Use of Transesophageal Echocardiography for the Assessment of Traumatic Aortic Injuries

Unusual complication of late presentation deceleration aortic injury

A 50-year-old patient presented with a stroke. An ascending aortic mass noted by computed tomography was attached to the aortic wall and was found to be thrombus at surgery. Pathologic examination revealed an intraluminal thrombus attached to a focal segment of intimal fragmentation. Sectioning of the aortic wall revealed what were findings consistent with what would be noted with a previously unrecognized traumatic ascending aortic deceleration injury. To our knowledge, this is the first case of a late presentation of deceleration aortic injury, presenting with a thrombus within the ascending aorta.

Aortic dissection in childhood and adolescence: an analysis of occurrences over a 10-year interval in New York State

BACKGROUND

Rarely occurring in the pediatric and adolescent population, aortic dissection is a condition with many predisposing factors. Previous studies have suggested that congenital cardiovascular disorders are the most common predisposing conditions. Trauma-associated aortic dissection is considered a rare occurrence.

METHODS

The Statewide Planning and Research Cooperative System database of New York State was used to retrieve cases of aortic dissection in persons < or = 21 years old over a 10-year period. A retrospective analysis for risk or associated conditions was undertaken.

RESULTS

Forty-five of a total of 12,142 cases of aortic dissection (0.37%) occurred in persons < or = 21 years old. No patient was younger than 15 years of age. Six of the 45 died (13%). Most patients were male (37 of 45, or 82%). Contrary to previous reports, the most common associated condition was trauma (19 of 45, or 42%), with Marfan syndrome the second most common (11 of 45, or 24%). Ten of 45 adolescent and young adult patients (22%) had no apparent risk factors.

CONCLUSIONS

Traumatic aortic disruptions must be considered in children and adolescents who survive serious chest trauma. Family members of pediatric and young adult patients with trauma-associated aortic dissection may need to be evaluated for possible risk of aortic dissection.

Endovascular treatment of blunt traumatic thoracic aortic injury

Blunt traumatic thoracic aortic injury (BTTAI) is a lethal injury associated with a prehospital mortality of 80% to 90%. Patients arriving in the emergency room and considered appropriate to undergo emergency open surgical repair still have a mortality rate of 15% to 30% because of severe associated injuries. Conventional open surgical repair requires a left thoracotomy, single lung ventilation, aortic-cross clamping and unclamping, with or without the adjunct use of partial or full cardiopulmonary bypass and systemic heparinization. All this leads to significant physiological stress and surgical trauma resulting in perioperative complications such as major blood loss, coagulopathy, myocardial infarction, stroke, respiratory failure, renal failure, bowel infarction, and paraplegia. Despite advances in anesthesia, critical care medicine, and surgical techniques, a recent meta-analysis showed no definite improvement in operative mortality over the past decade, following open surgical repair in patients with BTTAI. Endovascular repair of BTTAI does not require a thoracotomy, single lung ventilation, aorticcross clamping and unclamping, or systemic heparinization. As a result, endovascular repair of BTTAI has emerged as an effective, minimally invasive treatment alternative, especially in patients with severe concomitant injuries, which may be prohibitive to open surgical repair. Recent published studies have shown that endovascular repair of BTTAI is associated with lower morbidity, mortality, stroke, and paraplegia/paraparesis rates, when compared with open surgical repair of BTTAI.

Differential transesophageal echocardiographic diagnosis between linear artifacts and intraluminal flap of aortic dissection or disruption

BACKGROUND

The relatively low specificity of transesophageal echocardiography (TEE) for the diagnosis of aortic dissection (AD) or traumatic disruption of the aorta (TDA) has been attributed to linear artifacts. We sought to determine the incidence of intra-aortic linear artifacts in a cohort of patients with suspected AD or TDA, to establish the differential TEE diagnostic criteria between these artifacts and true aortic flaps, and to evaluate their impact on TEE diagnostic accuracy.

METHODS AND RESULTS

During an 8-year period, patients at high risk of AD (n = 261) or TDA (n = 90) who underwent a TEE study and had confirmed final diagnoses were studied. In an initial retrospective series, linear artifacts were observed within the ascending and descending aorta in 59 of 230 patients (26%) and 17 of 230 patients (7%), respectively. TEE findings associated with linear artifacts in the ascending aorta were as follows: displacement parallel to aortic walls; similar blood flow velocities on both sides; angle with the aortic wall > 85 degrees; and thickness > 2.5 mm. Diagnostic criteria of reverberant images in the descending aorta were as follows: displacement parallel to aortic walls, overimposition of blood flow, and similar blood flow velocities on both sides of the image. In a subsequent prospective series (n = 121), systematic use of these diagnostic criteria resulted in improved TEE specificity for the identification of true intra-aortic flaps.

CONCLUSIONS

Misleading intra-aortic linear artifacts are frequently observed in patients undergoing a TEE study for suspected AD or TDA. Routine use of the herein-proposed diagnostic criteria promises to further improve TEE diagnostic accuracy in the setting of severely ill patients with potential need for prompt surgery.