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Blunt Traumatic Aortic Injury a Review of Initial Diagnostic Modalities and a Proposed Diagnostic Algorithm

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Blunt Traumatic Aortic Injury a Review of Initial Diagnostic Modalities and a Proposed Diagnostic Algorithm European Journal of Trauma Review Article Blunt Traumatic Aortic Injury A Review of Initial Diagnostic Modalities and a Proposed Diagnostic Algorithm Joseph Yuk Sang Ting1 Abstract used when the results from other modalities are incon- Background: Blunt traumatic aortic injury (TAI) is clini- clusive. cally difficult to diagnose, as signs and symptoms are unreliable and variable. The identification of TAI may Key Words be obscured by other injuries that are more apparent. Aortic injury · Blunt thoracic trauma · Mediastinum · Furthermore, radiologic evaluation of the mediastinum CT angiography · Transesophageal echocardiogra- for this injury is not well defined. Most patients with phy TAI die immediately. Survivors have a contained rupture which requires crucial early diagnosis and treatment. Eur J Trauma 2003;29:1–I Material and Methods: A Medline search was conduct- DOI 10.1007/s00068-003-1291-7 ed using the terms “traumatic aortic injury”, “aortic injury”, “aortic trauma”, and “thoracic trauma” from 1966 until December 2002. Investigations used in the diagnostic evaluation of blunt TAI were reviewed and Introduction an initial investigative approach to this condition for- High immediate mortality from aortic injury due to mulated. exsanguination remains a major problem in trauma Results: The choice of investigation for TAI depends on management [1]. This risk persists for survivors in clinical suspicion, hemodynamic stability, availability, whom aortic injury remains undetected and therefore and rapidity of access to tests. These include chest radi- untreated. 90% of traumatic aortic injuries (TAI) result ography, helical computed tomography angiography from penetrating causes such as gunshot or stab (CT-A), transesophageal echocardiography (TEE), aor- wounds, with only 10% being due to blunt thoracic trau- tography, and intraarterial digital subtraction angiog- ma [2]. Blunt TAI is rapidly lethal in 90% of cases due to raphy (IA-DSA). CT-A is considered an excellent test in exsanguination [3–6], with survivors having a contained hemodynamically stable blunt thoracic trauma aortic leak [2, 7, 8]. TAI is the second most frequent patients. TEE is preferred in unstable patients. cause of death in blunt trauma, causing 8,000 deaths in Conclusion: Investigations must confirm or exclude TAI the USA each year [5]. There are two groups of sur- with great precision. CT-A is a reliable screening and vivors. Both present with a contained aortic hematoma now primary diagnostic test in the hemodynamically but are at risk of subsequent rupture [8]. The first group stable patient. A negative CT-A excludes aortic injury, are hemodynamically unstable on arrival to hospital with a positive or equivocal CT-A leading to treatment and have a 2% survival rate. The second group are sta- or further diagnostic evaluation. TEE is appropriate for ble, and 75% survive with early diagnosis and treatment the hemodynamically unstable patient but is operator- [9, 10]. Prompt recognition and treatment in survivors dependent and not widely available. Aortography is improves outcome [5] by lessening the risk of cata- still considered the reference test for blunt TAI and is strophic rupture [11], which increases with time [4]. Left 1 Departments of Emergency Medicine, Mater Adult and Children’s Hospitals, Brisbane, Queensland, Australia. Received: January 9, 2003; revision accepted: April 22, 2003. European Journal of Trauma 2003 · No. 3 © Urban & Vogel 1 Ting JYS. Blunt Traumatic Aortic Injury: an investigative approach unrepaired, delayed rupture and fistulization to adja- endovascular ultrasonography (USS), and intraarterial cent mediastinal structures can occur [2]. The outlook digital subtraction angiography (IA-DSA) [6]. for those treated nonsurgically is poor, with < 2% sur- Evaluation of the mediastinum for blunt TAI is not viving long-term owing to the formation of a chronic well defined. Investigation must confirm or exclude TAI pseudoaneurysm [4, 8]. with certainty due to the potentially lethal conse- Aortic injury results from shearing stresses (torque quences of a missed diagnosis and the risk of unneces- and compression) on the thoracic aorta from rapid sary surgical intervention [16]. deceleration. Relatively mobile sections of the aorta move in relation to fixed parts such as the ligamentum Material and Methods arteriosum, aortic isthmus and diaphragmatic hiatus [4]. Search Strategy The aorta is compressed between bony structures [2], A Medline search was conducted using the terms “trau- and acute aortic wall stress from intraluminal hyperten- matic aortic injury”, “aortic injury”, “aortic trauma”, sion