Traumatic aortic transection: Difference between revisions
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==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
[[File:PMC4040866 rju05301.png|thumb|Blunt thoracic aortic injury on CXR showing widened mediastinum]] | |||
[[File:PMC3874367 IJVM2013-797189.010.png|thumb|Acute traumatic aneurysm: small focal outpouching from the anterior aspect of the proximal descending thoracic aorta (curved arrow).]] | |||
[[File:PMC3443276 13244 2012 187 Fig23 HTML.png|thumb|Traumatic dissection of the descending aorta. (a) Proximal border at the level of the isthmus. (b) Involvement of the abdominal part]] | |||
[[File:PMC3874367 IJVM2013-797189.010.png|thumb| | |||
[[File:PMC3443276 13244 2012 187 Fig23 HTML.png|thumb| | |||
*CT | *CT | ||
**Diagnostic study of choice | **Diagnostic study of choice | ||
**Good for aorta but not for branch vessels | **Good for aorta but not for branch vessels | ||
*[[CXR]] | *[[CXR]] (may be an initial screening study, but is not sensitive) | ||
**Widened mediastinum (>8cm on supine film) | **Widened mediastinum (>8cm on supine film) | ||
**Left apical cap | **Left apical cap | ||
Line 58: | Line 54: | ||
**No longer routinely performed, although previously the gold standard | **No longer routinely performed, although previously the gold standard | ||
**25% have complications (i.e. infection & hematoma) | **25% have complications (i.e. infection & hematoma) | ||
===Diagnosis=== | |||
====Classification<ref>Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408</ref>==== | |||
[[File:PMC4330229 13244 2014 380 Fig1 HTML.png|thumb|(a) Grade 1: Intimal flaps at the level of the proximal descending aorta and 10 cm distal to the subclavian artery (arrowheads) with accompanying mediastinal hematoma. (b) Grade 3: large pseudoaneurysm formation. (c) and (d) Traumatic aortic transection (grade 4) with massive para-aortic hematoma.]] | |||
''Based on CT findings'' | |||
*Type I: Intimal tear | |||
*Type II: Intramural hematoma | |||
*Type III: Pseudoaneurysm | |||
*Type IV: Rupture (free rupture, periaortic hematoma) | |||
==Management== | ==Management== | ||
*Management per ATLS for multiple injuries, hypotension | *Management per [[ATLS]] for multiple injuries, hypotension | ||
*Initial medical management similar to [[Nontraumatic thoracic aortic dissection]] | *Initial medical management similar to [[Nontraumatic thoracic aortic dissection]] | ||
*Keep SBP <120, HR 60-80 with α/β-blockers, calcium-channel blockers | *Keep SBP <120, HR 60-80 with α/[[beta blockers|β-blockers]], [[calcium-channel blockers]] | ||
*Type I injuries may be managed conservatively<ref>Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408</ref> | *Type I injuries may be managed conservatively<ref>Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408</ref> | ||
*Surgical management for type II and greater | *Surgical management for type II and greater |
Revision as of 16:54, 16 June 2020
Not to be confused with nontraumatic thoracic aortic dissection
Background
- Blunt traumatic mechanism, rapid deceleration
- Most common location is isthmus (90%) just distal to the left subclavian artery[1]
- Where the ligamentum arteriosum tethers the aorta and pulmonary artery
- Other locations are:
- Ascending aorta (5%)
- Diaphragmatic hiatus (5%)
- Often asymptomatic but die without warning (80% die at scene)
- Do NOT have Hypotension (just die, but may have initial hypertension in upper extremities)
- Need high suspicion to diagnose
Clinical Features
No signs or symptoms are sufficiently sensitive for dignosis[2]
Symptoms
Physical exam
- Seatbelt or steering wheel sign
- New murmur
- Subclavian hematoma
- Femoral pulse discrepancy
- Upper extremity hypertension if isolated traumatic aortic transection
- Aortic hematoma stretches sympathetic fibers, increasing systemic vascular resistance
- Patients either have moderately elevated BP or no blood pressure at all, as true rupture leads quickly to death
Differential Diagnosis
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Evaluation
Workup
- CT
- Diagnostic study of choice
- Good for aorta but not for branch vessels
- CXR (may be an initial screening study, but is not sensitive)
- Widened mediastinum (>8cm on supine film)
- Left apical cap
- Enlarged aortic knob
- Left hemothorax
- Rightward tracheal/esophageal deviation
- Depression of left mainstem bronchus
- Elevation of right mainstem bronchus
- Widened paratracheal stripe
- Widened paraspinal interfaces
- Aortography
- No longer routinely performed, although previously the gold standard
- 25% have complications (i.e. infection & hematoma)
Diagnosis
Classification[3]
Based on CT findings
- Type I: Intimal tear
- Type II: Intramural hematoma
- Type III: Pseudoaneurysm
- Type IV: Rupture (free rupture, periaortic hematoma)
Management
- Management per ATLS for multiple injuries, hypotension
- Initial medical management similar to Nontraumatic thoracic aortic dissection
- Keep SBP <120, HR 60-80 with α/β-blockers, calcium-channel blockers
- Type I injuries may be managed conservatively[4]
- Surgical management for type II and greater
Disposition
- Admission
See Also
References
- ↑ Wojciechowski J et al. Traumatic aortic injury: does the anatomy of the aortic arch influence aortic trauma severity? Nov 2016. Surg Today. 2017; 47(3): 328–334.
- ↑ Kram, H. B., Appel, P. L., Wohlmuth, D. A. and Shoemaker, W. C. (1989) ‘Diagnosis of traumatic thoracic aortic rupture: A 10-year retrospective analysis’, The Annals of Thoracic Surgery, 47(2), pp. 282–286
- ↑ Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408
- ↑ Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408