Trauma: Thoracic Vascular Trauma

Thoracic Vascular Injury

AAST Thoracic Vascular Injury Scale

Basics

  • Thoracic Vascular Injury Causes 50% of All Trauma Deaths
  • Most Common Large Vessel Injury:
    • Stab Wound: Ascending Aorta
    • GSW: Descending Aorta
    • Blunt: Aortic Isthmus (Just Beyond Left Subclavian Takeoff)
  • Postoperative Paraplegia Incidence:
    • Open Surgery: 8%
    • Endovascular: 1%

Blunt Aortic Injury (BAI)

  • Vancouver Classification:
    • Grade I: Intimal Flap, Thrombus or Intramural Hematoma < 1 cm
    • Grade II: Intimal Flap, Thrombus or Intramural Hematoma ≥ 1 cm
    • Grade III: Pseudoaneurysm without Contrast Extravasation
    • Grade IV: Free Rupture with Contrast Extravasation
  • Thoracic Aorta Transection
    • Cause: Rapid Deceleration
    • Highest Risk Sign: 1st/2nd Rib Fracture
    • Most Common Site: Ligamentum Arteriosum
  • Dx: CXR, Then CTA (If Stable)
  • Tx:
    • Grade I: Anti-Impulse Control
      • Goal SBP ≤ 100 mmHg
      • Goal HR ≤ 100
    • Grade II-IV: Repair
      • Stable:
        • Ascending or Arch: Open Repair
        • Descending: TEVAR (Thoracic Endovascular Aortic Repair)
          • Vs Open Repair – Lower Mortality, Blood Loss & Paraplegia Risk
          • May Require Coverage of Left Subclavian Depending on Location
      • Unstable: Open Repair

CXR Findings Suggestive of Vascular Injury

  • Indistinct Aortic Knob
  • Wide Mediastinum > 8 cm
  • Left Main Bronchus Depression > 140 Degrees
  • Deviation of NG/ET Tubes to the Right
  • Massive Hemothorax

Vancouver Classification of BAI 1

Aortic Pseudoaneurysm 2

BAI CXR (Indistinct Aortic Knob & Widened Mediastinum) 3

Injury Management

  • Great Vessels:
    • Endovascular vs Surgical Repair (Primary Repair or Bypass-Exclusion with Graft)
    • Consider Subclavian Ligation in Damage Control
  • Vertebral Artery Access:
    • Segment V1 (Pre-Foraminal) – Subclavian Incision
    • Segments V2-4 – Require Neurosurgery or Endovascular Repair
  • Azygous Vein: Primary Repair vs Ligation
  • Internal Mammary Artery: Ligation
  • Thoracic Duct: Ligation

Great Vessel Arterial Exposure

Bullet Embolism

  • Large Diameter of Thoracic Vessels Enables Bullets to Lodge & Migrate Distally
  • Most Commonly Lodge in Iliac or Femoral Arteries
  • Tx: First Control Thoracic Bleeding Then Bullet Embolectomy

Bullet Embolism CT 5

Bullet Embolism Angio 5

References

  1. Forcillo J, Philie M, Ojanguren A, Le Guillan S, Verdant A, Demers P, Lamarche Y. Outcomes of Traumatic Aortic Injury in a Primary Open Surgical Approach Paradigm. Trauma Mon. 2015 May;20(2):e18198. (License: CC BY-NC-4.0)
  2. Chen C, Schuster K, Bhattacharya B. Motor vehicle collision patient with simultaneous duodenal transection and thoracic aorta injury: a case report and review of the literature. Case Rep Surg. 2015;2015:519836. (License: CC BY-3.0)
  3. Alameddine AK, Alimov VK, Alvarez C, Rousou JA. Unexpected traumatic rupture of left atrium mimicking aortic rupture. J Emerg Trauma Shock. 2014 Oct;7(4):310-2. (License: CC BY-NC-SA-3.0)
  4. Anatomography. (License: CC BY-SA-2.1 JP)
  5. Huang J, Pandey V, Shah R, Yedavalli V, Joshi A, Stimpson R, Keldahl M, Zuiderveld L. Popliteal artery embolism of bullet after abdominal gunshot wound. Radiol Case Rep. 2016 Nov 2;11(4):282-286. (License: CC BY-NC-ND-4.0)