|Year : 2018 | Volume
| Issue : 1 | Page : 11-18
Blunt thoracic aortic injury
Tara Talaie, Jonathan J Morrison, James V O’Connor
R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
|Date of Web Publication||20-Dec-2018|
Jonathan J Morrison
R Adams Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, Maryland 21201
Source of Support: None, Conflict of Interest: None
Blunt thoracic aortic injury (BTAI) is a significant problem in cardiothoracic trauma. It is a leading cause of prehospital death from high energy motor vehicle crashes. Injuries can be classified into one of four grades: grade I – intimal tear; grade II – intra-mural hematoma; grade III – pseudoaneurysm and grade IV – uncontained rupture. Clinical symptoms and signs are often limited, especially in minor injury grades. Left sided hemothorax and a widened mediastinum on chest radiography are concerning features suggestive of BTAI. Computed scanning is now an indispensable tool used to evaluate patients and has largely replaced aortography. The aim of management is to control hemorrhage (if present) and to reduce the risk of delayed aortic rupture. Patients with pseudoaneurysm can undergo semi-elective repair, provided blood pressure can be controlled which is critical to preventing lesion progression and rupture. Patients presenting with an uncontained rupture require emergent repair. The preferred method of intervention is no longer operative repair (with bypass for distal perfusion), but thoracic endovascular aneurysm repair (TEVAR). An endovascular approach is associated with a lower morality and lower rates of spinal cord ischemia. The aim of this review is present the history of management and the supporting evidence along with an overview of current practice from a busy US trauma center.
Keywords: Blunt traumatic thoracic aortic injury, bypass for repair of aortic injury, endovascular repair of thoracic aortic rupture, surgical treatment of aortic injury, thoracic endovascular aneurysm repair
|How to cite this article:|
Talaie T, Morrison JJ, O’Connor JV. Blunt thoracic aortic injury. J Cardiothorac Trauma 2018;3:11-8
| Introduction|| |
Blunt thoracic aortic injury (BTAI) represents a spectrum of injury ranging from devastating transectional injuries, which are near universally fatal, to relatively minor intimal injuries, which heal spontaneously without the need for intervention. The understanding and management of BTAI have evolved considerably over the past two decades, guided by improvements in imaging and advances in surgical technology.,
The pathophysiology of BTAI relates to the transition from the relatively mobile aortic arch into the comparatively fixed thoracic aorta. When an acceleration-deceleration force is applied to this interface, the sheer forces result in an aortic tear. The degree of injury is proportional to the force applied, and it is important to characterize the injury grade as this partly drives management decisions.
Computed tomography (CT) angiography has revolutionized the ease and accuracy with which aortic imaging can be obtained. Injuries confined to the intima can be observed; however, large tears with active hemorrhage mandate intervention. The management of intermediate grade injuries is controversial and still evolving. Conventionally, contained pseudoaneurysms were considered at high risk of rupture; however, with aggressive blood pressure management, delayed repair or even surveillance of such lesions, may, in fact, enhance survival.
Finally, the method with which these injuries can be repaired has been transformed with endovascular techniques. Thoracic endovascular aneurysm repair (TEVAR) has become the standard of care in BTAI, largely replacing operative intervention., However, complexities exist around endovascular solutions that can require hybrid approaches or specialist endografts depending on lesion anatomy. The aim of this article is to review the history and evidence base that underpins BTAI and to present a management philosophy as practiced at a busy US trauma center.
| Epidemiology|| |
The number of blunt-trauma victims suffering from thoracic aortic injury every year in the United States is estimated to be between 8000 and 9000. A recent analysis of the National Trauma Databank has found the overall incidence of BTAI to be 0.3%. The most common mechanisms of injury are motor vehicle crashes (>70%) followed by motorcycle accidents (13%), automobile-pedestrian accidents (7%), and falls (7%)., The National Vital Statistics Report recorded 37,661 motor vehicle deaths in 2010, of which 12,553 (33%) had BTAI. The incidence of BTAI increases with age and is rare in the pediatric population. An analysis of 5838 motor vehicle-pedestrian injuries showed no aortic injuries occurred in the 14 years and younger group while the incidence increased to 0.2% in the 15–65 years group and to 1.5% in the greater than 65 years group.
