Imaging and Endovascular Intervention for Thoracic Vascular Trauma

Abstract

This article describes mechanisms, manifestations, imaging, and endovascular treatment of thoracic vascular injuries. Improvements in automotive safety features have decreased the overall likelihood of traumatic rupture of the aorta (TRA) resulting from a collision. At the same time, reports of survival and successful repair after rupture of the ascending aorta have increased. Imaging of thoracic vascular injuries has also changed substantially during the last 5 to 10 years. Helical computed tomography (CT) now plays an extremely important role. After obtaining a high-quality contrast-enhanced helical CT, one can determine the presence or absence of TRA, quickly and noninvasively providing satisfactory information for surgical planning in most cases. Transesophageal echocardiography (TEE) is being investigated as a bedside modality to assess for TRA, but this method is limited by "blind spots" in the great vessels and the increasingly important ascending aorta. Arteriography is largely supplanted by CT in this clinical setting, but is still helpful in the unusual situation of equivocal CT results. Arteriography also provides access for a growing number of endovascular interventions. In small thoracic arteries where preservation of flow is not critical, such as in the internal mammary, embolotherapy can achieve hemostasis expediently. A growing number of case reports and small series describe the use of covered stents and stent grafts for endovascular repair of the thoracic aorta and great vessels where flow must be preserved. The major potential advantages are speed, minimal invasiveness, and a decrease in morbidity (such as paraplegia) and mortality. Although initial experience has been quite favorable, the long-term effects of these endoprostheses are unknown. Device refinements and prospective trials will be necessary to determine which of these devices are the best and/or most appropriate ones.Objectives: Upon completion of this article, the reader should be able to (1) describe the clinical setting and mechanisms by which TRAs occur, (2) correlate the pathologic and radiologic appearance with an understanding of the role of various imaging modalities (x-ray, CT, TEE), (3) discuss the evolving role of arteriography in diagnosis and endovascular treatment, and (4) list other injuries to the great vessels and consider interventional options for management. Accreditation: Tufts University School of Medicine (TUSM) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. TUSM takes responsibility for the content, quality, and scientific integrity of this CME activity. Credit: TUSM designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.Downloaded by: Universite Laval. Copyrighted material.