Blunt thoracic aortic injury
- David G Neschis, MD
David G Neschis, MD
- Clinical Associate Professor of Surgery
- University of Maryland School of Medicine
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
Patients involved in high-energy blunt trauma involving rapid deceleration are at significant risk for blunt aortic injury. The majority of blunt aortic injuries are due to motor vehicle collision. In the United States, blunt aortic injury is the second leading cause of death behind head injury for individuals aged 4 to 34 [1,2]. Only about 20 percent of patients with blunt aortic injury survive long enough following the injury to be treated .
The presence of risk factors for blunt aortic injury should prompt a diagnostic evaluation, the nature of which depends upon the patient’s clinical status. The grade of injury taken together with the patient’s associated injuries and medical comorbidities determine the timing and type of thoracic aortic repair.
Blunt thoracic aortic injury will be reviewed here. The factors that determine whether an open surgical or endovascular approach should be taken to repair these injuries are discussed separately. (See "Surgical and endovascular repair of blunt thoracic aortic injury".)
MECHANISM OF INJURY
The incidence of blunt thoracic aortic injury is estimated between 1.5 and 2 percent of patients who sustain blunt thoracic trauma [4-7]. In a multicenter study involving 274 cases of blunt aortic injury, 81 percent were caused by automobile collisions . Other etiologies of blunt thoracic aortic injury include motorcycle and aircraft crashes, automobile versus pedestrian accidents, falls, and crush injury . About 70 percent of victims are male , with about 67 percent of patients described as overweight or obese .
The main risk factor for blunt thoracic aortic injury is rapid deceleration, either from high-speed motor vehicle collision or falls from a significant height. Injury mechanism and other patient-related factors that increase the risk for blunt thoracic aortic injury are discussed elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Epidemiology'.)
- Smith RS, Chang FC. Traumatic rupture of the aorta: still a lethal injury. Am J Surg 1986; 152:660.
- Schulman CI, Carvajal D, Lopez PP, et al. Incidence and crash mechanisms of aortic injury during the past decade. J Trauma 2007; 62:664.
- Sevitt S. The mechanisms of traumatic rupture of the thoracic aorta. Br J Surg 1977; 64:166.
- Dyer DS, Moore EE, Ilke DN, et al. Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients. J Trauma 2000; 48:673.
- Mirvis SE, Shanmuganathan K, Buell J, Rodriguez A. Use of spiral computed tomography for the assessment of blunt trauma patients with potential aortic injury. J Trauma 1998; 45:922.
- Steenburg SD, Ravenel JG. Acute traumatic thoracic aortic injuries: experience with 64-MDCT. AJR Am J Roentgenol 2008; 191:1564.
- Ungar TC, Wolf SJ, Haukoos JS, et al. Derivation of a clinical decision rule to exclude thoracic aortic imaging in patients with blunt chest trauma after motor vehicle collisions. J Trauma 2006; 61:1150.
- 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; 42:374.
- Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med 2008; 359:1708.
- Cowley RA, Turney SZ, Hankins JR, et al. Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience. J Thorac Cardiovasc Surg 1990; 100:652.
- Moar JJ. Traumatic rupture of the thoracic aorta. An autopsy and histopathological study. S Afr Med J 1985; 67:383.
- Azizzadeh A, Keyhani K, Miller CC 3rd, et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009; 49:1403.
- Kram HB, Appel PL, Wohlmuth DA, Shoemaker WC. Diagnosis of traumatic thoracic aortic rupture: a 10-year retrospective analysis. Ann Thorac Surg 1989; 47:282.
- Nikolic S, Atanasijevic T, Mihailovic Z, et al. Mechanisms of aortic blunt rupture in fatally injured front-seat passengers in frontal car collisions: an autopsy study. Am J Forensic Med Pathol 2006; 27:292.
- Cindy M, Sabrina H, Kim D, et al. Traumatic aortic rupture: 30 years of experience. Ann Vasc Surg 2011; 25:474.
