Traumatic aortic rupture

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Traumatic aortic rupture
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Traumatic aortic rupture, also called traumatic aortic disruption or transection, is a condition in which the aorta, the largest artery in the body, is torn or ruptured as a result of trauma to the body. The condition is frequently fatal due to the profuse bleeding that results from the rupture. Since the aorta branches directly from the heart to supply blood to the rest of the body, the pressure within it is very great, and blood may be pumped out of a tear in the blood vessel very rapidly. This can quickly result in shock and death. Thus traumatic aortic rupture is a common killer in automotive accidents and other traumas, [1] with up to 18% of deaths that occur in automobile collisions being related to the injury. [2] In fact, aortic disruption due to blunt chest trauma is the second leading cause of injury death behind traumatic brain injury. [3] [4]

Contents

Aortic rupture can also be caused by non-traumatic mechanisms, particularly abdominal aortic aneurysm rupture.

Symptoms and signs

Symptoms are often unreliable, but include severe tearing chest pain; cough; dyspnea (shortness of breath); dysphagia (difficulty swallowing); back pain; and hoarseness. Blood pressure is usually high in the upper body, but low in the lower body. A widened mediastinum and a massive left hemothorax are often found in an X-ray. There can be bruising of the anterior chest wall, and a systolic murmur can be heard on the bottom of the heart. [5]

Causes

The injury is usually caused by high speed impacts such as those that occur in vehicle collisions and serious falls. [1] It may be due to different rates of deceleration of the heart and the aorta, which is in a fixed position. [6]

Location of rupture

By far the most common site for tearing in traumatic aortic rupture is the proximal descending aorta, near where the left subclavian artery branches off from the aorta. [7] The tethering of the aorta by the ligamentum arteriosum makes the site prone to shearing forces during sudden deceleration. [8]

A study of people who died after traumatic aortic rupture found that in 55–65% of cases the damage was at the aortic isthmus and in 10–14% it was in the ascending aorta or aortic arch. [4] An angiogram will often show an irregular outpouching beyond the takeoff of the left subclavian artery at the aortic isthmus, representing an aortic pseudoaneurysm caused by the trauma. Damage can also be in the lower thoracic or abdominal aorta. [4]

Pathology

The aorta is not always torn completely through; it may also tear some but not all layers of the arterial wall, sometimes forming a false aneurysm. [4] A sub-intimal hemorrhage is the least serious type. [4]

Intimal tear

Being the mildest form, it often does not weaken the wall of the aorta and may heal on its own. Usually, it occurs in the descending aorta. It was originally defined as a small intimal flap with less than one centimeter length and with little or no haematoma. It is 10-28% of aortic injuries. [9]

Diagnosis

The condition is difficult to detect and may go unnoticed, because many patients have no specific symptoms. Diagnosis is further complicated by the fact that many patients with the injury experienced multiple other serious injuries as well, [10] so the attention of hospital staff may be distracted from the possibility of aortic rupture. In fact most cases occur along with other injuries. [4]

A common symptom is unusually high blood pressure in the upper body and very low blood pressure in lower limbs. Another sign is kidney failure where the creatinine level shoots very high and urine output becomes negligible. In most cases, however, the doctors would misinterpret kidney failure as due to issues with the kidney itself and may recommend dialysis.[ citation needed ]

Though not completely reliable, chest X-rays are the first-line investigation, [4] initially used to diagnose this condition when the patient is unstable and cannot be sent to the CT bay. The preferred method of diagnosis used to be CT angiogram until it was found to cause complications in some people. As of 2013 it is reserved for when CT scans are inconclusive. [4]

The classical findings on a chest X-ray will be widened mediastinum, [4] apical cap, and displacement of the trachea, left main bronchus, or nasogastric tube. A normal chest x-ray does not exclude transection, but will diagnose conditions such as pneumothorax or hydrothorax. The aorta may also be torn at the point where it is connected to the heart. The aorta may be completely torn away from the heart, but patients with such injuries rarely survive very long after the injury; thus it is much more common for hospital staff to treat patients with partially torn aortas. [1] When the aorta is partially torn, it may form a "pseudoaneurysm". In patients who do live long enough to be seen in a hospital, a majority have only a partially torn blood vessel, with the outermost adventitial layer still intact. [2] In some of these patients, the adventitia and nearby structures within the chest may serve to prevent severe bleeding. [2] After trauma, the aorta can be assessed by a CT angiogram or a direct angiogram, in which contrast is introduced into the aorta via a catheter.

