blunt aortic injury

1. 23 September 2011 Blunt Aortic Injury Greg Magee

2. 23 September 2011 2 Blunt Aortic Injury Causes Associated injuries Diagnosis Treatment Case studies (3 last week) Some pictures first.Some pictures first.

3. 23 September 2011 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

4. 23 September 2011 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%) � of cases have normal CXRs

5. 23 September 2011 5 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. 23 September 2011 6 Diagnosis Gold standard historically aortography Newer evidence supports use of CT angiogram Very sensitive But more false positives

7. 23 September 2011 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

8. 23 September 2011 8 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%

9. 23 September 2011 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%

10. 23 September 2011 10 Areas most-likely injured Where aorta is fixed Isthmus � 86% Arch � 7% Diaphragm � 7% Ascending � 1%

11. 23 September 2011 11 CT findings Intimal flap Minor � 39% Moderate � 30% Severe � 30% Pseudoaneurysm Absent � 12% Small � 20% Medium � 13% Large � 55%

12. 23 September 2011 12 CT findings

13. 23 September 2011 13 CT findings

14. 23 September 2011 14 CT findings

15. 23 September 2011 15 CT findings

16. 23 September 2011 16 Comparison of survivors to non-survivors Age 36 vs. 47 (p value=0.02) Injury severity score 31 vs. 39 (p value=0.01) Glascow coma scale 14 vs. 8 (p value=0.0001)

17. 23 September 2011 17 Treatment Immediate operative repair Delayed operative repair after medically optimized Medical management alone

18. 23 September 2011 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

19. 23 September 2011 19 Medical management Use of anti-hypertensives first described at MGH Successful in mgt of dissecting aortic aneurysms -> reducing shearing forces Goal: maintain MAP of 80, HR < 80

20. 23 September 2011 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

21. 23 September 2011 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%

22. 23 September 2011 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

23. 23 September 2011 23 Mr. MT 48M s/p MCA Aortic tear w/ pseudoaneurysm at isthmus Associated injuries: displaced clavicle fx rib fxs bilateral pleural effusions

24. 23 September 2011 24 Mr. MT

25. 23 September 2011 25 Mr. SS 92M s/p MVA Aortic tear at the arch Associated injuries: Sternal fx

26. 23 September 2011 26 Mr. SS

27. 23 September 2011 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

28. 23 September 2011 28 Mr. MA

29. 23 September 2011 29 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 1998;227(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 1997;42:374-83. Maggisano R, Nathens A, Alexandrova N, et al. Traumatic rupture of the thoracic aorta: should one always operate immediately? Ann Emerg Med 1992; 21:391-96. Warren R, Akins C, Conn A, et al. Acute traumatic disruption of the thoracic aorta: emergency department management. Massachusetts General Hospital. Ann Emerg Med 1992;21:391-96. 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 1981;31:305-309 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 2004;56:565-70. Parmley L, Mattingly T, Manion T, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;XVII:1086-1101. 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. 2002;183:571-575. Jahromi A, Kazemi K, Safar H, Doobay B, Cina C. Traumatic rupture of the thoracic aorta: cohort study and systemic review. J Vasc Surg. 2001;34:1029-34.

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