- Rajani RR, Johnson LS, Brewer BL, et al. Anatomic characteristics of aortic transection: centerline analysis to facilitate graft selection. Ann Vasc Surg 2014; 28:433.
- Mosquera VX, Marini M, Muñiz J, et al. Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study. Injury 2013; 44:1191.
- LUNDERVALL J. THE MECHANISM OF TRAUMATIC RUPTURE OF THE AORTA. Acta Pathol Microbiol Scand 1964; 62:34.
- Rizoli SB, Brenneman FD, Boulanger BR, Maggisano R. Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex. Ann Thorac Surg 1994; 58:1404.
- Richens D, Field M, Neale M, Oakley C. The mechanism of injury in blunt traumatic rupture of the aorta. Eur J Cardiothorac Surg 2002; 21:288.
- Crass JR, Cohen AM, Motta AO, et al. A proposed new mechanism of traumatic aortic rupture: the osseous pinch. Radiology 1990; 176:645.
- Stemper BD, Yoganandan N, Pintar FA, Brasel KJ. Multiple subfailures characterize blunt aortic injury. J Trauma 2007; 62:1171.
- http://www.facs.org/trauma/atls/information.html (Accessed on December 10, 2012).
- PARMLEY LF, MATTINGLY TW, MANION WC, JAHNKE EJ Jr. Nonpenetrating traumatic injury of the aorta. Circulation 1958; 17:1086.
- Woodring JH. The normal mediastinum in blunt traumatic rupture of the thoracic aorta and brachiocephalic arteries. J Emerg Med 1990; 8:467.
- Woodring JH, Dillon ML. Radiographic manifestations of mediastinal hemorrhage from blunt chest trauma. Ann Thorac Surg 1984; 37:171.
- Demehri S, Rybicki FJ, Desjardins B, et al. ACR Appropriateness Criteria(®) blunt chest trauma--suspected aortic injury. Emerg Radiol 2012; 19:287.
- Dyer DS, Moore EE, Mestek MF, et al. Can chest CT be used to exclude aortic injury? Radiology 1999; 213:195.
- Bruckner BA, DiBardino DJ, Cumbie TC, et al. Critical evaluation of chest computed tomography scans for blunt descending thoracic aortic injury. Ann Thorac Surg 2006; 81:1339.
- Demetriades D, Velmahos GC, Scalea TM, et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma 2008; 64:1415.
- Melton SM, Kerby JD, McGiffin D, et al. The evolution of chest computed tomography for the definitive diagnosis of blunt aortic injury: a single-center experience. J Trauma 2004; 56:243.
- 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; 227:666.
- Ellis JD, Mayo JR. Computed tomography evaluation of traumatic rupture of the thoracic aorta: an outcome study. Can Assoc Radiol J 2007; 58:22.
- Parker MS, Matheson TL, Rao AV, et al. Making the transition: the role of helical CT in the evaluation of potentially acute thoracic aortic injuries. AJR Am J Roentgenol 2001; 176:1267.
- Hunink MG, Bos JJ. Triage of patients to angiography for detection of aortic rupture after blunt chest trauma: cost-effectiveness analysis of using CT. AJR Am J Roentgenol 1995; 165:27.
- Exadaktylos AK, Duwe J, Eckstein F, et al. The role of contrast-enhanced spiral CT imaging versus chest X-rays in surgical therapeutic concepts and thoracic aortic injury: a 29-year Swiss retrospective analysis of aortic surgery. Cardiovasc J S Afr 2005; 16:162.
- Mirvis SE, Shanmuganathan K, Miller BH, et al. Traumatic aortic injury: diagnosis with contrast-enhanced thoracic CT--five-year experience at a major trauma center. Radiology 1996; 200:413.
- Abe H, Funaki S, Chiba K, et al. Traumatic rupture of the false lumen in a patient with preexisting chronic dissection of the descending thoracic aorta. Gen Thorac Cardiovasc Surg 2011; 59:559.