Treatment

Aortic transection

Traumatic aortic rupture is treated with surgery. However, morbidity and mortality rates for surgical repair of the aorta for this condition are among the highest of any cardiovascular surgery. [3] For example, surgery is associated with a high rate of paraplegia, [11] because the spinal cord is very sensitive to ischemia (lack of blood supply), and the nerve tissue can be damaged or killed by the interruption of the blood supply during surgery.[ citation needed ]

A less invasive option for treatment is endovascular repair, which does not require open thoracotomy and can be safer for people with other injuries to organs. [4]

Since high blood pressure could exacerbate an incomplete tear in the aorta or even separate it completely from the heart, which would almost inevitably kill the patient, hospital staff take measures to keep the blood pressure low. [1] Such measures include giving pain medication, keeping the patient calm, and avoiding procedures that could cause gagging or vomiting. [1] Beta blockers and vasodilators can be given to lower the blood pressure, and intravenous fluids that might normally be given are foregone to avoid raising it. [4]

In 1959, Passaro reported the first successful surgical repair of a torn aorta. Kirsh, in 1976, reported a 70% success rate in surgery to repair a torn aorta, based on 10 years of experience as a surgeon. Therefore, for those who make it to the hospital (85% do not), are successfully diagnosed in time and are quickly operated upon, the chances of survival are higher. [5]

Intimal tear

In some cases, intimal tears may resolve on their own. Therefore, conservative treatment like antihypertensives are usually initiated. There is limited data on the treatment of this type of aortic injury. In some places, endovascular repair is also an option for treatment. [9]

Prognosis

Death occurs immediately after traumatic rupture of the thoracic aorta 75%–90% of the time since bleeding is so severe, and 80–85% of patients die before arriving at a hospital. [2] Of those who live to reach a hospital, 23% die at the time of or shortly after arrival. [4] In the US, an estimated 7,500–8,000 cases occur yearly, of which 1,000–1,500 make it to a hospital alive; these low numbers make it difficult to estimate the efficacy of surgical options. [4] However, if surgery is performed in time, it can offer a chance of survival. [4]

Though there is a concern that a small, stable tear in the aorta could enlarge and cause complete rupture of the aorta and heavy bleeding, this may be less common than previously believed as long as the blood pressure does not get too high. [2]

There have been five rare cases of a traumatic aortic rupture going undiagnosed of more than a year, and presenting with chest and back pain. They had pseudoaneurysms or large aneurysms that caused pain. Asymptomatic chronic traumatic aneurysms are not always a risk for sudden death unless too large. Growing aneurysms, symptomatic or not, have a risk of rupture so the treatment is surgical removal. [12]

See also

Related Research Articles

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<span class="mw-page-title-main">Aneurysm</span> Bulge in the wall of a blood vessel

An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus for clot formation (thrombosis) and embolization. As an aneurysm increases in size, the risk of rupture, which leads to uncontrolled bleeding, increases. Although they may occur in any blood vessel, particularly lethal examples include aneurysms of the Circle of Willis in the brain, aortic aneurysms affecting the thoracic aorta, and abdominal aortic aneurysms. Aneurysms can arise in the heart itself following a heart attack, including both ventricular and atrial septal aneurysms. There are congenital atrial septal aneurysms, a rare heart defect.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

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<span class="mw-page-title-main">Vascular surgery</span> Medical specialty, operative procedures for the treatment of vascular disorders

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<span class="mw-page-title-main">Aortic aneurysm</span> Excessive enlargement of the human aorta

An aortic aneurysm is an enlargement (dilatation) of the aorta to greater than 1.5 times normal size. They usually cause no symptoms except when ruptured. Occasionally, there may be abdominal, back, or leg pain. The prevalence of abdominal aortic aneurysm ("AAA") has been reported to range from 2 to 12% and is found in about 8% of men more than 65 years of age. The mortality rate attributable to AAA is about 15,000 per year in the United States and 6,000 to 8,000 per year in the United Kingdom and Ireland. Between 2001 and 2006, there were approximately 230,000 AAA surgical repairs performed on Medicare patients in the United States.

