Endovascular Management of Traumatic Aortic Injury: Pictorial Review and Management Practice

Purpose: The purpose of this review is to provide a pictorial review of the grades of traumatic aortic injury, discuss preprocedural preparation and imaging, thoracic endovascular aneurysm repair (TEVAR) technique, and postprocedural management and complications.

Materials and Methods: Blunt traumatic aortic injury commonly occurs after motor vehicle collisions (MVCs). Traumatic aortic injury is graded from I to IV based on the degree of vessel wall damage, with I being intimal tear, II intramural hematoma, III pseudoaneurysm, and IV complete rupture. For both stable and unstable patients, TEVAR is the accepted standard.

Results: Deceleration injuries from MVC most commonly cause traumatic aortic injury at the isthmus. Whereas unstable patients with traumatic aortic injury should undergo emergent TEVAR, stable patients can undergo elective repair. TEVAR is preferred over open repair because of associated lower 30-day mortality, transfusion, and spinal cord ischemia rates compared with open repair. Computed tomography angiography (CTA) from the thoracic inlet to the femoral bifurcations is essential to plan for access and size of stent graft that can be placed. If elective, imaging should include evaluation for basilar communication of the left subclavian artery because this is often covered in the emergent setting because of a small stent landing zone and can result in posterior circulation ischemia if there is no collateral flow. After bilateral femoral artery access, an aortogram should be obtained to identify an adequate landing zone for the stent, with advancement of the stent graft via the contralateral femoral artery under fluoroscopy. TEVAR is performed over a stiff wire, with deployment of a covered stent over the area of dissection. Immediate complications can include stroke, aortic perforation, endoleak, and paraplegia. Mean arterial pressures should be kept between 80 and 100 mm Hg, and patients should undergo CTA of the chest to evaluate the stent graft before discharge.

Conclusions: TEVAR is the preferred modality for repair of traumatic aortic injury in both hemodynamically stable and unstable patients. It is important for interventionalists to understand the ideal preprocedural imaging, procedural technique, and short- term complications that can occur.