- Kushimoto S, Shiraishi S, Miyauchi M, et al. Visceral ischemia caused by acute aortic dissection following blunt aortic injury: report of a case. J Nippon Med Sch 2011; 78:110.
- Gammie JS, Katz WE, Swanson ER, Peitzman AB. Acute aortic dissection after blunt chest trauma. J Trauma 1996; 40:126.
- Ono M, Yagyu K, Furuse A, et al. A case of Stanford type A acute aortic dissection caused by blunt chest trauma. J Trauma 1998; 44:543.
- Rogers FB, Osler TM, Shackford SR. Aortic dissection after trauma: case report and review of the literature. J Trauma 1996; 41:906.
- Perchinsky M, Gin K, Mayo JR. Trauma-associated dissection of the thoracic aorta. J Trauma 1998; 45:626.
- 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; 53:187.
- Pate JW, Gavant ML, Weiman DS, Fabian TC. Traumatic rupture of the aortic isthmus: program of selective management. World J Surg 1999; 23:59.
- Tzilalis VD, Kamvysis D, Panagou P, et al. Increased pulse wave velocity and arterial hypertension in young patients with thoracic aortic endografts. Ann Vasc Surg 2012; 26:462.
- Pate JW, Fabian TC, Walker W. Traumatic rupture of the aortic isthmus: an emergency? World J Surg 1995; 19:119.
- Galli R, Pacini D, Di Bartolomeo R, et al. Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta. Ann Thorac Surg 1998; 65:461.
- Malhotra AK, Fabian TC, Croce MA, et al. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. J Trauma 2001; 51:1042.
- Gavant ML. Helical CT grading of traumatic aortic injuries. Impact on clinical guidelines for medical and surgical management. Radiol Clin North Am 1999; 37:553.
- Paul JS, Neideen T, Tutton S, et al. Minimal aortic injury after blunt trauma: selective nonoperative management is safe. J Trauma 2011; 71:1519.
- Starnes BW, Lundgren RS, Gunn M, et al. A new classification scheme for treating blunt aortic injury. J Vasc Surg 2012; 55:47.
- 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; 144:347.
- Holmes JH 4th, Bloch RD, Hall RA, et al. Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis. Ann Thorac Surg 2002; 73:1149.
- DuBose JJ, Leake SS, Brenner M, et al. Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study. J Trauma Acute Care Surg 2015; 78:360.
- Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg 2014; 59:334.
- Rabin J, DuBose J, Sliker CW, et al. Parameters for successful nonoperative management of traumatic aortic injury. J Thorac Cardiovasc Surg 2014; 147:143.
- 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; 216:1110.
- Caffarelli AD, Mallidi HR, Maggio PM, et al. Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma. J Thorac Cardiovasc Surg 2010; 140:598.
- Fisher RG, Oria RA, Mattox KL, et al. Conservative management of aortic lacerations due to blunt trauma. J Trauma 1990; 30:1562.
- Hirose H, Gill IS, Malangoni MA. Nonoperative management of traumatic aortic injury. J Trauma 2006; 60:597.
- Pacini D, Angeli E, Fattori R, et al. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg 2005; 129:880.
- Pierangeli A, Turinetto B, Galli R, et al. Delayed treatment of isthmic aortic rupture. Cardiovasc Surg 2000; 8:280.
- Kipfer B, Leupi F, Schuepbach P, et al. Acute traumatic rupture of the thoracic aorta: immediate or delayed surgical repair? Eur J Cardiothorac Surg 1994; 8:30.
- Maggisano R, Nathens A, Alexandrova NA, et al. Traumatic rupture of the thoracic aorta: should one always operate immediately? Ann Vasc Surg 1995; 9:44.
- 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; 66:967.
- Murad MH, Rizvi AZ, Malgor R, et al. Comparative effectiveness of the treatments for thoracic aortic transection [corrected]. J Vasc Surg 2011; 53:193.
