eMedicine Specialties > Radiology > Vascular/Interventional

Aorta, Trauma

Author: Evan J Samett, MD, Consulting Staff, Department of Radiology, MacNeal Hospital
Contributor Information and Disclosures

Updated: Jul 17, 2009

Introduction

Background

Traumatic aortic disruption is a time-sensitive injury requiring rapid and accurate diagnosis to prevent death. Although the clinical, or mechanism, score is of primary importance in the prompt diagnosis of patients with traumatic aortic injury (TAI), the radiologic findings play a vital supportive role.

Aorta, trauma. Left anterior oblique (45°) a...

Aorta, trauma. Left anterior oblique (45°) angiogram shows aortic disruption at the aortic isthmus. An irregular outpouching is present with an intimal flap and an angular transition that represents a contained disruption at the isthmus. This appearance is in contrast to the otherwise normal-appearing vessels.

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Aorta, trauma. Left anterior oblique (45°) a...

Aorta, trauma. Left anterior oblique (45°) angiogram shows aortic disruption at the aortic isthmus. An irregular outpouching is present with an intimal flap and an angular transition that represents a contained disruption at the isthmus. This appearance is in contrast to the otherwise normal-appearing vessels.


TAI syndrome is initially characterized by contained rupture (pseudoaneurysm), which is relatively clinically silent. After a variable period of time, contained rupture is followed by a rapid transition to free, uncontained pseudoaneurysm rupture, exsanguination, and death. The clinical challenges are to rapidly stabilize and evacuate the patient to a level I trauma center for evaluation, diagnosis, and definitive treatment before free rupture occurs.

Frequency

United States

Historically, traumatic aortic injury (TAI) has been reported to occur in 10-20% of persons who incur blunt aortic trauma (BAT). For example, investigators from the Medical College of Wisconsin (unpublished data, 1990) performed a retrospective review of 181 consecutive patients with BAT from January 1986 through August 1990. The patients underwent angiography, for which the yield for TAI was 17%.  Locations of TAI were as follows: isthmus, 23 (74%) of 31 (circumferential artery, 16 [52%] and anteromedial artery, 7 [23%]); innominate artery, 4 (13%); subclavian artery, 1 (3%); undersurface of the arch, 1 (3%); and other, 10 (32%).

The distribution of posttraumatic aortic pseudoaneurysms in the classic surgical literature differs from that in the pathology (autopsy) literature. These differences are likely due to differences in survival rates with injuries in various locations. Locations of TAI, as reported by Parmley et al in a 1958 review of 171 cases, are as follows: ascending aorta, 9.9%; arch, 9.4%; isthmus, 55.6%; thoracic aorta, 15.8%; abdominal aorta 6.4%; and multiple locations, 2.9%.1 Locations of TAI, as reported by Kadir in 1986, are as follows: ascending aorta, 1%; innominate artery, 4.5%; left common carotid artery, 0.8%; left subclavian artery, 2.7%; aortic isthmus, 88.2%; descending aorta, 1.8%; and aortic hiatus (diaphragm level), 0.4%.2 Abdominal aortic TAI is extremely rare, with only 46 cases reported as of 1990.

Traditional clinical series report TAI to occur at the aortic isthmus in 95% of patients surviving long enough to undergo surgery, versus 45-66% found in autopsy studies. The speed and efficiency of the trauma response system affects the overall survival rate and distribution of the rupture.

Mortality/Morbidity

Traumatic aortic rupture is an extremely unstable condition. The patient's survival depends on rapid diagnosis and treatment. The development of regional trauma centers and rapid patient transport has dramatically improved survival rates.3

  • In 1958, Parmley et al reported that 85% of patients with aortic injury died prior to reaching hospital and that their survival was dependent on the time from injury to surgery. Although some traumatic aortic pseudoaneurysms stabilize, mortality continues if the injury remains untreated. Of the subset of patients surviving at least 1 hour, death rates from TAI varied with the time until surgery, as follows1 : 15% with an interval of 6 hours; 27%, 24 hours; 61%, 1 week; and 88%, 4 months.
  • In 1976, Kirsh et al reported a survival rate of approximately 70% with prompt and aggressive treatment.4
  • In 1997, Fabian et al reported a 31% mortality rate in 274 patients (207 were operated on) who presented to the hospital with TAI.5 Approximately two thirds of deaths were due to the aortic rupture, and the rest were due to associated injuries.

