Traumatic aortic transection: Difference between revisions

(Text replacement - "== " to "==")
(41 intermediate revisions by 6 users not shown)
Line 2: Line 2:


==Background==
==Background==
[[File:PMC3443276 13244 2012 187 Fig22 HTML.png|thumb|Aortic isthmus laceration with pseudoaneurysm (arrow), mediastinal hematoma, and bilateral hemothorax]]
*Blunt traumatic mechanism, rapid deceleration
*Blunt traumatic mechanism, rapid deceleration
*Most common location is isthmus (90%) just distal to the left subclavian artery<ref>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.</ref>
**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)
*Often asymptomatic but die without warning (80% die at scene)
*Hypotension NOT from ruptured aorta (just die)
*Do NOT have [[Hypotension]] (just die, but may have initial hypertension in upper extremities)
*Need high suspicion to diagnose
*Need high suspicion to diagnose
===Classification===
*Classification based on CT findings<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: Intimal tear
**Type II: Intramural hematoma
**Type III: Pseudoaneurysm
**Type IV: Rupture (free rupture, periaortic hematoma)


==Clinical Features==
==Clinical Features==
Line 27: Line 26:
*Subclavian hematoma
*Subclavian hematoma
*Femoral pulse discrepancy
*Femoral pulse discrepancy
*Upper extremity [[hypertension]]
*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==
==Differential Diagnosis==
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


==Diagnosis==
==Evaluation==
*[[CXR]]
===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]]
*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)
**Widened mediastinum (>8cm on supine film)
**Left apical cap
**Left apical cap
Line 39: Line 47:
**Left hemothorax
**Left hemothorax
**Rightward tracheal/esophageal deviation
**Rightward tracheal/esophageal deviation
**Depression of L mainstem bronchus
**Depression of left mainstem bronchus
**Elevation of R mainstem bronchus
**Elevation of right mainstem bronchus
**Widened paratracheal stripe
**Widened paratracheal stripe
**Widened paraspinal interfaces
**Widened paraspinal interfaces
*CT
**Diagnostic study of choice
**Good for aorta but not for branch vessels
*Aortography
*Aortography
**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)
**No longer routinely performed
 
===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 w/ alpha/beta blockers, CCBs
*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

Aortic isthmus laceration with pseudoaneurysm (arrow), mediastinal hematoma, and bilateral hemothorax
  • 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

Evaluation

Workup

Blunt thoracic aortic injury on CXR showing widened mediastinum
Acute  traumatic  aneurysm: small focal outpouching from the anterior aspect of the proximal descending thoracic aorta (curved arrow).
Traumatic dissection of the descending aorta. (a) Proximal border at the level of the isthmus. (b) Involvement of the abdominal part
  • 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]

(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

Disposition

  • Admission

See Also

References

  1. ↑ 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.
  2. ↑ 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
  3. ↑ 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
  4. ↑ 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
Retrieved from "https://www.wikem.org/w/index.php?title=Traumatic_aortic_transection&oldid=258578"