TRAUMATIC AORTIC

INJURY
MI Zucker, MD
A dr Z Lecture on Aortic Injuries
 Aortic Injuries: Defined
• They are TEARS not dissections, so best
terminology would be:
Traumatic Aortic Injury or TAI
 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
 PATHOLOGY
• The lesion is an aortic wall TEAR, not a
dissection.
• The tear is through the intima and media,
with the thin but tough adventitia containing
the blood volume as a pseudoaneurysm for
a time.
• When the adventitia fails, the patient
usually immediately expires.
 Location of TAI

(On a Conventional Angiogram)

 TAI
In 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.
 But…
• If there has been enough deceleration force
to rupture small vessels, then there has been
enough force to tear the aorta.
 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
 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.
 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)
And: “I don’t know why, but the
mediastinum just don’t look
right.”

(You need a little experience to use

this one.)
 Of these,
• NONE is any better or worse than any
other.
• ONE abnormality makes the mediastinum
abnormal.
First, the NORMAL
Mediastinum
Young
Middle aged
Elderly
An “abnormal” mediastinum
in a normal patient
Caused by portable technique, supine
position, and poor inspiration
 Abnormal mediastinum
• Caused by Traumatic Aortic Injury.

• The subtle and the unsubtle.

• We are going to look for the mediastinum

abnormalities we just talked about on each film.
 So, Chest Film is Abnormal: What’s Next?

• CT • With contrast bolus CTA.

Multidetector unit

• Unstable patient. Operator

• TEE dependent

• Angiography • Invasive. Labor intensive

• Slow. Harder to manage

• MRI patient. Availability
ANGIOGRAPHY

Invasive
Labor intensive
The “gold standard”
 CTA

Universally available
Quick
Accurate
The new “gold standard”
 TREATMENT of TAI
Operate emergently
Graft placement
 Prognosis
• 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…
 A Case to Think About:

• Code Trauma
• Young man, MVA, stable, but multiple
injuries, including chest.
 The Chest Film

Multiple injuries, abnormal

mediastinum
 The CTA

Called “suggestive” of TAI, but

technically limited examination
 The Angiogram

Done because of uncertain CT.

Called “normal”
 So:
• Chest film: Abnormal

• CT: Abnormal, but uncertain for TAI

• Angiogram: Normal
 The Outcome:
• No surgery on aorta
• Patient recovered from other injuries
• Discharged
• Still alive, as far as we know
 But:

Was the Aorta Injured?

 ????
• Were the chest film and the CT results
correct and the angiogram, the so-called
“Gold Standard,” wrong?
• Is MDCT the new “Gold Standard”?
 “MINIMAL AORTIC INJURY”

• There are patients with aortic injury who

have survived without surgery.
• There may be a subtype of Minimal Intimal
Injury with a more benign outcome, where
the injured intima heals without
intervention.
• So, the 99% death rate without surgery may
be an overestimate.
Goodbye

• Copyright 2004
MI Zucker