Semin intervent Radiol 2021; 38(01): 084-095
DOI: 10.1055/s-0041-1724009
Review Article

Thoracic Trauma: Aortic Injuries

Akhil Monga
1   Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
,
Santosh B. Patil
1   Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
,
Mathew Cherian
1   Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
,
Santhosh Poyyamoli
1   Department of Radiology, Kovai Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
,
Pankaj Mehta
2   Department of Radiology, KMCH IHSR, Coimbatore, Tamil Nadu, India
› Author Affiliations

Abstract

Thoracic aortic injuries caused by high impact trauma are life-threatening and require emergent diagnosis and management. With improvement in the acute care services, an increasing number of such injuries are being managed such that patients survive to undergo definitive therapies. A high index of clinical suspicion is required to order appropriate imaging. Computed tomography angiography is used to classify the injuries and guide treatment strategy. While low-grade injuries might be managed conservatively, high-grade injuries require urgent surgical or endovascular intervention. Over the past decade, endovascular repair of the thoracic aorta with or without a surgical bypass has become the preferred treatment with reduced mortality and morbidity. Rapid advancements in the stent graft technology have reduced the anatomic barriers to endovascular therapy and increased the confidence of the operators. Detailed planning prior to the procedure, understanding of the anatomy, correct choice of hardware, and adherence to technical protocol are essential for a successful endovascular procedure. These patients are often young and the limited data on the long-term outcome of aortic stent grafts make a case for a robust follow-up protocol.



