thoracic aortic injuries are very rare, this presentation will give a brief idea regarding the presentation of Thoracic aortic injury and its management

1. Thoracic Aortic Injury
Awaneesh Katiyar
Senior Resident M.Ch.
Trauma Surgery & Critical Care
AIIMS, Rishikesh

2. Case Scenario
A 25 year-male driving car @140km/hour collided to a wall, arrived in ED
within 25min of car crash. Airway patent with full GCS. HR 134/min, BP
112/48, complaining of severe chest pain. O/E pattern abrasion of steering
noted over sternum and left chest with sign of sternum fracture. Right
Patella fracture , right both bone leg fracture also noted. PCT positive.
EFAST –pericardial fluid(no tamponade) with left hemothorax noted ,
abdomen - no fluid. P/A soft nontender.
• What are the differential diagnosis ?
• How you proceed ?
ThoracicAortic Injury 1

3. Introduction
• Incidence <1% of all blunt trauma ( > 70% HMV collision)1
• 80% - on scene death or transfer – counts for 10-15% MVC related
deaths2
• Sign and symptoms are non-specific – often associated with
distracting injuries
1. Akhmerov A, DuBose J, Azizzadeh A. Blunt thoracic aortic injury: current therapies, outcomes, and challenges. Annals of Vascular Diseases. 2019 Jan 22:ra-18.
2. Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521.
2Thoracic Aortic Injury

4. Deaths – untreated
Duration Deaths
First hour 10-15 %
Within 6 hours 20-30%
Within 24hours 30-50%
Within a week 60-70%
Parmley et. al 1958
Jahnkeetal1964
Gotzen,Hetzeretal1982
Hartfordetal1986
DeathPercentage
Duration (days)
3Thoracic Aortic Injury
Most deaths are Preventable death
-Depends on preparedness

5. Deaths*
* Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521.
4Thoracic Aortic Injury

6. 1. Hunt JP, Baker CC, Lentz CW, Rutledge RR, Oller DW, Flowe KM, Nayduch DA, Smith C, Clancy TV, Thomason MH, Meredith JW. Thoracic aorta injuries:
management and outcome of 144 patients. Journal of Trauma and Acute Care Surgery. 1996 Apr 1;40(4):547-56.
2. Parmley LF, MATTINGLY TW, MANION WC, JAHNKE JR, MAJ EJ. Nonpenetrating traumatic injury of the aorta. Circulation. 1958 Jun;17(6):1086-101.
1. 144 Emergency Cases ( Hunt et. al 1996) 2. 275 Post-Mortem Cases ( Parmley et. al 1958)
AA
DTA DTA
5Thoracic Aortic Injury

7. Mechanism of Injury
• Rapid decelerating injury
• Direct impact
• Fall from height
6Thoracic Aortic Injury

8. Rapid deceleration - Pathophysiology
Rapid deceleration
7ThoracicAortic Injury
Thoracic Aortic Injury – common in high velocity crash
Head injury
Cervical spine – whiplash injury
Knee, Hip – acetabulum
Retroperitoneal injury
Shearing force between
static and mobile parts of Aorta
Tear – distal to LSCA ( fixed)

9. Osseous Pinch - Pathophysiology
Blunt trauma chest – osseous pinch
8ThoracicAortic Injury

10. Water hammer effect - Pathophysiology
Water- Hammer effect
9ThoracicAortic Injury

11. Clinical presentation
• Hypotension (clinical suspicion)
• Upper extremity hypotension
• Expanding hematoma at thoracic out
• Intra-scapular murmur sternum fracture
• Left flail chest
• Associated thoracic spine fracture
1. Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521.
10Thoracic Aortic Injury

12. Chest radiograph – large hemothorax
11Thoracic Aortic Injury

13. Foreign body (FB) in proximity of great
vessels
12Thoracic Aortic Injury

14. Trajectory with confusing course / distal
embolization
13Thoracic Aortic Injury

15. Funny looking mediastinum
14Thoracic Aortic Injury
Loss of Aortic Knuckle
Sign of contained aortic rupture

16. Mediastinal clues *
• Aortic knob – obliteration or double
• Mediastinal widening > 8cm
• Depression of left main bronchus
>1400 from trachea
• Loss of paravertebral stripe
* Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521.
15Thoracic Aortic Injury

