Transesophageal echocardiography in traumatic rupture of the aortic isthmus
- Philippe Vignon, MD, PhD
Philippe Vignon, MD, PhD
- Professor of Critical Care Medicine
- Medical-Surgical Intensive Care Unit
- Teaching Hospital of Limoges, France
- Roberto M Lang, MD
Roberto M Lang, MD
- Professor of Medicine
- Pritzker School of Medicine of the University of Chicago
Traumatic aortic rupture (TAR) is a life-threatening injury. It usually occurs in the region corresponding to the aortic isthmus (located between the left subclavian and the first intercostal arteries) as a result of shear forces generated by unrestrained frontal collisions [1,2] or by side-impact crashes . The major risk of TAR is adventitial rupture which usually results in lethal hemorrhage. In a multicenter trial that enrolled 274 patients with TAR, the overall mortality rate reached 31 percent, with 63 percent of deaths attributable to aortic rupture . Despite modern acute care, hemodynamic instability remains a major mortality risk factor in patients with TAR . (See "Blunt thoracic aortic injury".)
Although aortography was previously considered the clinical gold standard for the diagnosis of TAR, contrast-enhanced computed tomography (CT)  and transesophageal echocardiography (TEE)  are now the predominant imaging modalities [8,9]. The main advantage of TEE is its portability and repeatability at the bedside in patients with multiple traumatic injuries consistent with management strategies . Intravascular ultrasound (IVUS) has more recently emerged as a valuable diagnostic tool for the precise characterization of TAR, especially when CT is equivocal , and on-line guidance of endovascular repair and accurate endograft sizing . (See "Blunt thoracic aortic injury", section on 'Imaging'.)
This review will discuss the specific role of TEE in traumatic rupture of the aortic isthmus. Diagnosis and management of blunt thoracic aortic injury, and the technical aspects of TEE are discussed separately. (See "Blunt thoracic aortic injury" and "Surgical and endovascular repair of blunt thoracic aortic injury" and "Transesophageal echocardiography: Indications, complications, and normal views".)
TEE FINDINGS ASSOCIATED WITH SUBADVENTITIAL TRAUMATIC AORTIC RUPTURE
The transesophageal echocardiography (TEE) diagnosis of subadventitial traumatic aortic rupture (TAR) requires the presence of a disruption of the aortic wall with flow on both sides of the lesion that can be identified by color Doppler imaging . TEE findings associated with subadventitial TAR are most frequently observed in the region corresponding to the aortic isthmus (typically about 25 to 35 cm from the incisors, immediately distal to the origin of the left subclavian artery).
Typically, a thick and irregular intraluminal flap is seen traversing the lumen of the aortic isthmus in the transverse view (image 1A). Since this lesion corresponds to disruption of the entire thickness of both intimal and medial aortic layers, it should be considered a "medial flap." In the longitudinal view, the medial flap is nearly perpendicular to the aortic wall, since traumatic lesions are usually confined to a few centimeters (image 1A-B).
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- TEE FINDINGS ASSOCIATED WITH SUBADVENTITIAL TRAUMATIC AORTIC RUPTURE
- Differential diagnosis
- OTHER TRAUMATIC AORTIC INJURIES
- Superficial traumatic aortic injuries
- Other traumatic aortic injuries
- DIAGNOSTIC ACCURACY OF TEE
- TEE AND THERAPEUTIC MANAGEMENT OF TRAUMATIC AORTIC INJURIES
- SUMMARY AND RECOMMENDATIONS