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).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- PARMLEY LF, MATTINGLY TW, MANION WC, JAHNKE EJ Jr. Nonpenetrating traumatic injury of the aorta. Circulation 1958; 17:1086.
- Fisher RG, Hadlock F. Laceration of the thoracic aorta and brachiocephalic arteries by blunt trauma. Report of 54 cases and review of the literature. Radiol Clin North Am 1981; 19:91.
- Fitzharris M, Franklyn M, Frampton R, et al. Thoracic aortic injury in motor vehicle crashes: the effect of impact direction, side of body struck, and seat belt use. J Trauma 2004; 57:582.
- 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.
- Duwayri Y, Abbas J, Cerilli G, et al. Outcome after thoracic aortic injury: experience in a level-1 trauma center. Ann Vasc Surg 2008; 22:309.
- Collier B, Hughes KM, Mishok K, et al. Is helical computed tomography effective for diagnosis of blunt aortic injury? Am J Emerg Med 2002; 20:558.
- Cinnella G, Dambrosio M, Brienza N, et al. Transesophageal echocardiography for diagnosis of traumatic aortic injury: an appraisal of the evidence. J Trauma 2004; 57:1246.
- Patel NH, Stephens KE Jr, Mirvis SE, et al. Imaging of acute thoracic aortic injury due to blunt trauma: a review. Radiology 1998; 209:335.
- Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266.
- Hainer C, Böckler D, Bernhard M, et al. [Blunt traumatic aortic injury: importance of transesophageal echocardiography]. Anaesthesist 2008; 57:262.
- Azizzadeh A, Valdes J, Miller CC 3rd, et al. The utility of intravascular ultrasound compared to angiography in the diagnosis of blunt traumatic aortic injury. J Vasc Surg 2011; 53:608.
- Shi Y, Tsai PI, Wall MJ Jr, Gilani R. Intravascular ultrasound enhanced aortic sizing for endovascular treatment of blunt aortic injury. J Trauma Acute Care Surg 2015; 79:817.
- Vignon P, Guéret P, Vedrinne JM, et al. Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption. Circulation 1995; 92:2959.
- Goarin JP, Catoire P, Jacquens Y, et al. Use of transesophageal echocardiography for diagnosis of traumatic aortic injury. Chest 1997; 112:71.
- Le Bret F, Ruel P, Rosier H, et al. Diagnosis of traumatic mediastinal hematoma with transesophageal echocardiography. Chest 1994; 105:373.
- Vignon P, Rambaud G, François B, et al. Quantification of traumatic hemomediastinum using transesophageal echocardiography: impact on patient management. Chest 1998; 113:1475.
- Buckmaster MJ, Kearney PA, Johnson SB, et al. Further experience with transesophageal echocardiography in the evaluation of thoracic aortic injury. J Trauma 1994; 37:989.
- Oxorn D, Towers M. Traumatic aortic disruption: false positive diagnosis on transesophageal echocardiography. J Trauma 1995; 39:386.
- Vignon P, Spencer KT, Rambaud G, et al. Differential transesophageal echocardiographic diagnosis between linear artifacts and intraluminal flap of aortic dissection or disruption. Chest 2001; 119:1778.
- Vilacosta I, San Román JA, Ferreirós J, et al. Natural history and serial morphology of aortic intramural hematoma: a novel variant of aortic dissection. Am Heart J 1997; 134:495.
- Chirillo F, Totis O, Cavarzerani A, et al. Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma. Heart 1996; 75:301.
- Gerstein NS, Jinkins LJ, Nguyen LC, et al. Atypical echocardiographic findings in traumatic aortic transection. Echocardiography 2017; 34:124.
- 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.
- Smith MD, Cassidy JM, Souther S, et al. Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. N Engl J Med 1995; 332:356.
- Goarin JP, Cluzel P, Gosgnach M, et al. Evaluation of transesophageal echocardiography for diagnosis of traumatic aortic injury. Anesthesiology 2000; 93:1373.
- Sun X, Hong J, Lowery R, et al. Ascending aortic injuries following blunt trauma. J Card Surg 2013; 28:749.
- Vignon P, Boncoeur MP, François B, et al. Comparison of multiplane transesophageal echocardiography and contrast-enhanced helical CT in the diagnosis of blunt traumatic cardiovascular injuries. Anesthesiology 2001; 94:615.
- Astarci P, Lacroix V, Glineur D, et al. Endovascular treatment of acute aortic isthmic rupture: concerning midterm results. Ann Vasc Surg 2009; 23:634.
- 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.
- Patel NH, Hahn D, Comess KA. Blunt chest trauma victims: role of intravascular ultrasound and transesophageal echocardiography in cases of abnormal thoracic aortogram. J Trauma 2003; 55:330.
- Vignon P, Martaillé JF, François B, et al. Transesophageal echocardiography and therapeutic management of patients sustaining blunt aortic injuries. J Trauma 2005; 58:1150.
- Kepros J, Angood P, Jaffe CC, Rabinovici R. Aortic intimal injuries from blunt trauma: resolution profile in nonoperative management. J Trauma 2002; 52:475.
- Mosquera VX, Marini M, Gulías D, et al. Minimal traumatic aortic injuries: meaning and natural history. Interact Cardiovasc Thorac Surg 2012; 14:773.
- Rabin J, DuBose J, Sliker CW, et al. Parameters for successful nonoperative management of traumatic aortic injury. J Thorac Cardiovasc Surg 2014; 147:143.
- Dobson G, Petrasek P, Alvarez N. Images in Anesthesia: transesophageal echocardiography enhances endovascular stent placement in traumatic trans-section of the thoracic aorta. Can J Anaesth 2004; 51:931.
- van der Starre P, Guta C, Dake M, et al. The value of transesophageal echocardiography for endovascular graft stenting of the ascending aorta. J Cardiothorac Vasc Anesth 2004; 18:466.
- Metaxa V, Tsagourias M, Matamis D. The role of echocardiography in the early diagnosis of the complications of endovascular repair of blunt aortic injury. J Crit Care 2011; 26:434.e7.
- 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