leads to rupture of the aorta [12]. Survival depends and “thoracic trauma” from 1966 until December 2002. on an intact adventitial layer and the formation of a con- All article abstracts, including those from non-English tained hematoma [4, 7, 12]. Most adult and pediatric citations and those available only as Internet publica- [13] blunt TAI are transverse lesions found within close tions, were examined. proximity of the ligamentum arteriosum [4, 6, 7] just dis- Articles looking at the diagnostic evaluation of tal to the origin of the left subclavian artery [6]. Ascend- blunt TAI were reviewed and an initial investigative ing aortic injury comprises 5% of cases but is uniformly approach to this condition was formulated. Emphasis lethal. 1–3% percent of injuries occur in the descending was given to large, rigorously conducted prospective aorta [6]. studies with uniform entry selection criteria that includ- Blunt TAI is rare in children and occurs with other ed high risk injury mechanisms and/or mediastinal severe injuries [13]. As in adults, good outcome depends abnormalities on chest film. These studies used well- on early detection and treatment [14]. A high index of defined diagnostic criteria, imaging studies were inter- suspicion is required to make the diagnosis based on a preted by radiologists and results correlated with refer- history of rapid deceleration and high-risk injury pat- ence diagnoses at surgery, autopsy or aortography. terns [4, 11]. These include high-speed collisions, ejec- Our search was unable to identify any study in tion, pedestrian impact, and high falls [5, 15]. Mecha- which patients were randomized at entry either to the nism of injury is a useful predictor of injury [11]. An imaging modality being tested or the widely accepted abnormal mediastinum on chest film in a patient with reference standard of aortography. Studies examined significant blunt thoracic trauma requires further evalu- used risk stratification based on injury mechanism and ation for aortic injury. Worryingly, a normal medi- mediastinal abnormalities on chest film. Subjects with astinum may be found in up to 8.3% of proven aortic very high risk of blunt TAI proceeded directly to aor- injuries [10, 16], with some clinicians advocating further tography even if no mediastinal abnormality was seen investigation in high-risk injury mechanisms despite a on chest film. Those sustaining blunt thoracic trauma normal chest film [11, 16]. with lesser risk of aortic injury underwent the investiga- TAI is difficult to detect [11], as only half [2, 8] to tion being tested. Test investigations that were equivo- two-thirds [7, 12] of patients have external signs of tho- cal or inadequate were clarified with aortography. racic trauma. Severe injuries requiring urgent interven- Using a nonrandomized clinical risk-stratification tool tion may be more apparent [4, 15]. Clinical findings such to determine what test is used initially may lead to mis- as systemic hypotension, upper limb hypertension, leading results. This strategy accepts the superiority of asymmetry of limb pulses and flow murmurs are not aortography without testing the assumption. As such, reliable for diagnosis [2, 11]. these comparative studies may overestimate the useful- Investigational method depends on clinical suspi- ness of aortography compared with other modalities. cion, hemodynamic stability, availability, and rapidity of Findings at surgery or at postmortem comprise better access to tests [4]. They include plain chest films, chest reference diagnoses and allow critical evaluation of aor- helical computed tomography angiography (CT-A), tography itself. transesophageal echocardiography (TEE), aortogra- Good studies blinded interpreting radiologists to phy, magnetic resonance angiography (MRA), reference results from aortography, surgery or autopsy. 2 European Journal of Trauma 2003 · No. 3 © Urban & Vogel Ting JYS. Blunt Traumatic Aortic Injury: an investigative approach Some studies conducted clinical follow-up or repeated the resuscitation area [4, 10]. Aortography has an asso- imaging studies even if the initial result was negative. ciated mortality of 0.03% [8]. This is expected to reduce misclassification due to false- Despite its disadvantages, a negative aortography negatives. However, in no study did patients with nega- rate as high as 90% is accepted because of the high mor- tive test results undergo aortography unless there was bidity and mortality of missed aortic injury [20]. A small high-risk mechanism, strong clinical suspicion despite number of false-positive aortograms [5, 21–24] can negative screening test or the results of initial tests were result from atheromatous or ulcerated aortic wall and equivocal. This would be expected to artifactually ductal diverticula. False-negatives result from inade- increase the diagnostic yield for aortography. quate contrast distribution
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