17. Mediastinal clues *
• Calcium layering at aortic knob
• Deviation of NG tube
• Lateral displacement of the trachea.
* Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521.
16Thoracic Aortic Injury

18. Associated organ injuries *
• 90% have other organ injuries
• 51% cerebral injury
• 62% other thoracic injury
• 22% intra-abdominal injuries
• 34% pelvic or extremities fracture
* Smith RS, Chang FC.Traumatic rupture of the aorta: still a lethal injury.The American journal of surgery. 1986
Dec 1;152(6):660-3.
17Thoracic Aortic Injury

19. Investigations
1. Chest X rays – Initial investigation
2. Aortography
3. Thoracic CT (Investigation of choice ) *
4. Thoracic MRI
5. Transesophageal echo (TEE)
6. IVUS
18
* Kumar R, Raja J, Munirathinam GK, Mishra AK, Singh RS,Thingnam SK.A case of traumatic thoracic aorta rupture-A life threatening emergency. Journal of Cardiovascular and
Thoracic Research. 2019;11(3):248.
Helical CT is more sensitive than
Aortogram and conventional CT *
Thoracic Aortic Injury

20. Traumatic Aortic Injury classification
Akhmerov A, DuBose J, Azizzadeh A. Blunt thoracic aortic injury: current therapies, outcomes, and challenges. Annals ofVascular Diseases. 2019 Jan 22:ra-18.
19Thoracic Aortic Injury

21. AAST grading
20Thoracic Aortic Injury

22. Aortogram: grade-I
21Thoracic Aortic Injury

23. CT / Aortogram: grade-II
22Thoracic Aortic Injury

24. X rays & Aortogram: grade-III
23Thoracic Aortic Injury

25. CT thorax: grade-IV
24Thoracic Aortic Injury

26. 25Thoracic Aortic Injury

27. Management of Aortic Injury
UpToDate 2020 - Management of Blunt Aortic injury
Initial Management – ATLS Protocol
Unstable Stable
Operation theatre Grade – I Grade – II, III, IV
Non– Operative Operative
26Thoracic Aortic Injury

28. Non-operative Management – MAI
• Anti-impulse therapy ( Negative Inotropic therapy) :
• <100 SBP and HR < 100/min
• Beta blocker - IV Esmolol
• Calcium channel blocker – diltiazem
• Non achievable – add vasodilator - Nitroprusside
1. UpToDate 2020 - Management of Blunt Aortic injury
2. Malhotra AK, Fabian TC, Croce MA, Weiman DS, Gavant ML, Pate JW. Minimal aortic injury: a lesion associated
with advancing diagnostic techniques. Journal of Trauma and Acute Care Surgery. 2001 Dec 1;51(6):1042-8.
Good clinical Practice – No Randomized control trial
Initial Management – ATLS Protocol
Minimal Aortic injury : <1 cm intimal tear with minimal or no peri-aortic hematoma 1,2
27Thoracic Aortic Injury

29. Follow –up for NOM
• No Established protocol – lack of data
• First – CT follow up – 1st three month after discharge. Exact timing
depends
• Judgement of surgeon
• Anatomical lesion
• Patient status – age / renal functions
Osgood MJ, Heck JM, Rellinger EJ, Doran SL, Garrard III CL, Guzman RJ, Naslund TC, Dattilo JB. Natural history of grade I-II blunt traumatic aortic injury. Journal of vascular surgery. 2014 Feb
1;59(2):334-42.
28Thoracic Aortic Injury

30. Fate of MAI – NOM
S.N. Author Study population Conclusion
1. Kepros et al 2002 5 - BOI <20 mm in hemodynamically stable patients treated
with beta-blockade resolve within several days( 10
days ) – TEE monitoring ( 3 -19 days ) all Survived 6
month follow-up.
2. Malhotra et al 2001
Virginia
96 ( 9 with MAI) 33% - patient developed – pseudo aneurysm ( 56. 60.
70)
44% - healthy 10 weeks follow –up
22% - died ( MODS/PE)
1. Kepros J, Angood P, Jaffe CC, Rabinovici R. Aortic intimal injuries from blunt trauma: resolution profile in nonoperative management. Journal of Trauma and Acute Care Surgery. 2002 Mar
1;52(3):475-8.
2. Malhotra AK, Fabian TC, Croce MA, Weiman DS, Gavant ML, Pate JW. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. Journal of Trauma and Acute Care
Surgery. 2001 Dec 1;51(6):1042-8. 29Thoracic Aortic Injury