Unfortunately, the majority of patients with BTAI die at the scene. The lethality of BTAI was first described by Parmley et al. in 1958 who reported the mortality to be 85% at the scene of injury. More recent studies have reported the percent of BTAI patient deaths at the scene to be 57%. In a study of 242 patients with BTAI, those surviving to hospital admission had a mortality of 37% within the first 4 h of admission and a 6% mortality at a time point greater than 4 h. A recent analysis of 304 deaths due to blunt trauma found that 33% of patients had a thoracic aorta rupture, among those with free aortic rupture 80% died at the scene, while only 20% died in the hospital.
| Pathophysiology and Grading|| |
While the entire thoracic aorta is susceptible to BTAI, the most common location is the aortic isthmus. In a prospective study of 185 cases of BTAI, the rupture involved the isthmus in 75% of cases, descending thoracic aorta in 22%, and the ascending aorta in 4%. Simulation studies using computational methods and cadavers have determined that there are increased intra-aortic pressure and rotational forces that apply focused stress at the isthmus; moreover, the tensile strength measured at the isthmus was found to be 63% that of the proximal aorta.
The most common types of TBAIs are false aneurysm (58%), dissections (25%), and intimal tears (20%). Patients who survive to hospital admission, most commonly have incomplete or non-circumferential injury to the media and intima. The morphology of the aortic lesion reflects the severity of the injury and has been incorporated into several grading systems, which are used to aid clinical decision making and the reporting of studies on BTAI [Table 1].
The most commonly used system of classification was proposed by Azizzadeh et al. in 2009 and has since been adopted by the Society of Vascular Surgery (SVS) BTAI guidelines [Figure 1]. Their system consisted of four grades of injury: intimal tear (Grade I), intramural hematoma (Grade II), pseudoaneurysm (Grade III), and uncontained rupture (Grade 4). So far, this system has been widely adopted and demonstrated to correlate with aortic related mortality.
|Figure 1: The grading system proposed by Azizzadeh et al. (a) Grade I-intimal tear. (b) Grade II-intramural hematoma. (c) Grade III – pseudoaneurysm. (d) Grade IV – free rupture|
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This classification has been further simplified by a group from Seattle, who proposed a three-group scheme of mild (intimal tears and intramural hematomas), moderate (pseudoaneurysm) and severe (uncontained rupture) injury [Table 1]. This was proposed to reflect management trends where mild injuries could be observed, moderate injuries managed by semi-elective TEVAR, and severe injuries requiring emergency TEVAR. This system is potentially more intuitive, but time has yet to decide on its durability.
| Patient Assessment|| |
All patients should be initially assessed per Advanced Trauma Life Support (ATLS) protocol, where priority is given to the assessment and concomitant intervention for immediately life-threatening problems. The initial process or “primary survey” is followed by a “secondary survey” where a more focused assessment is undertaken to better characterize the patient's entire injury pattern.
BTAI can present in a symptomatic or asymptomatic manner and as such can be identified during the primary or secondary survey. Patients who have a high-grade (SVS Grade 3 or 4) BTAI are more likely to present with symptoms and signs. The first step in assessment is to have an appropriate level of clinical suspicion. BTAI tends to present in high-energy transfer injuries; hence, awareness of the mechanisms of injury is useful.
Patients with a normal mental status may describe chest pain, which frequently relates to concomitant blunt chest injury (e.g., rib or sternal fractures) but may also have distracting injuries or altered mental status, which limits the usefulness of the history or physical examination. Clinicians should be alerted to features suggestive of significant energy transfer and other signs, which will be discussed later with more detail.
