Blunt Aortic Injury

1
Blunt Aortic Injury

• Greg Magee

2
Blunt Aortic Injury

• Causes
• Associated injuries
• Diagnosis
• Treatment
• Case studies (3 last week)

3
Blunt Aortic Injury

• First characterized in detail by Parmley et al.
  in 1958
• 38 pts, 2 survived
• Conclusion
• Prompt dx required to avert exsanguination from
  aortic rupture

• Parmley L, Mattingly T, Manion T, et al.
  Nonpenetrating traumatic injury of the aorta.
  Circulation 1958XVII1086-1101.

4
Blunt Aortic Injury

• Caused by high acceleration/deceleration
• e.g. MVA, MCA, ped vs. auto
• CXR
• Suspicion if
• widened mediastinum (although only present in 2/3
  of cases)
• Indistinct aortic knob (21)
• ¼ of cases have normal CXRs

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

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Associated injuries

• Closed head 39
• Closed head w/ bleed 22
• Rib fxs 68
• Lung contusion 42
• Pelvic fx 34
• Femur fx 25
• Tibial fx 25
• Facial fx 25
• Liver 25
• Spleen 13

6
Diagnosis

• Gold standard historically aortography
• Newer evidence supports use of CT angiogram
• Very sensitive
• But more false positives

• Fabian T, Richardson J, Croce M, et al.
  Prospective study of blunt aortic injury
  multicenter trial of the American Association for
  the Surgery of Trauma. University of Tennesse. J
  Trauma 199742374-83.
• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

7
Diagnosis

• Advantages of CT over aortography
• 1) easier, faster, less invasive, less expensive
• 2) pts likely to get CTs for other injuries
• 3) reconstructions can be made
• 4) CT may be better at dx extent of injuries

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CT angio

• One prospective study evaluated 8000 CTs for
  blunt torso trauma over 4 years
• 494 had mediastinal hematoma, or aortic injury,
  or both on CT
• 71 dx w/ aortic injury
• MVA 92, ped vs. auto 4, MCA 3
• 71 male
• Incidence in MVA 1.2

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

9
CT angio

• Sensitivity 100, Specificity 83, Positive
  Predictive Valve 50
• Aortogram 92, 99, 97
• Therefore only need aortogram if CT is positive
  or indeterminate
• this decreased of aortograms by 66

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

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Areas most-likely injured

• Where aorta is fixed
• Isthmus 86
• Arch 7
• Diaphragm 7
• Ascending 1

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

11
CT findings

• Intimal flap
• Minor 39
• Moderate 30
• Severe 30
• Pseudoaneurysm
• Absent 12
• Small 20
• Medium 13
• Large 55

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

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CT findings
13
CT findings
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CT findings
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CT findings
16
Comparison of survivors to non-survivors

• Age
• 36 vs. 47 (p value0.02)
• Injury severity score
• 31 vs. 39 (p value0.01)
• Glascow coma scale
• 14 vs. 8 (p value0.0001)

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

17
Treatment

• Immediate operative repair
• Delayed operative repair after medically
  optimized
• Medical management alone

18
Operative repair

• Immediate repair if hemodynamically unstable
• Delayed repair if hemodynamically stable pt has
  other major injuries
• closed head injury, lung injury, abd injury, etc.
• Close f/u to determine if clinically significant

• Jamieson W, Janusz M, Gudas V, Burr L, Fradet G,
  Henerson C. Traumatic rupture of the thoracic
  aorta third decade of experience. Am J Surg.
  2002183571-575.
• Jahromi A, Kazemi K, Safar H, Doobay B, Cina C.
  Traumatic rupture of the thoracic aorta cohort
  study and systemic review. J Vasc Surg.
  2001341029-34

19
Medical management

• Use of anti-hypertensives first described at MGH
• Successful in mgt of dissecting aortic aneurysms
  -gt reducing shearing forces
• Goal maintain MAP of 80, HR lt 80

