Blunt Thoracic Aortic Injury: An Evidence-Based Review

Purpose: To discuss the epidemiology, presentation, diagnosis and treatment of blunt thoracic aortic injury (BTAI) with a special focus on its endovascular management.

Materials and Methods: BTAI is a life-threatening pathology and is the second most common cause of death among all nonpenetrating traumatic injuries. It is defined as a tear in the aorta that is a result of a combination of shear and stretch forces, rapid deceleration, increased intravascular pressure, and compression of the aorta between the anterior chest wall and vertebrae. A high index of suspicion should be maintained on the basis of clinical presentation and the mechanism of injury; early diagnosis is crucial because many patients with BTAI die within 24 hours if not managed. Chest x-ray and focused assessment with sonography for trauma (FAST)scan ultrasounds can help with the diagnosis of BTAI, but they have a low sensitivity and specificity, Computed tomographic angiography is the imaging modality of choice because of its high sensitivity.

Results: BTAI are graded according to the Society of Vascular Surgery guidelines into four grades, grade I (intimal tear), grade II (intramural hematoma), grade III (pseudoaneurysm), and grade IV (rupture). Grade I injuries and some grade II injuries are managed with conservative management with close follow-up, whereas some grade II, grade III, and grade IV injuries are managed with endovascular or open surgical repair. The use of thoracic endovascular aortic repair (TEVAR) was evaluated in the AAST trials and they showed an increase in TEVAR use from 0% to 65% from 1997 to 2007. The second AAST trial showed a mortality rate of 9% in the TEVAR group versus 16% in the open repair group (P = 0.001). For a patient to be a candidate for endovascular repair, a landing zone with 2 cm proximal and 10 cm distal to the injury is needed. Trails evaluating the use of TEVAR for BTAI, TEVAR technique, and complications are described in the exhibit.

Conclusions: BTAI require a high level of suspicion to make an early diagnosis in patients with blunt thoracic trauma. Endovascular approaches have slowly replaced the conventional open surgical repair for management of BTAI. Multidisciplinary coordination is critical in management of these patients.