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Semin intervent Radiol 2007; 24(2): 180-196
DOI: 10.1055/s-2007-980042
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Thoracic Aortic and Great Vessel Trauma and Its Management

Simon J. McPherson1
  • 1Department of Radiology, Leeds General Infirmary, Leeds, United Kingdom
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Publication History

Publication Date:
12 June 2007 (online)

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ABSTRACT

Interventional radiologists (IRs) now play a major role in the management of thoracic aortic and great vessel trauma. The recent availability of a wide range of stent grafts able to treat vessels from 3 to 46 mm in diameter is clearly a significant contributor to this change. Stent grafts can now treat the majority of incomplete aortic injuries with much lower morbidity and mortality than open surgery. Short- to medium-term follow-up is encouraging, but the long-term durability is unknown, and close monitoring of these patients must continue. In great vessel trauma, stent grafts are a useful adjunct to balloon tamponade, embolization, and bare stents. As a result, a wide range of head neck and upper limb vascular injuries can be managed with less local trauma, blood loss, and physiological stress. The increased involvement of IR in the management of vascular trauma is not simply the result of technological advances. IRs have increasingly made themselves available to carry out these emergency procedures. IRs should assist in the development of trauma protocols and management algorithms that involve endovascular expertise early in the assessment of the major trauma patient.