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<span class="mw-page-title-main">Abdominal aortic aneurysm</span> Medical condition

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<span class="mw-page-title-main">Thoracic aortic aneurysm</span> Medical condition

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<span class="mw-page-title-main">Endovascular aneurysm repair</span> Surgery used to treat abdominal aortic aneurysm

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<span class="mw-page-title-main">Aortic rupture</span> Rupture or breakage of the aorta, the largest artery in the body

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<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

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<span class="mw-page-title-main">Thoracic aorta injury</span> Medical condition

Injury of the thoracic aorta refers to any injury which affects the portion of the aorta which lies within the chest cavity. Injuries of the thoracic aorta are usually the result of physical trauma; however, they can also be the result of a pathological process. The main causes of this injury are deceleration and crush injuries. There are different grades to injuries to the aorta depending on the extent of injury, and the treatment whether surgical or medical depends on that grade. It is difficult to determine if a patient has a thoracic injury just by their symptoms, but through imaging and a physical exam the extent of injury can be determined. All patients with a thoracic aortic injury need to be treated either surgically with endovascular repair or open surgical repair or with medicine to keep their blood pressure and heart rate in the appropriate range. However, most patients that have a thoracic aortic injury do not live for 24 hours.

<span class="mw-page-title-main">Familial aortic dissection</span> Medical condition

Familial aortic dissection or FAD refers to the splitting of the wall of the aorta in either the arch, ascending or descending portions. FAD is thought to be passed down as an autosomal dominant disease and once inherited will result in dissection of the aorta, and dissecting aneurysm of the aorta, or rarely aortic or arterial dilation at a young age. Dissection refers to the actual tearing open of the aorta. However, the exact gene(s) involved has not yet been identified. It can occur in the absence of clinical features of Marfan syndrome and of systemic hypertension. Over time this weakness, along with systolic pressure, results in a tear in the aortic intima layer thus allowing blood to enter between the layers of tissue and cause further tearing. Eventually complete rupture of the aorta occurs and the pleural cavity fills with blood. Warning signs include chest pain, ischemia, and hemorrhaging in the chest cavity. This condition, unless found and treated early, usually results in death. Immediate surgery is the best treatment in most cases. FAD is not to be confused with PAU and IMH, both of which present in ways similar to that of familial aortic dissection.

<span class="mw-page-title-main">Open aortic surgery</span> Surgical technique

Open aortic surgery (OAS), also known as open aortic repair (OAR), describes a technique whereby an abdominal, thoracic or retroperitoneal surgical incision is used to visualize and control the aorta for purposes of treatment, usually by the replacement of the affected segment with a prosthetic graft. OAS is used to treat aneurysms of the abdominal and thoracic aorta, aortic dissection, acute aortic syndrome, and aortic ruptures. Aortobifemoral bypass is also used to treat atherosclerotic disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by endovascular aneurysm repair (EVAR) as the most common technique for repairing abdominal aortic aneurysms in the United States.

<span class="mw-page-title-main">Inflammatory aortic aneurysm</span> Medical condition

Inflammatory aortic aneurysm (IAA), also known as Inflammatory abdominal aortic aneurysm (IAAA), is a type of abdominal aortic aneurysm (AAA) where the walls of the aneurysm become thick and inflamed. Similar to AAA, IAA occurs in the abdominal region. IAA is closely associated and believed to be a response to and extensive peri-aneurysmal fibrosis, which is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process IAA accounts for 5-10% of aortic aneurysms. IAA occurs mainly in a population that is on average younger by 10 years than most AAA patients. Some common symptoms of IAA may include back pain, abdominal tenderness, fevers, weight loss or elevated Erythrocyte sedimentation rate (ESR) levels. Corticosteroids and other immunosuppressive drugs have been found to decrease symptoms and the degree of peri-aortic inflammation and fibrosis

Endovascular and hybrid trauma and bleeding management is a new and rapidly evolving concept within medical healthcare and endovascular resuscitation. It involves early multidisciplinary evaluation and management of hemodynamically unstable patients with traumatic injuries as well as being a bridge to definitive treatment. It has recently been shown that the EVTM concept may also be applied to non-traumatic hemodynamically unstable patients.