31. 145 – Thoracic aortic injury
30 – NOM
15
delayed repair
3days – 90 days
15
NOM
15 NOM – 5 expired due to severe head injury
10 NOM – (till 5 years follow up)
5 resolved completely
5 developed – stable pseudoaneurysm
30Thoracic Aortic Injury

32. Conclusion – MAI
• MAI ( Grade 1) – should follow regularly once monthly
• Screened with – CT Angio orTEE
• While discharging patient – warning sign should be explained –
severe chest pain ( MC)
• Counselled may required surgery within three months
• Even after 3 months 50% patient have probability to develop
pseudoaneurysm
31Thoracic Aortic Injury

33. Operative Management - Grade II,III,IV
• Unstable – Immediate repair ( Grade 4)
• Stable –– delayed repair
• Immediate repair associated with higher mortality and complications
over delayed repair.
• Immediate repair – In Extremis.
Pacini D, Angeli E, Fattori R, Lovato L, Rocchi G, Di Marco L, Bergonzini M, Grillone G, Di Bartolomeo R. Traumatic rupture of the thoracic aorta: ten years of delayed
management. The Journal of Thoracic and Cardiovascular Surgery. 2005 Apr 1;129(4):880-4.
32Thoracic Aortic Injury

34. Immediate Vs Delayed
S.N Authors and Year Cases Conclusion
1. Davide Pacini el al
2005
69
21 Immediate(1)
48 delayed(2)
Group 1 – 8 hrs (mean time)
4 died (19%)
Group 2 – 3.4± 1.9 days( mean time)
2 died ( 4.2%)
33Thoracic Aortic Injury

35. ORIGINALARTICLES
Diagnosis andTreatment of BluntThoracic Aortic
Injuries: Changing Perspectives
AAST 1 – 1997 AAST 2 – 2007
Study 274 – 30 centers 193 – 18 centers
Diagnosis CT 34.8%, Aortography 87.0%, and
11.9% TEE
CT scan – 93.3% , 8.3% Aortography , 0.1%
TEE
Mean time ( injury to
repair)
16.5 hours 54.6 hours
Open Vs
Endovascular
100% open 35.2% open repair
64.8% endovascular stent-grafts.
Bypass use 64.7% 83.8%
Mortality ( excluded
in-extremis
presentation)
22% 13%
Paraplegia 8.7% 1.6%
Graft related
complication
0.5% 18.4%
Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, Hemmila MR, O’Connor JV, McKenney MO, Moore FO, London J. Diagnosis and treatment of blunt thoracic
aortic injuries: changing perspectives. Journal of Trauma and Acute Care Surgery. 2008 Jun 1;64(6):1415-9.
34Thoracic Aortic Injury

36. OpenVs Endovascular
• Open thoracic repair -primary repair of the aorta or replacement of
the diseased aortic segment with a prosthetic tube graft through a
thoracotomy incision
• Endovascular thoracic aortic repair(TEVAR) - placement of modular
graft components - via the iliac or femoral arteries to line the
thoracic aorta and exclude the injury from the circulation
2020 35Thoracic Aortic Injury

37. Comparative effectiveness of the treatments for
thoracic aortic transection (Retrospective)
JVasc Surg. 2011
Author NOM Open TEVAR
Murad MH
et. al
2011
7728 pts
Mortality 46% 19% 9%
Paraplegia 3% 9% 3%
End stage renal ds 3% 8% 5%
Graft site infection NA 11% 3%
Murad MH, Rizvi AZ, Malgor R, Carey J, AlkatibAA, Erwin PJ, Lee WA, Fairman RM. Comparative effectiveness of the treatments for thoracic aortic transaction. Journal of
vascular surgery. 2011 Jan 1;53(1):193-9.
36Thoracic Aortic Injury

38. Reduced mortality, paraplegia, and stroke with
stent graft repair of blunt aortic transections: A
modern meta-analysis
JVasc Surg. 2011
TangGL,Tehrani HY, Usman A, Katariya K,OteroC, Perez E, Eskandari MK. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a
modern meta-analysis. Journal of vascular surgery. 2008 Mar 1;47(3):671-5.
Authors Open (370 ) Endo (329)
Tang GL
et. al
2008
699 pts
Mortality 15.2 % 7.6 %
Paraplegia 5.6% 0.%
Stroke 0.85 % 5.3 %
Specific RLN - 14.1%
Procedure specific – 17%
Iliac rupture – 5
Thrombosis – 2
Procedure related 13.3%
37Thoracic Aortic Injury

