TRAUMATIC AORTIC INJURY

8/7/2019 TRAUMATIC AORTIC INJURY

1/49

TRAUMATIC AORTIC

INJURY

MI Zucker, MD


2/49

Adr Z Lecture on

Aortic Injuries


3/49

Aortic Injuries: Defined

They are TEARS not dissections, so best

terminology would be:

Traumatic Aortic Injury or TAI


4/49

Epidemiology Major deceleration force as in high speed

MVA, auto vs pedestrian, fall from a height

80-85% die at scene, aortic root area tear

15-20% survive to ED, aortic isthmus tear


5/49

PATHOLOGY

The lesion is an aortic wall TEAR, not adissection.

The tear is through the intima and media,with the thin but tough adventitia containingthe blood volume as a pseudoaneurysm fora time.

When the adventitia fails, the patientusually immediately expires.


6/49

Location of TA

I

(On a Conventional Angiogram)


7/49


8/49

TA

IIn TAI, the mediastinum is of abnormal size

or contour.

Abnormal mediastinum MAY be due to

hemorrhage into the mediastinum.

The hemorrhage is due to small vessel

bleeding, rarely from the torn aorta itself.


9/49

But

If there has been enough deceleration force

to rupture small vessels, then there has been

enough force to tear the aorta.


10/49

However Other things may and often do alter the

mediastinum size and contour:

Supine position

Portable film

Poor inspiration

Tortuous aorta

Fat, non-trauma diseases


11/49

And so

The chest film is very sensitive, but not

specific for TAI.

If fact, 90-95% of patients with trauma and

abnormal mediastinum DO NOT have TAI.

But, only 1 % with normal mediastinum DO

have TAI.


12/49

CHEST FILM FINDINGS of TAI

Abnormal shape or size of aortic arch

Indistinct aortic arch or aortopulmonary window

Abnormally wide right paratracheal stripe

Deviation of trachea or esophagus (NGT) to right

Left apical cap

Abnormal paraspinal line Wide mediastinum (over 8 cm)


13/49


14/49

Of these, NONE is any better or worse than any

other.

ONE abnormality makes the mediastinum

abnormal.


15/49

First, the NORMAL

Mediastinum

Young

Middle agedElderly


16/49


17/49


18/49


19/49


20/49


21/49

Abnormal mediastinum

Caused by TraumaticAortic Injury.

The subtle and the unsubtle.

We are going to look for the mediastinumabnormalities we just talked about on each film.


22/49


23/49


24/49


25/49


26/49


27/49


28/49

So, Chest Film is Abnormal: Whats Next?

CT

TEE

Angiography

MRI

With contrast bolus CTA.Multidetector unit

Unstable patient.Operator dependent

Invasive. Labor intensive

Slow. Harder to managepatient. Availability


29/49

ANGIOG

RAPHY

Invasive

Labor intensiveThe gold standard


30/49


31/49


32/49

CTA

Universally available

QuickAccurate

The new gold standard


33/49


34/49


35/49

TR

EA

TMENT of TA

IOperate emergently

Graft placement


36/49

P

rognosis Without surgery, classical data show 99%

death rate

With surgery, 70% survival. Most of post-

operative deaths due to associated injuries,

especially head trauma, not to TAI.

But


37/49

A

Case to ThinkA

bout:

Code Trauma

Young man, MVA, stable, but multiple

injuries, including chest.


38/49

The Chest Film

Multiple injuries, abnormal

mediastinum


39/49


40/49

The CTA

Called suggestive of TAI, but

technically limited examination


41/49


42/49

TheA

ngiogram

Done because of uncertain CT.

Called normal


43/49


44/49

S

o: Chest film: Abnormal

CT: Abnormal, but uncertain for TAI

Angiogram: Normal


45/49

The Outcome: No surgery on aorta

Patient recovered from other injuries

Discharged

Still alive, as far as we know


46/49

B

ut:

Was the Aorta Injured?


47/49

???? Were the chest film and the CT results

correct and the angiogram, the so-called

Gold Standard, wrong?

Is MDCT the new Gold Standard?


48/49

MINIMAL AORTIC INJURY

There are patients with aortic injury whohave survived without surgery.

There may be a subtype of Minimal IntimalInjury with a more benign outcome, wherethe injured intima heals withoutintervention.

So, the 99% death rate without surgery maybe an overestimate.


49/49

Goodbye

Copyright 2004

MI Zucker

TRAUMATIC AORTIC INJURY

Documents