Traumatic aortic injury tai is a life threatening condition that requires prompt diagnosis and management. Introduction blunt thoracic aortic injury, which is a lifethreatening injury, usually occurs at the aortic isthmus just distal to the left subclavian artery, but other sites can be affected the grade of aortic injury taken together with the patients associated injuries and medical comorbidities determines the need for, timing, and type of thoracic aortic repair. A practice management guideline from the eastern association for the surgery of trauma nicole fox, md, diane schwartz, md, jose h. Blunt traumatic thoracic aortic injury is associated with a high mortality rate, and has been implicated as the second most common cause of death in trauma patients, behind only to intracranial hemorrhage. Ct image shows a pseudoaneurysm arrow at the level of the aortic isthmus. Aortic injuries and aortic dissection emergencypedia. Crawford classification of thoracoabdominal aneurysms.
Initial management of blunt thoracic aortic injury. Our experience joseph brungardt, robert dunwoody, kristine so, christopher wixon, anthony avino, b. There was no correlation between the grade of aortic injury and the incidence of anatomic aortic. Thoracic aortic injury is the most common type of traumatic aortic injury and is a critical lifethreatening, and often life ending event. Irc16106 ircobi conference 2016 investigations and. Aortic injury is rare in adult ed blunt trauma patients who survive to receive imaging. Dec 07, 2015 traumatic aortic disruption is a timesensitive injury requiring rapid and accurate diagnosis to prevent death. Traumatic aortic injury aortic aneurysm or dissection vascular anomalies masses lung or mediastinal thymus lymphadenopathy technical factors rotation, poor inspiration1. Parameters for successful nonoperative management of. Current diagnosis and management of blunt traumatic rupture. An aortic rupture occurs after there is trauma to the aorta such as that from a motor vehicle accident or a penetrating injury.
Traumatic aortic rupture the doctor will see you now. In the setting of trauma, the chest radiograph typically serves as the initial imaging evaluation and can be useful in detecting signs of mediastinal hematoma. The aasts list of organ injury scaling tables originated in a set of papers that published in the journal of trauma. Unfortunately, aortic injuries rarely occur in isolation, and there has been no good cutoff value to help select the appropriate. Because of the lower invasivity endovascular repair can be applied in traumatic aortic injury with very low risk and limited impact on trauma destabilization. Selection criteria thoracic endovascular aortic repair was considered for adult patients with traumatic aortic injury and with the following anatomic characteristics. Use of transesophageal echocardiography for diagnosis of. Guidelines for the diagnosis and management of blunt aortic. Traumatic rupture of the thoracic aorta is a lifethreatening lesion and it occurs in 10 to 30% of deaths due to blunt thoracic trauma and it is the second most common cause of death after head injuries 1,2. Ct is the imaging tool of choice, and the knowledge of direct and indirect signs of injury, grading system, and current. Traumatic aortic injury most commonly occurs at the aortic isthmus and has many associated signs on plain radiograph and ct. Optimal management of traumatic aortic injury sciencedirect.
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. The length of the proximal neck of the aorta from the lsa to the site of the aortic injury is greater than 2 cm. Evaluation and management of blunt traumatic aortic injury. The aorta can rupture completely or incompletely after blunt or penetrating chest trauma. Traumatic aortic injury transection is usually caused high speed impact to the chest or back, such as a motor vehicle accident or serious fall. No randomized trials comparing delayed versus early repair have been. Road traffic accidents are the main cause of aortic trauma. Injuries of the thoracic aorta are usually the result of physical trauma. Management of simultaneous traumatic brain injury and. This finding is associated with a higher success rate for endovascular repair. With the improved infield emergency care available today more patients survive to obtain diagnostic imaging and treatment. The trauma medical directors and program managers workgroup is an open forum for designated trauma services in washington state to share ideas and concerns about providing trauma care. Multicenter trial of the american association for the. It is estimated that aortic injuries are lethal in 8090% of cases.
Multicenter trial of the american association for the surgery of trauma. Unfortunately, because these injuries are relatively rare, subtle forms of these injuries may be missed, and normal variants may mimic tai leading to misdia. Guidelines for the diagnosis and management of blunt. The mechanism of injury in blunt traumatic rupture of the aorta. Traumatic injury of the thoracic aorta is a major clinical concern in patients who sustain deceleration or crush injuries. Jan 02, 2011 minimal aortic injury minimal aortic injury is used to describe a lesion of the aorta associated with blunt injury that carry a relatively low risk of rupture. The analysis of this subgroup is the object of this paper. Multidetector ct is the diagnostic test of choice for detection of atai in the stable patient.