Publication History

Article published online:
15 April 2021

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  • References

  • 1 Road traffic injuries [Internet]. [cited August 16, 2020]. Accessed October 9, 2020 at: https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
  • 2 Parmley LF, Mattingly TW, Manion WC, Jahnke Jr EJ. Nonpenetrating traumatic injury of the aorta. Circulation 1958; 17 (06) 1086-1101
  • 3 de Mestral C, Dueck A, Sharma SS. et al. Evolution of the incidence, management, and mortality of blunt thoracic aortic injury: a population-based analysis. J Am Coll Surg 2013; 216 (06) 1110-1115
  • 4 Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience. J Thorac Cardiovasc Surg 1990; 100 (05) 652-660 , discussion 660–661
  • 5 Arthurs ZM, Starnes BW, Sohn VY, Singh N, Martin MJ, Andersen CA. Functional and survival outcomes in traumatic blunt thoracic aortic injuries: an analysis of the National Trauma Databank. J Vasc Surg 2009; 49 (04) 988-994
  • 6 Vesalius ABT. Sepulchretum sive anatomia practica ex cadaveribus morbo denatis. Sect 2. Leonard Chouet. 1679: 290
  • 7 Teixeira PGR, Inaba K, Barmparas G. et al. Blunt thoracic aortic injuries: an autopsy study. J Trauma 2011; 70 (01) 197-202
  • 8 Kodali S, Jamieson WR, Leia-Stephens M, Miyagishima RT, Janusz MT, Tyers GF. Traumatic rupture of the thoracic aorta. A 20-year review: 1969-1989. Circulation 1991; 84 (5, Suppl): III40-III46
  • 9 Dosios TJ, Salemis N, Angouras D, Nonas E. Blunt and penetrating trauma of the thoracic aorta and aortic arch branches: an autopsy study. J Trauma 2000; 49 (04) 696-703
  • 10 Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J. Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 2007; 62 (03) 664-667
  • 11 Dischinger PC, Cushing BM, Kerns TJ. Injury patterns associated with direction of impact: drivers admitted to trauma centers. J Trauma 1993; 35 (03) 454-458 , discussion 458–459
  • 12 Shkrum MJ, McClafferty KJ, Green RN, Nowak ES, Young JG. Mechanisms of aortic injury in fatalities occurring in motor vehicle collisions. J Forensic Sci 1999; 44 (01) 44-56
  • 13 Katyal D, McLellan BA, Brenneman FD, Boulanger BR, Sharkey PW, Waddell JP. Lateral impact motor vehicle collisions: significant cause of blunt traumatic rupture of the thoracic aorta. J Trauma 1997; 42 (05) 769-772
  • 14 Richens D, Field M, Neale M, Oakley C. The mechanism of injury in blunt traumatic rupture of the aorta. Eur J Cardiothorac Surg 2002; 21 (02) 288-293
  • 15 Feczko JD, Lynch L, Pless JE, Clark MA, McClain J, Hawley DA. An autopsy case review of 142 nonpenetrating (blunt) injuries of the aorta. J Trauma 1992; 33 (06) 846-849
  • 16 Lundervall J. The mechanism of traumatic rupture of the aorta. Acta Pathol Microbiol Scand 1964; 62: 34-46
  • 17 Creasy JD, Chiles C, Routh WD, Dyer RB. Overview of traumatic injury of the thoracic aorta. Radiographics 1997; 17 (01) 27-45
  • 18 Crass JR, Cohen AM, Motta AO, Tomashefski Jr JF, Wiesen EJ. A proposed new mechanism of traumatic aortic rupture: the osseous pinch. Radiology 1990; 176 (03) 645-649
  • 19 Fabian TC, Richardson JD, Croce MA. et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma 1997; 42 (03) 374-380 , discussion 380–383
  • 20 Burkhart HM, Gomez GA, Jacobson LE, Pless JE, Broadie TA. Fatal blunt aortic injuries: a review of 242 autopsy cases. J Trauma 2001; 50 (01) 113-115
  • 21 Rabinsky I, Sidhu GS, Wagner RB. Mid-descending aortic traumatic aneurysms. Ann Thorac Surg 1990; 50 (01) 155-160
  • 22 Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med 2008; 359 (16) 1708-1716
  • 23 Groskin SA. Selected topics in chest trauma. Semin Ultrasound CT MR 1996; 17 (02) 119-141
  • 24 Merrill WH, Lee RB, Hammon Jr JW, Frist WH, Stewart JR, Bender Jr HW. Surgical treatment of acute traumatic tear of the thoracic aorta. Ann Surg 1988; 207 (06) 699-706
  • 25 Kram HB, Wohlmuth DA, Appel PL, Shoemaker WC. Clinical and radiographic indications for aortography in blunt chest trauma. J Vasc Surg 1987; 6 (02) 168-176
  • 26 Marnocha KE, Maglinte DD, Woods J, Goodman M, Peterson P. Mediastinal-width/chest-width ratio in blunt chest trauma: a reappraisal. AJR Am J Roentgenol 1984; 142 (02) 275-277