- Demetriades D. Blunt thoracic aortic injuries: crossing the Rubicon. J Am Coll Surg 2012; 214:247.
- Takagi H, Manabe H, Kawai N, et al. Endovascular versus open repair for blunt thoracic aortic injury. Ann Thorac Surg 2009; 87:349.
- Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 78:136.
- Neschis DG, Moainie S, Flinn WR, et al. Endograft repair of traumatic aortic injury-a technique in evolution: a single institution's experience. Ann Surg 2009; 250:377.
- Di Eusanio M, Folesani G, Berretta P, et al. Delayed management of blunt traumatic aortic injury: open surgical versus endovascular repair. Ann Thorac Surg 2013; 95:1591.
- 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; 56:13.
- Symbas PN, Sherman AJ, Silver JM, et al. Traumatic rupture of the aorta: immediate or delayed repair? Ann Surg 2002; 235:796.
- Malgor RD, Bilfinger TV, McCormack J, et al. Trends in clinical presentation, management, and mortality of blunt aortic traumatic injury over an 18-year period. Vasc Endovascular Surg 2013; 47:19.
- Lang JL, Minei JP, Modrall JG, et al. The limitations of thoracic endovascular aortic repair in altering the natural history of blunt aortic injury. J Vasc Surg 2010; 52:290.
- Xenos ES, Minion DJ, Davenport DL, et al. Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis. Eur J Cardiothorac Surg 2009; 35:282.
- Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc Interv Radiol 2008; 19:1153.
- Tang GL, Tehrani HY, Usman A, et al. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. J Vasc Surg 2008; 47:671.
- Kepros J, Angood P, Jaffe CC, Rabinovici R. Aortic intimal injuries from blunt trauma: resolution profile in nonoperative management. J Trauma 2002; 52:475.
- Kidane B, Plourde M, Chadi SA, et al. The effect of loss to follow-up on treatment of blunt traumatic thoracic aortic injury. J Vasc Surg 2015; 61:1624.
- Kidane B, Parry NG, Forbes TL. Review of the management of blunt thoracic aortic injuries according to current treatment recommendations. Ann Vasc Surg 2013; 27:1014.
- Greendyke RM. Traumatic rupture of aorta; special reference to automobile accidents. JAMA 1966; 195:527.
- Malgor RD, Bilfinger TV, McCormack J, Tassiopoulos AK. Outcomes of blunt thoracic aortic injury in adolescents. Ann Vasc Surg 2015; 29:502.
- Hong MS, Feezor RJ, Lee WA, Nelson PR. The advent of thoracic endovascular aortic repair is associated with broadened treatment eligibility and decreased overall mortality in traumatic thoracic aortic injury. J Vasc Surg 2011; 53:36.
- Jonker FH, Giacovelli JK, Muhs BE, et al. Trends and outcomes of endovascular and open treatment for traumatic thoracic aortic injury. J Vasc Surg 2010; 51:565.
- Avery LE, Stahlfeld KR, Corcos AC, et al. Evolving role of endovascular techniques for traumatic vascular injury: a changing landscape? J Trauma Acute Care Surg 2012; 72:41.
- Riesenman PJ, Brooks JD, Farber MA. Acute blunt traumatic injury to the descending thoracic aorta. J Vasc Surg 2012; 56:1274.
- MECHANISM OF INJURY
- Associated injuries
- PATHOPHYSIOLOGY OF INJURY
- TRAUMA EVALUATION
- History and physical examination
- Plain chest film
- Laboratory studies
- DIFFERENTIAL DIAGNOSIS
- INITIAL MANAGEMENT
- Heart rate and blood pressure control
- Patient transfer
- AORTIC INJURY GRADING
- APPROACH TO MANAGEMENT
- Immediate versus delayed repair
- Thoracic aortic repair
- SUMMARY AND RECOMMENDATIONS