Update from the aortic trauma foundation lt col usaf mc associate professor of surgery uniformed services university of the health sciences associate professor of surgery university of maryland medical system r adams cowley shock trauma center. Tar can be remarkably occult and the emergency physician is paramount in making the initial diagnosis. Traumatic deceleration injury of the thoracic aorta. Traumatic aortic injury radiology reference article. However, with prompt diagnosis, patients can undergo lifesaving open or endovascular repair. May 01, 2000 traumatic aortic disruption often first shows up on a chest xray, although a chest xray does not always settle the matter. In july 2010, a 17yearold boy was airlifted to harborview medical center in seattle with traumatic transection of his thoracic aorta, often referred to as blunt aortic injury bai. Oct 15, 2008 with the traditional method to repair this type of traumatic aortic injury, surgeons would make a large incision to open the chest and then insert a fabric tube, or graft, to make the repair. With improved detection and treatment, however, patients who initially.
Use of spiral computed tomography for the assessment of blunt trauma patients with potential aortic injury. In trauma patients incurring aortic injury, between 20% and 50% have associated injuries 1. Pdf despite recent advances in prehospital care, multidetector computed tomographic ct technology, and rapid definitive therapy, trauma to the aorta. Blunt traumatic aortic injury btai is the second most common cause of death in trauma patients. Endovascular repair of blunt traumatic thoracic aortic. Relationship between the injury and the nearest arterial branch vessel congenital vascular variations in anatomy e. The highest mortality usually occurs within the first few hours after injury. Diagnosis is often suspected because of the mechanism of injury andor chest xray. Traumatic blunt aortic injury often involves rapid deceleration, likely from a fall from height or motor vehicle collision, and can be life threatening.
Signs may include asymmetric pulses or bp, decreased blood flow to the lower extremities, and precordial systolic murmur. Typical acute aortic injury in a 21yearold man after a motor vehicle collision. Endovascular repair of blunt traumatic thoracic aortic injuries btai is common at most trauma centres, with excellent results. Backgroundblunt traumatic aortic injury btai is the second most common cause of death in trauma patients. Imaging of acute traumatic aortic injury springerlink. Pulmonary blast injury at szmc january 29, 2004, bus bombing 23 patients evaluated 11 patients admitted 1011 admissions had radiographic evidence of pulmonary blast injury 410 patients with blast injury patients required intubation and mechanical ventilation deaths. Acute traumatic aortic injury atai is a lifethreatening injury. The patient was cliff jumping with friends in idaho from a 50foottall ridge into still water below. Current diagnosis and management of blunt traumatic rupture of the.
In all cases the tears was just distal to the ligamentum arteriosum and proximal to the descending thoracic aorta, and the aortic laceration had a transverse orientation. For many years traumatic aortic injury has been considered a highly lethal lesion and a potential cause of death in blunt chest trauma. Diagnosing traumatic rupture of the thoracic aorta in the. Endovascular management of acute blunt traumatic thoracic aortic injury. Lundgren md a martin gunn mbchb b samantha quade md a thomas s. Despite evidence in the literature of lower morbidity and mortality, initial medical management of uncomplicated aortic injury and subsequent delayed surgery has not been easily accepted in the clinical practice. Therefore, early triage of this condition is critically important. Immediate mortality is 85% but in the group who survive to reach hospital there is a reasonable chance of successful surgical repair.
Rapid diagnosis and treatment of atai is the standard of care. However, the aast does not hold the to this material. If suggestive, but often subtle features are not recognised in the. Traumatic thoracic aortic injury and ruptures girma tefera, md, madison, wisc descending thoracic aortic injury dtai is the most frequent cause of death at the site of severe motor vehicle crash and is associated with deceleration injury. Injury scoring scale a resource for trauma care professionals. Apr 14, 2014 traumatic aortic injury tai is a life threatening condition that requires prompt diagnosis and management. Twentyeight patients tal underwent tee, and they were compared with a control group of 30 thoracic trauma patients without aortic injury. Most ed aortic injury patients have associated thoracic injuries and survive to hospital discharge. In the current era, definitive diagnosis of atai is made.
This can make diagnosis difficult because the patient often has multiple traumatic injuries with symptoms that may mask the ruptured aorta. This research was supported in whole or in part by hca andor an hca affiliated entity. A cute traumatic aortic injury atai is a serious outcome of blunt chest trauma. The majority of blunt aortic injuries are due to motor vehicle collision. Blunt thoracic aorta injury bai is second only to head injury as cause of mortality in blunt trauma. Experience of endovascular repair of thoracic aortic. Several mechanical factors may explain the typical locations of thoracic aortic rupture aortic isthmus, ascending aorta. It has been suggested that 20 percent of patients with blunt aortic injury survive long enough following the injury to be treated. The tee signs were classified as direct or indirect signs, and the quality of imaging was assessed. Traumatic aortic rupture is a relatively uncommon lesion that presents the cardiothoracic sur geon with unique challenges in diagnosis and. Clinical science endovascular and open repair for blunt aortic injury, treated in one clinical institution in brazil. It is estimated that aortic injuries are lethal in 8090% of. Jan 23, 20 a traumatic thoracic aortic injury is a severe and lifethreatening clinical entity.