Vital signs are important in the assessing trauma patients. Curiously, acute aortic pathology often presents with hypertension, which depending on the injury pattern may require antihypertensive agents. Hyperdynamic circulation can increase the shear forces transmitted to the aortic wall, increasing the risk of aortic rupture. However, hypertension can also be the manifestation of other pathologies such as the Cushing's response, where severely elevated intracranial pressure produces hypertension and bradycardia. These points highlight the importance of a thorough patient assessment, before making key management decisions.
Patients rarely present with uncontained rupture and profound circulatory collapse, which is highly lethal. All shocked trauma patients should be assessed per ATLS to identify and treat correctable pathology. Regrettably, an uncontained thoracic aortic rupture that presents with gross instability is rarely treatable.
Imaging has become crucial in the assessment of trauma patients. During the primary survey, both plain chest radiography and ultrasonography can assist in the identification of signs of BTAI. There are several well-recognized signs on plain chest radiography that can aid clinicians: a widened mediastinum, pleural cap, left hemothorax, tracheal deviation, nasogastric tube deviation, loss of the aortopulmonary window, widened paratracheal, and paraspinal stripe are examples.
Before the availability of CT, the gold standard imaging modality was aortography through a retrograde femoral catheter.,, While this was associated with <1% morbidity, risks included access site complications and stroke, while instrumenting the aortic arch, made this diagnostic modality suboptimal, especially for a relatively low yield test. Initial experiences with computed axial tomography scanning were poor, largely due to the slow rate of image acquisition leading to movement artifact.
The advent of helical CT scanning has revolutionized the diagnosis of BTAI. The first comparison of helical CT was performed in 1998, demonstrated a sensitivity of 100% and a specificity of 83% (vs. 92% and 99%, respectively for aortography). The new gold standard imaging for BTAI is arterial phase, contrast enhanced, multi-detector, CT scanning. Many institutions liberally utilize pan-CT screening for trauma, which has become an indispensable tool in trauma care. CT features of BTAI include signs of a mediastinal hematoma as well as the actual aortic injury.
| Management|| |
History of intervention
The goal of BTAI management is to control hemorrhage (if present), prevent thoracic aortic rupture and provide optimal circumstances for aortic healing and remodeling. Since Parmley et al. first recognized BTAI as a clinical entity in 1958, the management of this condition has changed substantially, largely driven by the advent of improved imaging and the availability of endovascular techniques.
In the early years of aortic surgery, diagnosis was dependent on screening chest radiograph, with aortography performed for appropriate clinical signs. The intervention was operative with an open repair requiring aortic cross clamping. Different strategies have been employed to mitigate the complications of distal hypoperfusion, specifically spinal cord ischemia. These generally involved various bypass circuits to maintain distal perfusion and have increased in complexity as knowledge of extra-corporeal bypass has expanded.
Endovascular intervention in the form of endoluminal stent-grafts has revolutionized management of BTAI, almost eliminating the need for operative intervention. TEVAR was first described in 1994 using custom devices and has become a mainstream therapy since the early 2000's., Device reliability, durability, and availability have greatly improved over the last decade.
Finally, as the quality of imaging has improved, permitting the reliable grading of BTAI, it is clear that not all grades of injury require interventions; selected lesions can be definitely treated with medical management and surveillance. The critical concept has been the appreciating “anti-impulse” therapy, which reduces aortic shear forces and risk of rupture.
The aim of this section is to provide an overview of all aspects of interventions for BTAI. While open procedures are performed less frequently, they have taught important lessons which should be ignored, especially as the long-term results of TEVAR are still unknown.
