Aortic Injury

Ruptured thoracic aorta

Epidemiology

· Descending aorta most frequently injured great vessel

· Incidence

— 0.25% of truama pts reaching hospital alive

— <10% all vascular injuries

Aetiology

Blunt

· Rapid deceleration

— Vertical deceleration & transient aortic stretching

— Horizontal deceleration ± chest compression

· Compression after frontal impact

— Osseous pinch between manubrium & spine

· Crush injury

Penetrating

Pathology

· Rupture @ aortic isthmus

— Between L subclavian & lig arteriosum

· Transverse tears most common

· 600-2500 mmHg required

Clinical (presented like aortic dissection)

· Retrosternal / subscapular pain

· SOB / LOC

· ¯BP or upper extremity ­BP or inequal BP

· Multiple rib # ± Haemothorax

· Steering wheel imprint

· # 1st or 2nd rib or sternum

· Hoarseness without laryngeal injury

· Neck haematoma

· SVC obsn

· Associated injuries common

— Head

— Facial

— Abdo

— Pulmonary

Ix

· High index suspicion

— High speed RTA / deceleration

— Death of other occupants

· No single or combination D

· CXR

— Unreliable

— »6% false –ve

— » 10% wide mediastinum +ve on aortogram

— Findings

Superior mediastinal widening >8cm at the level of aortic knob

Aortic knob (cap) ± medial aspect LUL obscured

L Haemo / pneumothorax

Obliteration of outline of aortic knob and desc aorta

Loss of aorto-pulmonary window

# 1st or 2nd rib or sternum

Tracheal devaiation to R

Deviation of oesophagus / NGT to R @ T4

Depression L main stem bronchus > 110°

· CT

— Spiral with IV contrast

v Mirvis J Trauma

100% sens, 99% spec, 100% -ve predictive

Equally as effective as angio with correct protocol & consultant radiologist

· Angio

— Gold standard

— Road map for surgery

— Comes with experienced consultant opinion

· TOE

— Needs experienced operator

— Can localise injury & define multiple tears

Mx

· ABCD

· If penetrating trauma

— Lower extremity access

— Consider emergency room thoracotomy

3rd / 4th space left anterolateral thoracotomy

· For blunt trauma

· Once diagnosis suspected – immediate control of BP significantly reduces the risk of rupture during workup.

· Aim for BP less than 120. Pain control is often all that is required. Can use short-acting B-blocker (esmolol or labetolol).

· Triage with other injuries may take precedence – 75% have associated injuries.

· Hypotensive patients should undergo FAST or DPL if positive laparotomy.

· Patients with haemothorax or supraclavicular haematoma have a high risk of free rupture and should proceed to surgery immediately unless contra-indicated.

· Hypotensive therapy is associated with risks – exacerbating secondary brain injury and organ failure due to hypoperfusion.

Operation

· Expose & prep:

— Anterior neck

— Thorax

— Abdomen

— ³ 1 leg

— ± arm if ? subclavian injury

· Incisions

— Usually Left posterolateral thoracotomy through the 4^th interspace

—   In stable patients left heart bypass is often instituted before proximal exposure

—   Repair usually requires a graft, primary anastomosis can be used and primary repair for small lesions done by cardiac surgeon

If severe ¯ BP

Can extend across as ‘clamshell’

Prognosis

· 10-15% RTA deaths 2° aortic rupture

· 10-20% survive initial trauma

Operartive mortality

· Overall » 20%

· Paraplegia 10%

Abdominal aorta

Epidemiology

· 15% abdo trauma are major vessel injury

· 15% reach hospital alive

· Incidence

— 0.05% after blunt trauma

· Infrarenal most frequent

Aetiology

· As thoracic

— Except compression 2° seat belt

Pathology

· Types

— Avulsion of small branches

— Subadventitial haematoma / intimal tears ® thrombosis

— False aneurysm

v NB GIT injury in almost all cases where seat belt injury

Clnical

· High suspicion

— Especially penetrating

· ¯BP

· Signs peritoneal irritation

· Rapidly expanding abdo

· Audible bruit

· Assymetric lower extremity pulses

Ix

· DPL

· FAST

· ±CT with contrast

Rx

Operation

· Position & prep as AAA in addition prep chest

· Incision may need to encompass L thoracotomy / sternotomy

· Proximal control

— Supracoeliac intinally

— Consider Mattox manoeuvre

Scoop LUQ contents to R ± kidney

— For IVC R sided Mattox

— After initial control, open posterior peritoneum

— Re establish proximal control, & gain distal control

— Repair:

Arterriorraphy

Resection and graft

Extra-anatomic bypass

Consider if GIT injury

Endoluminal repair – evolving ?

Prognosis

Survival

· Infrarenal 50%

· Suprarenal 35%