Race

No race-related difference in anatomy or physiology causes a predisposition to traumatic aortic injury (TAI). Differences in the incidence of TAI are strictly due to the likelihood of severe blunt injury.

Sex

No sex-related difference in anatomy or physiology causes a predisposition to traumatic aortic injury (TAI). Differences in the incidence of TAI are strictly due to the likelihood of severe blunt injury.

Age

TAI is essentially an entity of the adult. Pediatric cases are extremely rare.

Presentation

Anatomy

The Goodman classification describes the contour of the aortic isthmus as follows6 :

  • Type I: concave
  • Type II: mild straightening or convexity without a discrete bulge 
  • Type III: a discrete focal bulge of the aortic isthmus, called the ductus diverticulum.

Ductus diverticulum is commonly thought of as the remnant of the ductus arteriosum, although Grollman theorized that the ductus is a remnant of the right dorsal aortic root.7 The aortic isthmus is located anteromedially, just distal to the origin of the left subclavian artery. This is also the most common site of rupture. For that reason, differentiating a traumatic pseudoaneurysm at the aortic isthmus from a normal ductus diverticulum (type III ductus) is the most common diagnostic challenge in traumatic aortic injury (TAI). Smooth anteromedial outpouching of the aortic isthmus represents the normal ductus diverticulum and should not be confused with a pseudoaneurysm.



Aorta, trauma. Left anterior oblique angiogram (L...

Aorta, trauma. Left anterior oblique angiogram (LAO) shows the typical appearance of the normal ductus diverticulum. The smooth walls and transition would be better delineated on a steep LAO or lateral view (not shown).

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Aorta, trauma. Left anterior oblique angiogram (L...

Aorta, trauma. Left anterior oblique angiogram (LAO) shows the typical appearance of the normal ductus diverticulum. The smooth walls and transition would be better delineated on a steep LAO or lateral view (not shown).


Another normal variant is a fusiform enlargement or prominence of the proximal descending aorta (see Images 39 and 40). It is considered normal unless other findings of TAI are present.

Pathophysiology

 Blunt aortic injury is part of the spectrum of blunt or deceleration polytrauma. The major regions of concern in the thorax are the heart, major vessels, abdominal organs, neck, spine, and aerodigestive tract. Penetrating injury (eg, stabbing or gunshot injury) is a different clinical entity from blunt or deceleration trauma.

Blunt or deceleration injury to the aorta is mostly confined to the thoracic aorta, except in the seat-belt injury, which involves the abdominal aorta. The radiologic evaluation must be as accurate as possible, because thoracotomy entails a significant risk but a missed diagnosis is life threatening.

For this discussion, aortic rupture or disruption includes the aorta, the proximal portion of the great vessels, and the sinuses of Valsalva. The most common location for TAI is at the isthmus, just beyond the origins of the great vessels. In decreasing order of frequency, other locations are the descending thoracic aorta, the ascending aorta, the aortic arch, and the abdominal aorta. Ruptures at the aortic hiatus (diaphragm level) are less common. Competing theories of the mechanism of TAI have been proposed. Suffice it to say that the deceleration or crush forces interact with the asymmetric aortic fixation, and the resulting translational and rotational forces cause aortic injury.

Pathologically, an aortic tear is usually transverse and involves the layers of the aorta to varying degrees. A complete tear through the intima, media, and adventitia usually leads to rapid exsanguination and death. In aortic rupture survivors, the pseudoaneurysm is contained by the adventitia and occasionally the mediastinal structures. Blunt aortic trauma (BAT) is usually the result of a crush or deceleration injury, which often occurs during a motor vehicle accident or a fall from substantial height. Clinical evaluation and triage are vital to the patient's survival. The severity, likelihood, and clinical impact of potential injuries must be considered in the context of the patient's polytrauma as a whole.