<span class="mw-page-title-main">Resuscitative endovascular balloon occlusion of the aorta</span> Temporary procedure to support blood pressure and stem blood loss

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure performed during resuscitation of critically injured trauma patients. Originally developed as a less invasive alternative to emergency thoracotomy with aortic cross clamping, REBOA is performed to gain rapid control of non-compressible truncal or junctional hemorrhage. REBOA is performed first by achieving access to the common femoral artery (CFA) and advancing a catheter within the aorta. Upon successful catheter placement, an occluding balloon may be inflated either within the descending thoracic aorta (Zone 1) or infrarenal abdominal aorta (Zone 3). REBOA stanches downstream hemorrhage and improves cardiac index, cerebral perfusion, and coronary perfusion. Although REBOA does not eliminate the need for definitive hemorrhage control, it may serve as a temporizing measure during initial resuscitation. Despite the benefits of REBOA, there are significant local and systemic ischemic risks. Establishing standardized REBOA procedural indications and mitigating the risk of ischemic injury are topics of ongoing investigation. Although this technique has been successfully deployed in adult patients, it has not yet been studied in children.

<span class="mw-page-title-main">Hazim J. Safi</span> Physician

Hazim J. Safi, MD, FACS, is a physician and surgeon who is well-known for his research in the surgical treatment of aortic disease. Safi and his colleagues at Baylor College of Medicine were the first to identify variables associated with early death and postoperative complications in patients undergoing thoracoabdominal aortic operations. Safi now serves as professor of cardiothoracic surgery, and founding chair at McGovern Medical School at The University of Texas Health Science Center in Houston, TX.

References

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  3. 1 2 Plummer D, Petro K, Akbari C, O'Donnell S (2006). "Endovascular repair of traumatic thoracic aortic disruption". Perspectives in Vascular Surgery and Endovascular Therapy. 18 (2): 132–139. doi:10.1177/1531003506293453. PMID   17060230.
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  6. ↑ Rittenhouse EA, Dillard DH, Winterscheid LC, Merendino KA (1969). "Traumatic rupture of the thoracic aorta: a review of the literature and a report of five cases with attention to special problems in early surgical management". Ann. Surg. 170 (1): 87–100. doi:10.1097/00000658-196907000-00010. PMC   1387606 . PMID   5789533.
  7. ↑ McKnight JT, Meyer JA, Neville JF (1964). "Nonpenetrating Traumatic Rupture of the Thoracic Aorta". Ann. Surg. 160 (6): 1069–1072. doi:10.1097/00000658-196412000-00022. PMC   1408872 . PMID   14246145.
  8. ↑ Benjamin, Mina; Roberts (April 2012). "Fatal aortic rupture from nonpenetrating chest trauma". Baylor University Medical Center Proceedings. 25 (2): 121–123. doi:10.1080/08998280.2012.11928805. PMC   3310507 . PMID   22481840.
  9. 1 2 Tatco, Vincent. "Minimal aortic injury | Radiology Reference Article | Radiopaedia.org". radiopaedia.org. Retrieved 2018-04-02.
  10. ↑ Vloeberghs M, Duinslaeger M, Van den Brande P, Cham B, Welch W (1988). "Posttraumatic rupture of the thoracic aorta". Acta Chir. Belg. 88 (1): 33–38. PMID   3376665.
  11. ↑ Attar S, Cardarelli MG, Downing SW, et al. (1999). "Traumatic aortic rupture: Recent outcome with regard to neurologic deficit". Ann. Thorac. Surg. 67 (4): 959–64, discussion 964–5. doi: 10.1016/S0003-4975(99)00174-5 . PMID   10320235.
  12. ↑ Steinberg, Israel (1957-11-07). "Chronic Traumatic Aneurysm of the Thoracic Aorta". New England Journal of Medicine. 257 (19): 913–918. doi:10.1056/NEJM195711072571903. ISSN   0028-4793. PMID   13477411.
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