39. Thoracic Aortic Injury 38

40. Immediate-openApproach
S.N. Vessels Incision – approach
1. Ascending Aorta Median sternotomy
2. Transverse Aorta Median Sternotomy ± neck extension
3. Descending Thoracic Aorta Left posterolateral thoracotomy
4th ICS
39Thoracic Aortic Injury
No Cardiopulmonary bypass associated with poor outcome – in terms of mortality, paraplegia, Nerve injury,

41. Conclusion
S.N. Points Summary Recommendation
1.
Initial resuscitation
1. Two wide bore cannula
2. Permissive hypotension
3. Anti- Impulse therapy
Grade 2C
1. HR < 100
2. BP < 100 SBP
Grade 2C
2. Unstable Patient 1. Emergent exploration – identify source of bleeding GCP
3. Stable patient 1. Grade I tear – NOM Grade 2C
1. Grade II, III , IV injury – operative management Grade 1B
4. Operative
1. Suitable anatomy and stable patient – preferred
Endovascular management
Grade 2C
1B – strong recommendation , 2C – poor recommendationUpToDate2020
40Thoracic Aortic Injury

42. Author’s suggestion
• Don’t ignore – High index of suspicion – sinister badness beneath the surface.
• Properly evaluate aorta – distal to LSCA
• Don’t ignore – Abnormal CXR and mediastinal sign
• Guidelines for MAI ( not defined) – management & follow-up
• Monthly follow-up ( surgeon’s choice and patient condition )
• 2-3 mo. CT follow-up
• 6 months mandatory ( for stable pseudoaneurysm 5 yrs F/U)
41Thoracic Aortic Injury

43. • In stable patient prefer –TEVAR over Open
• Consider safe transfer over Open repair in stable patients.
Author’s suggestion
42Thoracic Aortic Injury

44. Thoracic Aortic Injury 43
If you want to save 20%
you need to screen 80% extra with same intention

45. Q.1 A 32 yrs/ M is involved in a high-speed motor vehicle accident collided to the
wall. A- patent , Breathing – Left CCT positive, C – Intact P 140, BP 124/78 all
pulses palpable , D-GCS – 15 with signs of clavicle fracture .CXR confirmed left
clavicle and multiple ribs fracture with Left hemothorax. Given the suspected
diagnosis, which of the following vessels should be evaluated for injury?
1. Right subclavian artery
2. Proximal innominate artery
3. Left common carotid artery
4. Left subclavian artery
44Thoracic Aortic Injury

46. Q.2 A 36 yrs/M is involved in a high-speed motor vehicle accident. He was wearing
seat belt, and he decelerate rapidly to save a pedestrian and swerved into a ditch.
At presentation vitals stable, he complained of severe chest pain. Physical
examination reveals several bruises on the chest. His respiratory examination is
unremarkable. A chest x ray shown below .What will be the next investigation?
1. CT Angiography
2. Aortogram
3. 2D echo
4. IVUS
45Thoracic Aortic Injury

47. Q.3 A 36 yrs/M is involved in a high-speed motor vehicle accident. He was wearing
seat belt, and he decelerate rapidly to save a pedestrian and swerved into a ditch.
At presentation vitals stable, he complained of severe chest pain. Physical
examination reveals several bruises on the chest. His respiratory examination is
unremarkable. A Helical CT shown below
.What will be the management ?
1. NOM
2. TEVAR
3. REBOA
4. Open repair
46Thoracic Aortic Injury

48. Q.4 A 24 yrs/M is involved in RTI driving bike ( 120Km/Hr) collided to truck . He was
wearing helmet At presentation- patient was in in-extremis, bike handle pattern
noted over sternum. Left flail chest visible, E1V2M4 CXR shown below, not
responding to IV fluids.What will be the management ?
1. Resuscitate with fluid
2. Explore for bleeding source
3. REBOA
4. TEVAR
47Thoracic Aortic Injury

49. Q.5What will be the grade ofThoracic great vessels injury ( AAST)
1. Grade 4
2. Grade 5
3. Grade 6
4. Grade 3
48Thoracic Aortic Injury