Traumatic aortic transection

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

Acute  traumatic  aneurysm: small focal outpouching from the anterior aspect of the proximal descending thoracic aorta (curved arrow).
Grading of traumatic aortic injury in para-sagittal CT reformations with additional schematic presentation: (a) Grade 1 injury in a 38-year-old patient after a fall from 10 m. Intimal flaps are demonstrated at the level of the upper and lower curvature of the proximal descending aorta and 10 cm distal to the subclavian artery (arrowheads) and accompanying mediastinal haematoma. (b) Grade 3 injury in a 35-year-old female patient after a motor vehicle accident. A large pseudoaneurysm formation is seen in the typical position. (c) and (d) Traumatic aortic transection (grade 4) in a 79-year-old female patient after a fall from 4 m height. There is also a massive para-aortic haematoma. The patient died immediately after the CT examination
a, bTraumatic dissection of the descending aorta. aProximal border at the level of the isthmus. bInvolvement 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]

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

  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
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