Mcgovern medical school discussion in a patient in a major trauma, a widened mediastinum is extremely concerning for aortic. Three main types of injuries can occur see figure below. Blunt aortic injury is a potentially lifethreatening condition that will require repair in patients with anything more than a minimal injury and is second only to traumatic brain injury as a cause of death in injured patients. We report an atypical presentation of bai, highlighting the diagnostic challenges of this condition in the emergency department. Experience of endovascular repair of thoracic aortic dissection after blunt trauma injury in a district general hospital background. Article information, pdf download for traumatic aortic injury presenting to an. Traumatic aortic injury transection is a condition where the aorta, the main blood vessel that travels from the heart, ruptures or tears. Aortic disruption in trauma typically involves a tear on the aortic wall due to accelerationdeceleration forces may result from penetrating usually succumb in the field or blunt injury those that make it to hospital may only have the outer aortic wall layer, the adventitia, intact containing a hematoma. Pdf evaluation and management of blunt traumatic aortic. Blunt aortic injury occurs in less than 1% of motor vehicle crashes but is responsible for 16% of the deaths. A case series igor rafael sincos, ricardo aun, sergio quilici belczak, luciano dias nascimento, boulanger mioto netto.
Pdf endovascular management of acute blunt traumatic. Thoracic trauma, thoracic aorta, thoracic aortic rupture, endovascular repair, endoprosthesis, stent graft, paraplegia. Traumatic aortic injury tai is rare, but frequently lethal. Clinical science endovascular and open repair for blunt. Injury grade is a predictor of aortic related death among patients with blunt thoracic aortic injury gerald r. Although the clinical, or mechanism, score is of primary importance in the prompt diagnosis of patients with traumatic aortic injury tai, the radiologic findings play a vital supportive role. Additionally, surgical interventions for aortic injury often require full anticoagulation, which is contraindicated in patients with tbi. Injury scoring scale the american association for the. Thoracic endovascular aortic repair was successful in treating the aortic injury in all patients and there were no instances of procedurerelated death, stroke, or paraplegia. Classification of blunt traumatic aortic injury uw. Injury grade is a predictor of aorticrelated death among. Traumatic aortic rupture the annals of thoracic surgery.
Management of blunt traumatic aortic injury endovascular. Blunt aortic injury, evaluation and management of practice. The issues of how to diagnose, treat, and manage btai were first addressed by the eastern association for the sur. Traumatic thoracic aortic dissection is uncommon in clinical practice. Diagnosis is often suspected because of the mechanism of injury andor chest xray findings and confirmed by ct, ultrasonography, or aortography. Traumatic aortic injury presenting to an adult major trauma centre.
The high incidence of concomitant injuries in patients with traumatic aortic rupture makes them poorly suited to undergo a major operative proce. It is estimated that aortic injuries are lethal in 8090 % of. Thoracic aortic injury radiology reference article. Presented at the 2010 vascular annual meeting of the society for vascular surgery, june 10, 2010, boston, mass. The issues of how to diagnose, treat, and manage btai were first. Traumatic aortic transection aortic rupture cedarssinai. Results among the 24 treated patients mean age, 41 years. Clinical practice guidelines of the society for vascular surgery. Natural history of minimal aortic injury following blunt. Traumatic aortic injury tai is most often caused by blunt trauma referred to as btai and is best described in terms of injury location, type and severity. In the united states, blunt aortic injury is the second leading cause of death behind head injury for individuals aged 4 to 34. Approximately 8090% of all atais are immediately fatal.
Traumatic injury of the large vessels is being seen with increasing incidence in tertiary trauma units. While most patients do not survive till arrival at the hospital, for the remainder, prompt diagnosis and treatment greatly improve outcomes. How to best utilize tevar to treat this challenging presentation. Minimal aortic injury can be present in approximately 10% of patients whose blunt aortic injury is identified by helical ct. 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. Endovascular repair of traumatic thoracic aortic injury. Irc16106 ircobi conference 2016 investigations and injury. However, little is known regarding which injuries do not require intervention. Bovine arch was the most common variant, followed by an anomalous origin of the arch vasculature. Acute traumatic aortic injuries rsna publications online. Thus traumatic aortic rupture is a common killer in automotive accidents and other traumas, with up to 18% of deaths that occur in automobile collisions being related to the injury. Traumatic aortic injurytransection uf health aortic. Acute thoracic aortic injuries atai secondary to severe blunt chest trauma were recently found to be the second most common cause of death in patients who.
Overview of traumatic injury of the thoracic aorta. Management of traumatic aortic rupture springerlink. Diagnosis of traumatic aortic injuries springerlink. Incidental vascular findings on abdominal ct or mri.
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