  • 27 Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology 2008; 248 (03) 748-762
  • 28 Gutierrez A, Inaba K, Siboni S. et al. The utility of chest X-ray as a screening tool for blunt thoracic aortic injury. Injury 2016; 47 (01) 32-36
  • 29 Mirvis SE, Shanmuganathan K, Miller BH, White CS, Turney SZ. Traumatic aortic injury: diagnosis with contrast-enhanced thoracic CT--five-year experience at a major trauma center. Radiology 1996; 200 (02) 413-422
  • 30 Fishman JE, Nuñez Jr D, Kane A, Rivas LA, Jacobs WE. Direct versus indirect signs of traumatic aortic injury revealed by helical CT: performance characteristics and interobserver agreement. AJR Am J Roentgenol 1999; 172 (04) 1027-1031
  • 31 Azizzadeh A, Keyhani K, Miller III CC, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009; 49 (06) 1403-1408
  • 32 Lee WA, Matsumura JS, Mitchell RS. et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011; 53 (01) 187-192
  • 33 Lamarche Y, Berger FH, Nicolaou S. et al. Vancouver simplified grading system with computed tomographic angiography for blunt aortic injury. J Thorac Cardiovasc Surg 2012; 144 (02) 347-354 , 354.e1
  • 34 Heneghan RE, Aarabi S, Quiroga E, Gunn ML, Singh N, Starnes BW. Call for a new classification system and treatment strategy in blunt aortic injury. J Vasc Surg 2016; 64 (01) 171-176
  • 35 Hemmila MR, Arbabi S, Rowe SA. et al. Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair?. J Trauma 2004; 56 (01) 13-23
  • 36 Fabian TC, Davis KA, Gavant ML. et al. Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg 1998; 227 (05) 666-676 , discussion 676–677
  • 37 Harris DG, Rabin J, Starnes BW. et al. Evolution of lesion-specific management of blunt thoracic aortic injury. J Vasc Surg 2016; 64 (02) 500-505
  • 38 Demetriades D, Velmahos GC, Scalea TM. et al. Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study. J Trauma 2009; 66 (04) 967-973
  • 39 Pacini D, Angeli E, Fattori R. et al. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005; 129 (04) 880-884
  • 40 von Oppell UO, Dunne TT, De Groot MK, Zilla P. Traumatic aortic rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994; 58 (02) 585-593
  • 41 Amabile P, Collart F, Gariboldi V, Rollet G, Bartoli J-M, Piquet P. Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004; 40 (05) 873-879
  • 42 Oppell UOv, Dunne TT, Groot KMD, Zilla P. Spinal cord protection in the absence of collateral circulation. Meta-analysis of mortality and paraplegia. J Card Surg 1994; 9 (06) 685-691
  • 43 Demetriades D, Velmahos GC, Scalea TM. et al; American Association for the Surgery of Trauma Thoracic Aortic Injury Study Group. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma 2008; 64 (03) 561-570 , discussion 570–571
  • 44 Khoynezhad A, Azizzadeh A, Donayre CE, Matsumoto A, Velazquez O, White R. RESCUE Investigators. Results of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Vasc Surg 2013; 57 (04) 899-905.e1
  • 45 Ultee KHJ, Soden PA, Chien V. et al. National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries. J Vasc Surg 2016; 63 (05) 1232-1239.e1
  • 46 Cannon CP, Harrington RA, James S. et al; PLATelet Inhibition and Patient Outcomes Investigators. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet 2010; 375 (9711): 283-293
  • 47 Torsello GB, Torsello GF, Osada N, Teebken OE, Ratusinski C-M, Nienaber CA. Midterm results from the TRAVIATA registry: treatment of thoracic aortic disease with the valiant stent graft. J Endovasc Ther 2010; 17 (02) 137-150
  • 48 Ito E, Kanaoka Y, Maeda K, Ohta H, Ishida A, Ohki T. Deployment Accuracy of the Conformable GORE(®) TAG(®) Thoracic Endoprosthesis in the Treatment of Zones 2 and 3 Aortic Arch Aneurysms Compared with the Previous TAG(®). Ann Vasc Dis 2015; 8 (02) 74-78
  • 49 Findeiss LK, Cody ME. Endovascular repair of thoracic aortic aneurysms. Semin Intervent Radiol 2011; 28 (01) 107-117
  • 50 Alberta HB, Secor JL, Smits TC. et al. Comparison of thoracic aortic diameter changes after endograft placement in patients with traumatic and aneurysmal disease. J Vasc Surg 2014; 59 (05) 1241-1246
  • 51 Farber MA, Mendes RR. Endovascular repair of blunt thoracic aortic injury: techniques and tips. J Vasc Surg 2009; 50 (03) 683-686
