Traumatic Aortic Injuries

Excerpt

In the United States (US), trauma is the fourth leading cause of death in adults and the leading cause of death in children and adolescents. Traumatic aortic injuries are a rare but serious subset of traumatic emergencies, with potentially catastrophic consequences if not promptly recognized and managed. Traumatic aortic injuries are usually secondary to penetrating chest injuries, deceleration injuries, or blunt chest trauma. Traumatic aortic injuries range from aortic bruising to complete aortic transection, also known as an aortic rupture. Traumatic aortic injuries may manifest initially as a contained rupture or pseudoaneurysm, which may not elicit significant clinical symptoms. However, this relatively silent phase is transient, as the pseudoaneurysm progresses to uncontained rupture, leading to rapid exsanguination and, ultimately, death.

Occurring primarily as a result of blunt traumatic mechanisms, traumatic aortic injuries often present formidable challenges to healthcare professionals due to their elusive clinical manifestations and rapid progression to life-threatening complications. Despite their infrequent occurrence, traumatic aortic injuries are a significant contributor to morbidity and mortality in trauma patients, second only to traumatic brain injury. Trauma disproportionately affects the thoracic aorta at anatomical fixation points. Thoracic aortic injuries account for one-third of automobile accident fatalities; the prehospital mortality rate for such patients approaches 80%.

Patients with a blunt traumatic aortic injury will exhibit a spectrum of presentations and severity levels, categorized into 3 main groups based on clinical outcomes. Between 80% and 85% of patients succumb to their injuries at the scene. Another subset presents alive but hemodynamically unstable, constituting 2% to 5% of cases; mortality rates range from 90% to 98%. The remaining patients, approximately 15% to 20%, present with hemodynamic stability, and the diagnosis of traumatic aortic injury is typically established within 4 to 18 hours after injury. Despite advancements in trauma care, a significant proportion of patients with blunt aortic injury face high mortality rates in the hospital; the 24-hour mortality rate is 32% to 50%. However, many deaths may not be directly attributable to the aortic injury, as most of these patients have polytrauma.

Traumatic aortic injuries can also occur as a result of penetrating trauma such as gunshot wounds and stabbings; these mechanisms of injury are much more likely to injure the abdominal aorta. While the survival rates from a penetrating traumatic aortic injury are slightly better than from a blunt force injury, the overall mortality still approximates 80%.

A high index of clinical suspicion, rapid diagnosis, and prompt management dictates the survival of patients with traumatic aortic injuries. Injury mechanism and severity, clinical stability, and associated traumatic injuries all influence the timing and method of aortic repair. The treatment of these injuries has dramatically shifted within the last 2 decades with the advent of endovascular treatments. Endovascular stent grafts are the mainstay of treatment, with fewer complications and improved morbidity and survival profiles compared to open surgical treatment.