KEYWORDS

Blunt aortic trauma - aortic transection - stent graft - endoluminal repair

REFERENCES

  • 1 Lebl D R, Dicker R A, Spain D A, Brundage S I. Dramatic shift in the primary management of traumatic thoracic aortic rupture.  Arch Surg. 2006;  141 177-180
    CrossrefPubMedGoogle Scholar
  • 2 Macura K J, Corl F M, Fishman E K, Bleumke D A. Pathogenesis in acute aortic syndromes: aortic aneurysm leak and rupture and traumatic aortic transaction.  AJR Am J Roentgenol. 2003;  181 303-397
    PubMedGoogle Scholar
  • 3 Lundevall J. The mechanism of traumatic rupture of the aorta.  Acta Pathol Microbiol Scand. 1964;  62 34-46
    PubMedGoogle Scholar
  • 4 Williams J S, Graff J A, Uku J M, Steinig J P. Aortic injury in vehicular trauma.  Ann Thorac Surg. 1994;  57 726-730
    PubMedGoogle Scholar
  • 5 Shkrum M J, McClafferty K J, Green R N, Nowak E S, Young J G. Mechanisms of aortic injury in fatalities occurring in motor vehicle accidents.  J Forensic Sci. 1999;  44 44-56
    PubMedGoogle Scholar
  • 6 Parmley L F, Mattingly T W, Manion W C, Jahnke E J. Nonpenetrating traumatic injury of the aorta.  Circulation. 1958;  17 1086-1101
    CrossrefPubMedGoogle Scholar
  • 7 Ahrar K, Smith D C, Bansal R C, Razzouk A, Catalano R D. Angiography in blunt thoracic aortic injury.  J Trauma. 1997;  42 665-669
    PubMedGoogle Scholar
  • 8 Hunt J P, Baker C C, Lentz C W. Thoracic aortic injuries: management and outcome of 144 patients.  J Trauma. 1996;  40 547-556
    PubMedGoogle Scholar
  • 9 Guvendik L, Davis N R, Starr A. Repair of traumatic aortic dissection: a management protocol and review of twenty-one patients.  Thorac Cardiovasc Surg. 1988;  36 198-201
    PubMedGoogle Scholar
  • 10 Peterson B G, Matsumura J S, Morasch M D, West M A, Eskandari M K. Percutaneous endovascular repair of blunt thoracic aortic transection.  J Trauma. 2005;  59 1062-1065
    PubMedGoogle Scholar
  • 11 Crass J R, Cohen A M, Motta A O, Tomashefski J F, Wiesen E J. A proposed new mechanism of traumatic aortic injury: the osseous pinch.  Radiology. 1990;  176 645-649
    PubMedGoogle Scholar
  • 12 Javadpour H, O'Toole J J, McEniff J N, Luke D A, Young V K. Traumatic aortic transection: evidence for the osseous pinch mechanism.  Ann Thorac Surg. 2002;  73 951-953
    CrossrefPubMedGoogle Scholar
  • 13 Ben-Menachem Y. The mechanism of injury. In: Ben-Menachem Y Angiography in Trauma: A Work Atlas. Philadelphia; WB Saunders 1981: 25-47
    Google Scholar
  • 14 Wicky S, Capasso P, Meuli R, Fisher A, von-Segesser L, Schnyder P. Spiral CT aortography: an efficient technique for the diagnosis of traumatic aortic injury.  Eur Radiol. 1998;  8 828-833
    CrossrefPubMedGoogle Scholar
  • 15 Rousseau H, Dambtin C, Marcheix B et al.. Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair.  J Thorac Cardiovasc Surg. 2005;  129 1050-1055
    CrossrefPubMedGoogle Scholar
  • 16 Braatz T, Mirvis S E, Killeen K, Lightman N I. CT diagnosis of internal mammary artery injury caused by blunt trauma.  Clin Radiol. 2001;  56 120-123
    CrossrefPubMedGoogle Scholar
  • 17 Nicholson A A, Patel J V. Air-space diseases. In: Adam A, Dixon AK, Grainger RG, Allison DJ Grainger & Allison's Diagnostic Radiology. 5th ed. Oxford; Churchill Livingstone 2007 In press
    Google Scholar
  • 18 Nzewi O, Slight R D, Zamvar V. Management of blunt aortic injury.  Eur J Vasc Endovasc Surg. 2006;  31 18-27
    CrossrefPubMedGoogle Scholar
  • 19 Woodring J H. The normal mediastinum in blunt traumatic rupture of the thoracic aorta and brachiocephalic arteries.  J Emerg Med. 1990;  8 467-476
    CrossrefPubMedGoogle Scholar
  • 20 Wintermark M, Wicky S, Schnyder P. Imaging of acute traumatic injuries of the thoracic aorta.  Eur Radiol. 2002;  12 431-442
    CrossrefPubMedGoogle Scholar
  • 21 Trupka A, Waydas C, Hallfeldt K KJ, Nast-Kolb D, Pfeifer K J, Schweiberer L. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study.  J Trauma. 1997;  43 405-412
    PubMedGoogle Scholar
  • 22 Downing S W, Sperling J S, Mirvis S E et al.. Experience with spiral computed tomography as the sole diagnostic method for traumatic aortic rupture.  Ann Thorac Surg. 2001;  72 495-501
    CrossrefPubMedGoogle Scholar
  • 23 Uflacker R, Phillips G, Selby J B. Intravascular sonography in the assessment of traumatic injury of the thoracic aorta.  AJR Am J Roentgenol. 1999;  173 665-670
    PubMedGoogle Scholar
  • 24 Cleverley J R, Barrie J R, Raymond G S, Primack S L, Mayo J R. Direct findings of aortic injury on contrast-enhanced CT in surgically proven traumatic aortic injury: a multi-centre review.  Clin Radiol. 2002;  57 281-286
    CrossrefPubMedGoogle Scholar
  • 25 Parker M S, Matheson T L, Rao A V 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 1267-1272
    PubMedGoogle Scholar
  • 26 Nicholson A A. Vascular radiology in trauma.  Cardiovasc Intervent Radiol. 2004;  27 105-120
    PubMedGoogle Scholar
  • 27 Hirose H, Inderjit S, Malangoni M. Nonoperative management of traumatic aortic injury.  J Trauma. 2006;  60 597-601
    PubMedGoogle Scholar
  • 28 Kasirajan K, Heffernan D, Langfield M. Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and non-operative management.  Ann Vasc Surg. 2003;  17 589-595
    CrossrefPubMedGoogle Scholar
  • 29 Sweeney M S, Young D J, Frazier O H, Adams P R, Kapusta M O, Macris M P. Traumatic aortic transactions: eight year experience with clamp-sew technique.  Ann Thorac Surg. 1997;  64 384-387
    CrossrefPubMedGoogle Scholar