The first successful open operative repair of BTAI was performed by DeBakey and Cooley in 1954 and consequently, their “clamp and sew technique” became the standard of care many decades. This approach involves a left posterolateral thoracotomy, lung isolation, aortic cross clamping proximal and distal to the lesion, followed by the rapid anastomosis of an appropriately sized interposition graft [Figure 2]. This technique has the advantage of being relatively rapid and does not require systemic anticoagulation; however, the lack of distal aortic perfusion during the “clamp and sew technique” resulted in substantial rates of paraplegia when aortic cross-clamping exceeded 30 min. The last large published series of BTAI patients which included “clamp-and-sew” was the American Association for the Surgery of Trauma (AAST) prospective, multicenter, observational study published in 1997, which reported a paraplegia rate of 16.4%.
|Figure 2: Options for operative repair. (a) Fifth interspace posterolateral thoracotomy. (b) “Clamp-and-sew” with interposition graft rapidly sutured between proximal and distal clamps. (c) “Passive” bypass with blood from the arch perfused into the distal aorta through a shunt. (d) “Active” bypass with blood from the left atrium is circulated through a roller pump and perfused into the femoral artery through a retrograde catheter|
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In the 1980s, the use of extracorporeal bypass circuits to provide distal aortic perfusion, saw a significant reduction in the risk of paraplegia. The AAST study reported a rate of 4.5% when distal aortic perfusion was utilized. That study also demonstrated that the most significant independent risk factor for paraplegia was a cross-clamp time of greater than 30 min (odds ratio 15).
Several options exist for maintaining distal perfusion during open repair and cross-clamping and can be considered as passive or active systems. Passive systems (e.g., Gott shunt) consist of a plastic conduit which allows blood to circulate from the proximal to distal aorta, dependent on the pressure generated by the native circulation. Active systems include a device such as a roller or centrifugal pump to generate pressure to drive the bypass circuit. The most common of is partial left heart bypass, where the inflow cannula is inserted into the left atrium via the appendage. Blood circulates through an extracorporeal circuit and returned through an outflow cannula in the distal aorta or femoral artery. An alternative option is right atrial to distal aortic cannulation, which requires an oxygenator and full heparization, and therefore, rarely used in trauma, due to the risk of hemorrhage from associated injuries.
With the rise in utilization of endovascular aortic repairs, open repair reduced from 35% to 16% between 1997 and 2007, as demonstrated by serial AAST observational studies. In addition, the overall incidence in procedure-related paraplegia in open repairs decreased from 8.7% to 1.6%, respectively (P = 0.001). Several studies have demonstrated a significant reduction in paraplegia when using active versus passive distal perfusion. A meta-analysis of 1492 patients showed an overall paraplegia rate of 9.9%, and patients undergoing aortic clamping without distal perfusion had a 16% mortality rate and a paraplegia rate of 19.2%. The utilization of passive shunts reduced these rates to 12.3% and 11.1%, respectively, and active perfusion further reduced the paraplegia rate to 2.3%.
TEVAR has revolutionized the management of high-grade BTAI. The basic principle of an endoluminal stent-graft is a metallic tubular frame over-which a fabric covering is attached. The stent-graft is constrained onto a delivery system and then deployed into the desired location under fluoroscopic guidance. As the fabric is impervious to blood, deployment of the stent-graft effectively excludes that portion of the blood vessel from the circulation. In general, the metal frame is constructed from nitinol (a nickel-titanium alloy), which has the useful property of “shape-memory,” where the original structure is retained despite distortion when the graft is constrained on the delivery system before deployment.
The first description of TEVAR in 1994 utilized bespoke devices specially constructed for each patient. As technology has proliferated, off-the-shelf devices have become available, which include a range of diameters and lengths. However, independent of these strides, certain features remain common to all TEVAR systems. Any stent-graft device requires a length of normal artery proximally and distally where it can deploy securely, excluding the vessel (and pathology) located between these points. These points are referred to as the “landingzones” and a poor seal will result in failure to exclude the pathology, termed an “endoleak”. Thus, it is of critical importance to have a suitable landing zone and an appropriately sized stent-graft, essentially mandating pre-TEVAR imaging to determine anatomy and sizing data. In the current era, this is typically accomplished by CT scanning, although the same data can be obtained by intravascular ultrasound, angiography or cone-beam CT.