Clinical manifestations

 The clinical signs and symptoms associated with TAI are nonspecific and for the most part indirect. The exception is the rapid onset of severe hypovolemic shock associated with a free (noncontained) aortic rupture. The signs and symptoms of contained TAI are more related to the associated injuries of polytrauma, such as fractures and spinal cord and head injury. Some centers use criteria such as trauma mechanism or visible steering wheel injury in their polytrauma protocols. Fortunately, the evaluation for TAI is fairly easily incorporated into trauma center workflow.

Preferred Examination

Plain radiography is usually the first test to be performed. CT and angiography are the prime imaging modalities in planning treatment for blunt trauma. Nevertheless, the choice and timing of plain radiography, CT, and/or angiography must be considered in context of the patient's condition as a whole. The integrity of the airway, cardiovascular system, and spinal cord must be addressed before a potential blunt aortic injury is considered. Splenic or aortic disruption must be considered in patients with blunt trauma who present in hypovolemic shock.

As yet, no ideal diagnostic algorithm is available for traumatic aortic injury (TAI). The clinical history (mechanism score) is often used for the prompt diagnosis of TAI. Again, plain radiography is usually the first imaging study. The optimal upright posteroanterior (PA) chest evaluation is often deferred for a portable examination with the patient still on the backboard.

The choice between CT and angiography may depend on institutional preferences, the patient's condition, and the likelihood of other injuries. For example, a patient with hemorrhage from a crushed pelvis would undergo angiography first, whereas a hemodynamically stable patient with a suspected renal or splenic injury would undergo CT first. Diagnostic imaging should be deferred in patients presenting in hypovolemic shock or cardiac arrest. Advanced (64 slice and greater) spiral CT can produce near-angiographic quality images, and when available, it should be considered the diagnostic procedure of choice for TAI. Angiography is appropriate in cases where endovascular intervention (eg, stent-graft) is contemplated.

Except for cases involving exsanguinating hemorrhage from a pelvic fracture, angiography has no role in the early treatment of a patient with polytrauma who is in unstable condition. MRI generally has no role in the acute evaluation of polytrauma. Some centers advocate the early use of transesophageal echography, which is beyond the scope of this discussion.

Differential Diagnoses

Abdominal Aortic Aneurysm, Diagnosis
Abdominal Aortic Aneurysm, Rupture
Aorta, Coarctation
Aorta, Dissection
Aortic Regurgitation
Aortic Stenosis

Other Problems to Be Considered

Atherosclerosis

Bronchial and/or intercostal artery

Ductus diverticulum

Normal fusiform dilation of isthmus

Polytrauma: Spinal cord injury; bleeding; behavioral change; renal failure; and tracheobronchial tree, heart, and/or pericardial injuries

More on Aorta, Trauma

Overview: Aorta, Trauma
Imaging: Aorta, Trauma
Follow-up: Aorta, Trauma
Multimedia: Aorta, Trauma
References
Further Reading
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Keywords

aorta trauma, aortic trauma, traumatic aortic rupture, traumatic aortic transection, traumatic aortic disruption, TAI, traumatic aortic injury, BAT, blunt aortic trauma

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Contributor Information and Disclosures

Author

Evan J Samett, MD, Consulting Staff, Department of Radiology, MacNeal Hospital
Evan J Samett, MD is a member of the following medical societies: American College of Radiology and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Gary P Siskin, MD, Associate Professor, Department of Radiology, Albany Medical College; Chief, Division of Vascular and Interventional Radiology, Department of Radiology, Albany Medical Center
Gary P Siskin, MD is a member of the following medical societies: American Heart Association and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

John D Newell, Jr, MD, FACR, FCCP, FASER, Co-Director of Thoracic Imaging, UCDHSC; Director of Lung Imaging Center, Professor of Radiology and Professor of Medicine, Department of Radiology, University of Colorado Health Sciences Center, National Jewish Medical and Research Center; Univ. Colorado Hospital
John D Newell, Jr, MD, FACR, FCCP, FASER is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, American Thoracic Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Siemens Medical Grant/research funds Consulting; Forevision Technologies Ownership interest Consulting; Vida Corporation Ownership interest Board membership; TeraRecon Grant/research funds Consulting; eMedicine Honoraria Consulting

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR, William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System
Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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