Conservative management of aortic arch injury following penetrating trauma

Abstract

Aortic arch injuries following penetrating trauma are typically lethal events with high mortality rates. Traditionally, the standard of care for patients presenting with penetrating injury and aortic involvement has included surgical intervention. We report the case of a 31-year-old man who was managed non-operatively after sustaining multiple stab wounds to the left chest and presenting with mid aortic arch injury. Historically, penetrating injury to the thoracic aorta has been associated with mortality rates greater than 90% and it has one of the poorest prognoses of all penetrating injuries. 1 The majority of patients die at the scene and those who do arrive at hospital are usually in critical condition.Despite advances in trauma management and the development of dedicated trauma centres, morbidity and mortality rates have remained relatively unchanged in patients with penetrating aortic injury (PAI).1 The incidence of penetrating trauma to the aortic arch is not well documented as most patients exsanguinate before receiving treatment. 2 In an autopsy study from Athens, the authors found that traumatic aortic injury was responsible for 12.7% of all injury related fatalities and penetrating trauma was responsible for 13.6% of those deaths. 2 Also reported was the finding that the aortic arch along with the ascending aorta were the most common site of thoracic aortic injury following stab wounds.In patients who present with PAI, operative management is the norm and currently, there are no recommendations for conservative management. This is opposed to blunt aortic injury (BAI), where non-operative management has been explored and guidelines have been proposed by the Society for Vascular Surgery. 3 We present the case of a patient who was managed conservatively following an aortic arch injury secondary to penetrating trauma with strict blood pressure control and outpatient surveillance. Case HistoryA 31-year-old man received via the emergency medical services presented to our emergency department (ED) shortly after sustaining multiple stab wounds to the left anterior chest, left axilla and left upper extremity. En route, the patient's blood pressure was 112/70mmHg and he had a pulse rate of 80bpm. He was diaphoretic at the scene, which improved on arrival to the ED. A standard Advanced Trauma Life Support ® approach was initiated immediately in the trauma bay.The patient was sent for computed tomography (CT) of the chest with contrast in a stable condition. The CT revealed a left upper lobe laceration, a large left haemothorax, a small left pneumothorax and extensive haemorrhages in the mediastinum surrounding the aortic arch with a hint of tiny extrusion at the aortic arch but no obvious source of bleeding. A chest tube placed into the left haemothorax put out 1,800ml serosanguinous drainage in the first 24 hours. The subsequent CT angiography (CTA) revealed a nipple of contrast at the mid aortic arch. A mid aortic arch injury could not be distinguished on the CTA from a laceration of the arterial/ veno...

A Rare Case and Presentation of Traumatic Penetrating Aortic Arch Injury: A Case Report and Literature Review

“…It can show multiple signs such as widening of the superior mediastinum >8 cm and/or 25% of the width of the thorax (most common), loss of aortic knob, the obvious double contour of the aorta/abnormalities of the transverse aortic arch (sensitive finding), obliteration of the aortopulmonary window on lateral chest radiography (sensitive finding), massive hemothorax, and right deviation of the nasogastric, endotracheal, or esophageal tubes [8]. Normal vital signs with abnormal findings suggestive of a vascular injury should undergo CT aortography, the gold standard test, to confirm the diagnosis and facilitate operative planning since aortic injury grading is classified based on CT findings [25,34]. Signs on CT include abnormal aortic contour, sudden change in aortic caliber (pseudocoarctation), contained rupture, traumatic pseudoaneurysm, intimal flap, and intraluminal mural thrombus [25].…”

“…Normal vital signs with abnormal findings suggestive of a vascular injury should undergo CT aortography, the gold standard test, to confirm the diagnosis and facilitate operative planning since aortic injury grading is classified based on CT findings [25,34]. Signs on CT include abnormal aortic contour, sudden change in aortic caliber (pseudocoarctation), contained rupture, traumatic pseudoaneurysm, intimal flap, and intraluminal mural thrombus [25]. Alternatively, magnetic resonance imaging (MRI) of the thorax, conventional angiography, intravascular ultrasound (IVUS), or transesophageal echocardiogram (TOE) can be used as needed [25,34].…”

“…Signs on CT include abnormal aortic contour, sudden change in aortic caliber (pseudocoarctation), contained rupture, traumatic pseudoaneurysm, intimal flap, and intraluminal mural thrombus [25]. Alternatively, magnetic resonance imaging (MRI) of the thorax, conventional angiography, intravascular ultrasound (IVUS), or transesophageal echocardiogram (TOE) can be used as needed [25,34].…”

“…For type II, III, and IV injuries without concomitant injuries requiring emergency intervention such as laparotomy, craniotomy, or pelvic stabilization, immediate surgical repair is advised [25]. In the literature, there are cases of a contained penetrating thoracic aortic arch injury that were successfully treated with a non-operative approach, which may be a line of management in certain patient groups in the era of the magnificent development of higher resolution CT scans [25]. If surgical treatment for a contained aortic injury is delayed, patients should be aggressively treated with short-acting beta-blockers to reduce the ongoing wall stress sustained by the aorta and the incidence of aortic rupture.…”

“…If surgical treatment for a contained aortic injury is delayed, patients should be aggressively treated with short-acting beta-blockers to reduce the ongoing wall stress sustained by the aorta and the incidence of aortic rupture. The indications for urgent surgical intervention in penetrating aortic injury are initial loss of 1,500 mL of blood from the chest tube, continuing hemorrhage of >200 ml/hour from the chest tube, hemopericardium, cardiac tamponade, exsanguinating hemorrhage presenting from the supraclavicular wound, evidence of acute thoracic great vessel injury on imaging or radiographic, or other imaging evidence of chronic thoracic great vessel injury complications [25]. Therefore, since our patient was hemodynamically stable and CT angiography showed aortic arch transection with contrast extravasation, he underwent median sternotomy with the aortic arch repair without the use of cardiopulmonary bypass (CPB) or deep hypothermic circulatory arrest (DHCA) [2].…”