The importance of an appropriate landing zone cannot be understated. The absence of a suitable landing zone constitutes the biggest TEVAR contraindication [Figure 3]. While the required length varies between stent-graft system, 1–2 cm is generally required to achieve an effective seal. An aortic injury located close to the origin of the left subclavian artery (LSCA) with insufficient room to land a stent-graft without occluding this vessel, it is generally safe to do so if required. The exception is in patients who have LSCA dependence, such as a left internal mammary artery used for myocardial revascularization. If LSCA occlusion is likely to precipitate coronary or cerebrospinal complications, then the LSCA must be preserved.
|Figure 3: Various configurations of thoracic endovascular aneurysm repair depending on anatomy and clinical requirements. (a) Ideal configuration with a short stent-graft and left subclavian artery preserved. (b) Insufficient proximal “landing-zone,” the stent-graft covers the left subclavian artery. (c) The left subclavian artery requires preservation, specialist branch grafts now exist (d) Carotid-subclavian bypass to revascularize the left subclavian artery|
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In the early years of TEVAR, LSCA preservation generally involved performing an extra-anatomical bypass, such as a carotid-subclavian bypass, to increase the available proximal landing zone. However, several endovascular options now exist in the form of aortic branch grafts or chimney-grafts. The precise role or practical use of these solutions to BTAI with complex anatomy is poorly understood.
As with any new intervention, specific complications can arise, of which TEVAR is no different. Early in the experience, where endovascular devices were often used “off-label”, stent-grafts encountered technical related issues such as metal fatigue, stent fracture and stent-graft collapse, which could result in pseudocoarctation or aortic thrombosis, a devastating complication. As devices have become more reliable, endoleaks are the greatest source of morbidity.
Failure to obtain a proximal seal results in a type IA endoleak, with perfusion of the injured segment risking delayed rupture. This requires early intervention, ideally at the time of initial graft implantation, and may take the form of an additional stent-graft deployed proximally and/or other maneuvers to increase the available landing zone. A leak at the distal seal zone is termed a type IB endoleak and is less urgent. This can usually be treated by extending the graft distally, although the longer the graft, the greater the risk of spinal cord ischemia. Reperfusion of the injured segment via retrograde LSCA flow is termed a type II endoleak and can simply be treated by embolization of the proximal LSCA through a left upper extremity artery.
The other three types of endoleaks are exceptionally rare. Type III relate to leaks between stent-graft components, which can be avoided by using a single device. Type IV is due to porosity of graft material, which is no longer an issue with modern systems. Type V or “endotension” is a poorly defined concept relating to native vessel reperfusion without an obvious cause. A type V endoleak in relation to BTAI has never been described but is theoretically possible.,
Crucially, TEVAR has made intervention for BTAI safer while reducing the complication rate. The risk of mortality from open repair has an odds ratio 8.42 (P < 0.001) when compared to TEVAR in a multivariate analysis. Furthermore, the risk of paraplegia at open repair (3.5%) is significantly greater than for TEVAR (0.8%).
As one of the management aims in BTAI is the prevention of aortic rupture, where patients are stable without evidence of hemorrhage, consideration can be given to medical management, either as a bridge to an intervention or as definitive therapy. Elevated heart rate and blood pressure are associated with delayed rupture due to the increase in sheer forces distributed across the aorta. The concept of pharmaceutically controlling tachycardia and hypertension is conceptually attractive and has its origins in the management of nontraumatic acute aortic syndromes, where it is referred to as “anti-impulse” therapy.
Such a strategy has been gradually integrated into trauma practice since the 1980s; however, it was only until the late 1990s that it was prospectively studied by a group from Memphis who used beta-blockade with or without sodium nitroprusside in 58 patients. This approach eliminated in-hospital aortic ruptures without significant complications. Anti-impulse therapy has now become an essential component of BTAI management; however, controversy exists as to the optimum target indices.
