Traumatic Aortic Disruption

Snapshot

• A 22-year-old man presents to the emergency department after a high-speed motor vehicle accident. He was in the passenger seat and was wearing a seatbelt. The patient reports chest pain with breathing difficulty. Vital signs are significant for a blood pressure of 135/95 mmHg and a pulse of 105/min. On physical exam, the patient is stable with a seatbelt imprint on the skin of his chest. An anteroposterior radiograph of the chest demonstrates an obscured aortic knob. Preparations are made to get a contrast-enhanced CT scan of the chest and trauma surgery is consulted. 

Introduction

• Definition
  • blunt thoracic aortic injury
• Pathophysiology
  • typically results from rapid deceleration, which is seen in 
    • high-speed motor vehicle accidents (majority of cases)
    • falls from a significant height
• Anatomy
  • aortic isthmus (most commonly affected) 
    • distal to the left subclavian artery
• this is the transition zone of a relatively more mobile ascending aorta and arch to the descending thoracic aortic, which is relatively fixed

Presentation

• Symptoms
  • chest pain
  • intrascapular pain
  • breathing difficulty or swallowing
• Physical exam
  • steering wheel or seatbelt imprint on the skin surface
  • left subclavian hematoma
  • new interscapular murmur
  • may find
    • pseudocoarctation (upper extremity hypertension)
• absent bilateral femoral pulses

Imaging

• Plain anteroposterior chest radiograph
  • indication
    • initial imaging of choice
  • findings
    • widened mediastinum
    • abnormal aortic arch contour
    • abnormal aortic knob
    • tracheal deviation
• Tracheoesophageal echocardiography
  • indication
    • in hemodynamically unstable patients
• Contrast-enhanced chest CT
  • indication
• in hemodynamically stable patients

Treatment

• Operative
  • aortic repair
    • indication
      • definitive treatment