  • 30 von Oppell U O, Dunne T T, De Groot M K, Zilla P. Traumatic aortic rupture: twenty year meta-analysis of mortality and risk for paraplegia.  Ann Thorac Surg. 1994;  58 585-593
    CrossrefPubMedGoogle Scholar
  • 31 Katz N M, Blackstone E H, Kirklin J W, Karp R B. Incremental risk factors for spinal cord injury following operation for acute traumatic aortic transection.  J Thorac Cardiovasc Surg. 1981;  81 669-674
    PubMedGoogle Scholar
  • 32 Degiannis E, Boffard K. Critical decisions in trauma of the thoracic aorta.  Injury. 2002;  33 317-322
    CrossrefPubMedGoogle Scholar
  • 33 Marvasti M A, Meyer J A, Ford B E, Parker Jr F B. Spinal cord ischaemia following operation for traumatic aortic transaction.  Ann Thorac Surg. 1986;  42 425-428
    PubMedGoogle Scholar
  • 34 Kato N, Dake M D, Semba C P et al.. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts.  Radiology. 1997;  205 657-662
    CrossrefPubMedGoogle Scholar
  • 35 Ott M C, Stewart T C, Lawlor D K, Gray D K, Forbes T L. The management of blunt thoracic aortic injuries: endovascular stents versus open repair.  J Trauma. 2004;  56 565-570
    CrossrefPubMedGoogle Scholar
  • 36 Endovascular stent-graft placement in thoracic aortic aneurysms and dissections. London; National Institute for Health and Clinical Excellence June 2005 ISBN 1-84629-038-4
    Google Scholar
  • 37 Wellons E D, Milner R, Solis M, Levitt A, Rosenthal D. Stent-graft repair of traumatic thoracic aortic disruptions.  J Vasc Surg. 2004;  40 1095-1100
    CrossrefPubMedGoogle Scholar
  • 38 Fattori R, Napoli G, Lovato L et al.. Indications for, timing of and results of catheter-based treatment of traumatic injury to the aorta.  AJR Am J Roentgenol. 2002;  179 603-609
    PubMedGoogle Scholar
  • 39 Pate J W, Fabian T C, Walker W. Traumatic rupture of the aortic isthmus: an emergency?.  World J Surg. 1995;  19 119-126
    CrossrefPubMedGoogle Scholar
  • 40 Rousseau H, Suola P, Perreault P et al.. Delayed treatment of traumatic rupture of the thoracic aorta with endoluminal covered stent.  Circulation. 1999;  99 498-504
    PubMedGoogle Scholar
  • 41 Dunham M B, Zygun D, Petrasek P, Kortbeek J B, Karmy-Jones R, Moore R D. Endovascular stent grafts for acute blunt aortic injury.  J Trauma. 2004;  56 1173-1178
    PubMedGoogle Scholar
  • 42 England A, McPherson S J, Butterfield J S, Ashleigh R J. Endovascular repair following traumatic aortic transaction: experience from two centres. UK Radiological Congress; Birmingham, United Kingdom June 2006
    Google Scholar
  • 43 Reed A B, Thompson J K, Crafton C J, Delvecchio C, Giglia J S. Timing of endovascular repair of blunt traumatic aortic transactions.  J Vasc Surg. 2006;  43 684-688
    CrossrefPubMedGoogle Scholar
  • 44 Orford V P, Atkinson N R, Thomson K et al.. Blunt traumatic aortic transaction: endovascular experience.  Ann Thorac Surg. 2003;  75 106-111
    CrossrefPubMedGoogle Scholar
  • 45 Idu M M, Reekers J A, Balm R, Ponsen K J, de Mol B A, Legemate D A. Collapse of a stent-graft following treatment of a traumatic thoracic aortic rupture.  J Endovasc Ther. 2005;  12 503-507
    CrossrefPubMedGoogle Scholar
  • 46 Kramer S, Pamler R, Siefarth H, Brams H-J, Sunder-Plassman L, Gorich J. Endovascular grafting of traumatic aortic aneurysms in contaminated fields.  J Endovasc Ther. 2001;  8 262-267
    CrossrefPubMedGoogle Scholar
  • 47 Doty D B, Kongtahworn C, Ehrenhaft J L. Control of proximal subclavian artery injury with internal shunt catheter.  Ann Thorac Surg. 1973;  15 285-286
    PubMedGoogle Scholar
  • 48 Scalea T M, Sclafani S J. Angiographically placed balloons for arterial control: a description of a technique.  J Trauma. 1991;  31 1671-1677
    CrossrefPubMedGoogle Scholar
  • 49 Kidney D D. The endovascular approach to trauma. In: Dyett JF, Ettles DF, Nicholson AA, Wilson SE Textbook of Endovascular Procedures. Philadelphia; Churchill Livingstone 2000: 313-327
    Google Scholar
  • 50 Marin M L, Veith F J, Cynamon J et al.. Transfemoral endoluminal repair of a penetrating vascular injury.  J Vasc Interv Radiol. 1994;  5 592-594
    PubMedGoogle Scholar
  • 51 Maras D, Lioupis C, Magoufis G, Tsamopoulos N, Moulakais K, Andrikopoulos V. Covered stent-graft treatments of traumatic internal carotid artery pseudoaneurysms: a review.  Cardiovasc Intervent Radiol. 2006;  29 958-968
    CrossrefPubMedGoogle Scholar
  • 52 Smith T P. Embolization in the external carotid artery.  J Vasc Interv Radiol. 2006;  17 1897-1913
    CrossrefPubMedGoogle Scholar
  • 53 Yee L F, Olcott E W, Knudson M M et al.. Extraluminal, transluminal and observational treatment for vertebral artery injuries.  J Trauma. 1995;  39 480-486
    PubMedGoogle Scholar
  • 54 White R, Krajcer Z, Johnson M, Williams D, Bacharach M, O'Malley E. Results of a multicenter trial for the treatment of traumatic vascular injury with a covered stent.  J Trauma. 2006;  60 1189-1196
    CrossrefPubMedGoogle Scholar
  • 55 Demetriades D, Chahwan S, Gomez H et al.. Penetrating injuries of the subclavian and axillary arteries.  J Am Coll Surg. 1999;  188 290-295
    CrossrefPubMedGoogle Scholar
  • 56 Cronin P, McPherson S J, Meaney J F, Mavor A. Venous covered stent: successful occlusion of a symptomatic internal iliac arteriovenous fistula.  Cardiovasc Intervent Radiol. 2002;  25 323-325
    CrossrefPubMedGoogle Scholar

Simon J McPhersonB.Sc M.B.B.S. M.R.C.P. F.R.C.R. 

Consultant Vascular and Interventional Radiologist, Department of Radiology, Jubilee Wing, Leeds General Infirmary

Great George Street, Leeds LS1 3EX, United Kingdom

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