The Society for Vascular Surgery guidelines suggests that the heart rate should be <100 bpm, and the blood pressure should be around 100 mmHg. This is an achievable goal in a patient with an isolated BTAI; however, trauma is rarely straightforward. A BTAI with a concomitant head trauma presents competing priorities: maintain relative hypotension for BTAI and normal blood pressure for the head injury. A single episode of hypotension in the setting of a traumatic brain injury results in a less favorable neurologic outcome. An option in this situation is to expedite TEVAR; however, a cohort study from our group suggests that early TEVAR in patients with traumatic brain injury may have deleterious effects. A more pragmatic approach may be to accept a higher systolic blood pressure and fastidiously avoid hypotension. Better evidence is required to direct the management of this particular sub-group.
| Contemporary Management of Blunt Thoracic Aortic Injury: the Shock Trauma Approach in 2018|| |
Thus far, this review has “told-the-story” of BTAI from the pathology through to the evolution in imaging and management. We have resisted providing hard guidance on specific management components as every patient is different. Several organizations have published guidelines; however, technology and knowledge evolve over time, rendering some of these elements outdated. The following section outlines a management philosophy as practiced at a busy trauma center in the United States. The caveat is this may not be applicable in every center or circumstance but can serve as one approach to BTAI management in 2018.
Trauma is a team game, and the team with primary responsibility for the patient should have easy access and collaboration with critical care physicians and vascular surgeons, who ideally have a trauma interest. Key management decisions, such as the optimum timing of intervention(s) should be made collaboratively when it is best for the patient.
Grade I injuries
In general, these injuries are minor and can be managed expectantly. If the intimal tear is small, no further imaging or medication is required, if the tear is prominent or in multiple locations, repeating CT scanning within the first-week postinjury is a reasonable approach. It is remarkable how quickly the aorta will re-model and heal these lesions. Aspirin can also be considered if the intimal tear is considered large.
Grade II injuries
The current SVS recommendations suggest that these lesions should be repaired by a TEVAR. We differ in our approach, where medical management should be initiated, and other injuries assessed and treated. We would re-image early (within 24 h of injury), and if the lesion was stable on medical management, then elect for serial CT imaging. The concern is that such a lesion may progress and become aneurysmal.
Grade III injuries
There is consensus that most of these lesions should undergo intervention, but controversy exists around timing, and successful nonoperative management has been reported. Indications for immediate intervention, in our view, include pseudocoarctation, mass effect from the mediastinal hematoma and a left-sided massive hemothorax. In stable patients, who have responded to medical management, repair after 24 h appears safe and may benefit patients with a concomitant brain injury.
Regarding technique, we are strong proponents of TEVAR with coverage of the LSCA as dictated by anatomical considerations. In general, we would use as short a graft as possible (10 cm) to minimize coverage of intercostal arteries, which contribute to spinal perfusion. We selectively revascularize the LSCA based on special circumstances (e.g., myocardial revascularization). Moreover, we do not advocate the prophylactic insertion of a spinal drain, but only if patients show clinical signs of lower extremity weakness. It is crucial that the care team be vigilant for postoperative extremity weakness.
Grade IV injuries
Swift teamwork is the only way that patients with active hemorrhage from an uncontained BTAI can survive. Hypotension should be tolerated, and all elements of care expedited. A pre-operative CT scan is generally required to plan the stent-graft sizing and deployment. Postoperatively, patients frequently have complications such as multisystem organ failure requiring complex intensive care unit care. Even with the most comprehensive care, many of these patients regrettably do not survive.
| Conclusion|| |
BTAI is spectrum of injuries ranging from an incidental and asymptomatic lesion through to uncontained rupture, which is a leading cause of prehospital death. The most common mechanism relates to motor vehicle crashes, and the injury most commonly occurs at the aortic isthmus. Minor grade injuries can be managed nonoperatively with surveillance and blood pressure control. Pseudoaneurysms should undergo semi-elective intervention in parallel with aggressive blood pressure control. Uncontained ruptures require emergent intervention. The most common intervention is no longer operative, which has been almost entirely replaced by TEVAR.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]