  • 52 Krajcer Z, Wood DA, Strickman N. et al. Pivotal clinical study to evaluate the safety and effectiveness of the MANTA vascular closure device during percutaneous EVAR and TEVAR procedures. J Endovasc Ther 2020; 27 (03) 414-420
  • 53 Thomas RP, Kowald T, Schmuck B. Retrospective evaluation of percutaneous access for TEVAR and EVAR: Time to make it the standard approach?. Rofo 2017; 189 (04) 347-355
  • 54 Nelson PR, Kracjer Z, Kansal N. et al. A multicenter, randomized, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial). J Vasc Surg 2014; 59 (05) 1181-1193
  • 55 Ni ZH, Luo JF, Huang WH. et al. Totally percutaneous thoracic endovascular aortic repair with the preclosing technique: a case-control study. Chin Med J (Engl) 2011; 124 (06) 851-855
  • 56 Lee WA, Daniels MJ, Beaver TM, Klodell CT, Raghinaru DE, Hess Jr PJ. Late outcomes of a single-center experience of 400 consecutive thoracic endovascular aortic repairs. Circulation 2011; 123 (25) 2938-2945
  • 57 Domoto S, Azuma T, Nakazawa K. et al. Safety and efficacy of the percutaneous thoracic endovascular repair with regional anesthesia. Gen Thorac Cardiovasc Surg 2020; ; (epub ahead of print)
  • 58 Nicolaou G, Ismail M, Cheng D. Thoracic endovascular aortic repair: update on indications and guidelines. Anesthesiol Clin 2013; 31 (02) 451-478
  • 59 Lachat M, Pfammatter T, Witzke H. et al. Acute traumatic aortic rupture: early stent-graft repair. Eur J Cardiothorac Surg 2002; 21 (06) 959-963
  • 60 Hoornweg LL, Dinkelman MK, Goslings JC. et al. Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multicenter analysis of 28 cases in the Netherlands. J Vasc Surg 2006; 43 (06) 1096-1102 , discussion 1102
  • 61 Sepehripour AH, Ahmed K, Vecht JA. et al. Management of the left subclavian artery during endovascular stent grafting for traumatic aortic injury - a systematic review. Eur J Vasc Endovasc Surg 2011; 41 (06) 758-769
  • 62 Antonello M, Menegolo M, Maturi C. et al. Intentional coverage of the left subclavian artery during endovascular repair of traumatic descending thoracic aortic transection. J Vasc Surg 2013; 57 (03) 684-690.e1
  • 63 Eagleton MJ, Shah S, Petkosevek D, Mastracci TM, Greenberg RK. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg 2014; 59 (01) 89-94
  • 64 Gilani R, Ochoa L, Wall Jr MJ, Tsai PI, Mattox KL. Endovascular repair of traumatic aortic injury using a custom fenestrated endograft to preserve the left subclavian artery. Vasc Endovascular Surg 2011; 45 (06) 549-552
  • 65 Kurimoto Y, Asai Y, Nara S. et al. Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury. J Trauma 2009; 66 (04) 974-978 , discussion 978–979
  • 66 Drinkwater SL, Goebells A, Haydar A. et al; Regional Vascular Unit, St Mary's Hospital, Imperial College NHS Trust. The incidence of spinal cord ischaemia following thoracic and thoracoabdominal aortic endovascular intervention. Eur J Vasc Endovasc Surg 2010; 40 (06) 729-735
  • 67 Dijkstra ML, Vainas T, Zeebregts CJ, Hooft L, van der Laan MJ. Editor's choice - spinal cord ischaemia in endovascular thoracic and thoraco-abdominal aortic repair: review of preventive strategies. Eur J Vasc Endovasc Surg 2018; 55 (06) 829-841
  • 68 Zoli S, Roder F, Etz CD. et al. Predicting the risk of paraplegia after thoracic and thoracoabdominal aneurysm repair. Ann Thorac Surg 2010; 90 (04) 1237-1244 , discussion 1245
  • 69 Khoynezhad A, Donayre CE, Bui H, Kopchok GE, Walot I, White RA. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg 2007; 83 (02) S882-S889 , discussion S890–S892
  • 70 Martin DJ, Martin TD, Hess PJ, Daniels MJ, Feezor RJ, Lee WA. Spinal cord ischemia after TEVAR in patients with abdominal aortic aneurysms. J Vasc Surg 2009; 49 (02) 302-306 , discussion 306–307
  • 71 Wong CS, Healy D, Canning C, Coffey JC, Boyle JR, Walsh SR. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg 2012; 56 (05) 1438-1447
  • 72 Wong S, Mastracci TM. Part One: For the motion. All TEVAR patients must be followed lifelong by annual CTA/MRA. [Pro]. Eur J Vasc Endovasc Surg 2012; 44 (06) 534-537
  • 73 Katsargyris A, Verhoeven ELG. Part Two: Against the motion. All TEVAR patients do not require lifelong follow-up by annual CTA/MRA. [Con]. Eur J Vasc Endovasc Surg 2012; 44 (06) 538-541