Aortic trauma

AORTIC TRAUMA Aorta can be injured in variety of accidents or trauma. A piercing or penetrating injury by a sharp object can directly injure the aorta in the thorax or abdomen. These injuries are often instantly fatal due to severe bleeding.

More commonly aorta is injured in blunt trauma especially in high velocity deceleration accidents. Typically the person is thrown from a speeding bike and comes crashing. The relatively fixed part of aorta (close to the position of ligamentum arteriosum) takes the brunt of impact. So commonest site of injury in these injuries is opposite the left subclavian artery. Aorta may be sustain partial tear of intima and/or media or a complete tear. The complete tear is a devastating injury accounting for heavy mortality- 20% of victims die before reaching medical facility. Untreated another 10% die every hour following injury. Needless to say, this is a true surgical emergency. Sometimes the extensive traumatic dissection can cause malperfusion of the visceral vessels or intercostals. Bleeding into the chest can severe enough to cause hypotension and shock.

DIAGNOSIS:

Blunt chest trauma or decelerating injury is an indication for CT scan of chest with contrast. Apart from identifying the bony or soft tissue injuries, it can clearly demonstrate vascular trauma including aortic tears.

TREATMENT:

Once the CT scan is done the extent and severity of aortic injury becomes clear. Depending on the type of injury the treatment varies. A small hematoma on the aortic wall may be left alone. Even a small tear in the aortic intima (inner layer of aorta) may be treated conservatively with caution and rigorous follow up. However, more serious injuries need definitive treatment. A full thickness tear in the aortic wall is a potentially fatal injury. If the bleeding continues. the victim may develop hypovolemic (low blood volume in the circulation) shock. Large volume of blood can get collected in the thoracic cavity. Often after the initial bleed, the blood clot in the vicinity of injury prevents further bleeding. In these circumstances proper treatment can save the person fig(1).

There are two types of definitive treatment. Open Surgery and Endovascular Stenting. In open surgery, the injured part of aorta is replaced with artificial tubes or prosthetic grafts made of PTFE, Dacron or Polyester fig(2).

In Endovascular procedures, a folded tube with a self-expanding stent in inserted into the aorta from the femoral artery (Groin) and expanded inside the injured portion to seal the area and prevent bleeding. Sometimes a HYBRID technique is employed. ie., a combination of surgery and Endovascular procedure (fig 3)

FOLLOW UP: It is important to keep a close watch on these patients and get a CT aortogram at 3 and 12 months

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