Thoracic Aortic and Great Vessel Trauma and Its Management

Abstract

Interventional radiologists (IRs) now play a major role in the management of thoracic aortic and great vessel trauma. The recent availability of a wide range of stent grafts able to treat vessels from 3 to 46 mm in diameter is clearly a significant contributor to this change. Stent grafts can now treat the majority of incomplete aortic injuries with much lower morbidity and mortality than open surgery. Short-to medium-term follow-up is encouraging, but the long-term durability is unknown, and close monitoring of these patients must continue. In great vessel trauma, stent grafts are a useful adjunct to balloon tamponade, embolization, and bare stents. As a result, a wide range of head neck and upper limb vascular injuries can be managed with less local trauma, blood loss, and physiological stress. The increased involvement of IR in the management of vascular trauma is not simply the result of technological advances. IRs have increasingly made themselves available to carry out these emergency procedures. IRs should assist in the development of trauma protocols and management algorithms that involve endovascular expertise early in the assessment of the major trauma patient.

Dual-phase CT for the assessment of acute vascular injuries in high-energy blunt trauma: the imaging findings and management implications

“…Typically, Type I injuries heal spontaneously ( Figure 1) while Types II-IV should be repaired surgically. [32][33][34] When an intimal defect compromises the lumen for ,10% or an intimal flap of ,1 cm is present without or with minimal periaortic haematoma, the lesion can be considered "minimal" and follow-up is recommended ( Figure 1). Intimal tears may also lead to intraluminal thrombosis owing to the endoluminal exposure of thrombotic subintimal factors or evolve in vessel dissection.…”

“…An AVF may arise from a blunt or, more commonly, penetrating trauma. 24,33 On MDCT, AVF is an asymmetrical, early contrast opacification of a vein, during the arterial phase ( Figure 7); thus, an arterial phase is necessary to make the diagnosis.…”

Thoracic Vascular Trauma

“…However, the data is lacking on longterm results, a concern for young patients expected to have a considerable life expectancy following the incident. Such patients will need close follow-up and continued surveillance imaging; the associated cost for the continued evaluation and the radiation burden is a concern [26].…”

“…The rationale for treating blunt aortic injury is to essentially prevent early rupture from the acute injury and to prevent late aneurysm formation and subsequent rupture. The traditional approach is through a left thoracotomy with single lung ventilation, however, as noted previously, patients with pulmonary injuries and thoracic wall trauma may not tolerate single-lung ventilation [26][27][28].…”

“…The risk of paraplegia varies from 2.3% with active distal aortic perfusion to over 19% with the "clamp and sew" approach [26]. Mortality rates have been reported between 5% and 28% [28].…”