• Warren R, Akins C, Conn A, et al. Acute traumatic
  disruption of the thoracic aorta emergency
  department management. Massachusetts General
  Hospital. Ann Emerg Med 199221391-96.
• Maggisano R, Nathens A, Alexandrova N, et al.
  Traumatic rupture of the thoracic aorta should
  one always operate immediately? Ann Emerg Med
  1992 21391-96.
• Akins C, Buckley M, Daggett W, et al. Acute
  traumatic disruption of the thoracic aorta a
  10-year experience. Massachusetts General
  Hospital. Ann Thorac Surg 198131305-309

20
Medical management

• Beta blockers
• labetalol, esmolol
• Vasodilators if BP not controllable w/ B blockers
  alone
• Nitroprusside
• One study showed 0/71 ruptures w/ early dx and rx

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.

21
Endovascular vs. Open repair?

• In one study EV repair had decreased mortality,
  morbidity ICU length of stay compared to open
  repair
• Mortality 0 vs. 17
• Paraplegia 0 vs. 16
• Recurrent laryngeal nerve injury 0 vs. 8

• Ott M, Stewart T, Lawlor D, Gray D, Forbes T.
  Management of Blunt Thoracic Aortic Injuries
  Endovascular Stents versus Open Repair.
  University of Western Ontario. J Trauma
  200456565-70.

22
Case Studies

• 3 cases in 5 days last week at Stanford
• Mr. MT
• Mr. SS
• Mr. MA
• All treated non-operatively
• Tx strict BP control

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Mr. MT

• 48M s/p MCA
• Aortic tear w/ pseudoaneurysm at isthmus
• Associated injuries
• displaced clavicle fx
• rib fxs
• bilateral pleural effusions

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Mr. MT
25
Mr. SS

• 92M s/p MVA
• Aortic tear at the arch
• Associated injuries
• Sternal fx

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Mr. SS
27
Mr. MA

• 23M s/p MVA
• Aortic tear pseudoaneurysm at isthmus
• Associated injuries
• R post. rib fxs
• L hemo-pneumothorax
• L5 transverse process fx
• L sup. inf. pubic rami fxs

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Mr. MA
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References

• Fabian T, Davis K, Gavant M, Croce M, Melton S,
  Patton J, Haan C, Weiman D, Pate J. Prospective
  Study of Blunt Aortic Injury. University of
  Tennessee. Ann Surg 1998227(5)666-77.
• Fabian T, Richardson J, Croce M, et al.
  Prospective study of blunt aortic injury
  multicenter trial of the American Association for
  the Surgery of Trauma. University of Tennesse. J
  Trauma 199742374-83.
• Maggisano R, Nathens A, Alexandrova N, et al.
  Traumatic rupture of the thoracic aorta should
  one always operate immediately? Ann Emerg Med
  1992 21391-96.
• Warren R, Akins C, Conn A, et al. Acute traumatic
  disruption of the thoracic aorta emergency
  department management. Massachusetts General
  Hospital. Ann Emerg Med 199221391-96.
• Akins C, Buckley M, Daggett W, et al. Acute
  traumatic disruption of the thoracic aorta a
  10-year experience. Massachusetts General
  Hospital. Ann Thorac Surg 198131305-309
• Ott M, Stewart T, Lawlor D, Gray D, Forbes T.
  Management of Blunt Thoracic Aortic Injuries
  Endovascular Stents versus Open Repair.
  University of Western Ontario. J Trauma
  200456565-70.
• Parmley L, Mattingly T, Manion T, et al.
  Nonpenetrating traumatic injury of the aorta.
  Circulation 1958XVII1086-1101.
• Jamieson W, Janusz M, Gudas V, Burr L, Fradet G,
  Henerson C. Traumatic rupture of the thoracic
  aorta third decade of experience. Am J Surg.
  2002183571-575.
• Jahromi A, Kazemi K, Safar H, Doobay B, Cina C.
  Traumatic rupture of the thoracic aorta cohort
  study and systemic review. J Vasc Surg.
  2001341029-34.

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