position paper on vascular emergency surgery

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).

Blunt abdominal aortic injury: a Western Trauma Association multicenter study

BACKGROUND

Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level.

METHODS

The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications.

RESULTS

Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6-88; median Injury Severity Score [ISS], 34; range, 16-75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges.

CONCLUSION

This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted.

LEVEL OF EVIDENCE

Epidemiologic study, level III; therapeutic study, level IV.

CT and MRI in the Evaluation of Thoracic Aortic Diseases

Computed tomography (CT) and magnetic resonance imaging (MRI) are the most commonly used imaging examinations to evaluate thoracic aortic diseases because of their high spatial and temporal resolutions, large fields of view, and multiplanar imaging reconstruction capabilities. CT and MRI play an important role not only in the diagnosis of thoracic aortic disease but also in the preoperative assessment and followup after treatment. In this review, the CT and MRI appearances of various acquired thoracic aortic conditions are described and illustrated.

Management of simultaneous traumatic brain injury and aortic injury

Object

Simultaneous traumatic brain injury (TBI) and aortic injury has been considered unsurvivable for many years because treatments such as sedation and blood pressure goals conflict for these 2 conditions. Additionally, surgical interventions for aortic injury often require full anticoagulation, which is contraindicated in patients with TBI. For these reasons, and due to the relative rarity of aortic injury/TBI, little data are available to guide treating physicians.

Methods

A retrospective review was performed on all simultaneous TBI and aortic injury cases from 2000 to 2012 at a university-affiliated, Level I trauma center. Patient demographics, imaging studies, interventions, and outcomes were analyzed. Traumatic brain injury/aortic injury cases treated with endovascular stenting were specifically studied to determine trends in procedure timing, use of anticoagulation, and neurological outcome.

Results

Thirty-three patients with concurrent TBI and aortic injury were identified over a 12-year period. The median patient age was 44 years (range 16–86 years) and the overall mortality rate after imaging diagnosis was 46%. All surviving patients were awake and neurologically functional at discharge, and 83% were discharged home or to rehabilitation facilities. Patients who died had a higher Injury Severity Scale score (p = 0.006). Severe TBI (p = 0.045) or hemodynamic instability (p = 0.015) upon arrival to the hospital was also correlated with increased mortality rates. Thirty-three percent of aortic injury/TBI patients (n = 11) underwent endovascular stenting, and 7 of these patients received intravenous anticoagulation therapy at the time of surgery. Six of these 7 anticoagulation-treated patients experienced no significant progression on postoperative brain CT, whereas 1 patient died of hemodynamic instability prior to undergoing further imaging.

Conclusions

Simultaneous TBI and aortic injury is a rare condition with a historically poor prognosis. However, these results suggest that many patients can survive with a good quality of life. Technological advances such as endovascular aortic stenting may improve patient outcome, and anticoagulation is not absolutely contraindicated after TBI.

Blunt thoracic aortic injuries: CT characterisation and treatment outcomes of minor injury

OBJECTIVES

Computed tomography (CT)-defined anatomical differentiation of minor and major blunt traumatic aortic injuries (TAIs) was applied to determine injury grade and management/outcomes in minor TAIs, and if the presence of peri-aortic mediastinal haematoma (MH) correlated with TAI grade.

METHODS

Admission chest CT of blunt TAI cases during 2005-2011 were reviewed by consensus and categorised as major or minor. Minor was defined as pseudoaneurysm <10 % normal aortic lumen, intimal flap or contour abnormality. Presence/absence of MH was determined. Clinical management/outcome was ascertained from medical records.

RESULTS

Of 115 TAIs, 42 were minor (33 with MH, 9 without). Among the 73 with major TAI, 3 had no MH. Twenty-six (62 %) minor TAI patients were managed medically, 12 (29 %) percutaneous stent-grafts, 2 (5 %) died of non-aortic causes and 2 (5 %) underwent surgery. Of 26 managed without intervention, none developed complications from TAI at last clinical or CT follow-up. The relationship between presence/absence of peri-aortic MH and grade of TAI was statistically significant.

CONCLUSIONS

More than a third of multi-detector (MD) CT-diagnosed TAIs were minor. Minor TAIs treated medically were stable at last follow-up, suggesting this is a reasonable initial management approach. Absence of MH cannot be relied upon to exclude minor TAI, indicating the need for careful direct aortic inspection.

KEY POINTS

• MDCT can differentiate minor from major blunt traumatic aortic injuries. • About one-third of MDCT-diagnosed blunt traumatic aortic injuries are minor. • Minor aortic injuries are not necessarily accompanied by mediastinal haemorrhage. • MDCT diagnosis of minor aortic injury supports application of medical management.

Imaging vascular trauma

Background

Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.

Methods

A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.

Results

Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.

Conclusion

Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.