Section Menu  

Blunt Aortic Injury, Diagnosis and Management of

Archived PMG

Published 2000
Citation: J Trauma. 48(6)1128-11443, June 2000.

Download

Authors

EAST Practice Management Guidelines Workgroup

Kimberly Nagy, MD, Dept. of Trauma, Cook County Hospital, Chicago, IL
Timothy Fabian, MD, Dept. of Surgery, University of Tennessee, Memphis, TN
George Rodman, MD, Dept. of Surgery, Methodist Hospital, Indianapolis, IN
Gerard Fulda, MD, Dept. of Surgery, Medical Center of Delaware, Newark, DE
Aurelio Rodriguez, MD, Dept. of Surgery, Allegheny General Hospital, Pittsburgh, PA
Stuart Mirvis, MD, Dept. of Radiology, University of Maryland, Baltimore, MD

Correspondence to:

Kimberly Nagy, MD FACS
Trauma; M3241
1835 W. Harrison
Chicago, IL 60612
312-633-8075
312-633-7540 (fax)
knagy@rush.edu

I. Statement of the Problem

Blunt injury to the aorta (BAI) is responsible for approximately 8000 deaths each year in the United States. This injury most commonly results from motor vehicle collisions but may also result from pedestrian mishaps, falls from height, and crushing thoracic injuries. The majority of patients who sustain BAI die at the scene. The patients who reach the hospital alive have a reasonably good expectation of survival providing their BAI is diagnosed and treated in a timely manner. These patients are often multiply injured which complicates their diagnosis and treatment. In addition, operative management may result in complications such as paraplegia and acute renal failure. No single center has a large amount of experience with this injury, therefore it is important to consider all of the available data when coming to conclusions regarding the best method of diagnosis and treatment of BAI.

II. Process

A. Identification of references

A Medline search was performed for the years 1966–1997. All English language citations with the subject words “Thoracic Aorta” and “Wounds, non-penetrating” were retrieved. Letters to the editor, isolated case reports, animal studies, meta-analyses and review articles were deleted from further review. The bibliography sections of review articles and meta-analyses were used, however to identify additional references not retrieved with the Medline search. This process resulted in 137 articles which were reviewed by a group consisting of trauma surgeons, thoracic surgeons and a trauma radiologist. This group collaborated to produce the above recommendations and the following evidentiary table.

B. Quality of the references

The quality assessment instrument applied to the references was that developed by the Brain Trauma Foundation and subsequently adopted by the EAST Practice Management Guidelines Committee. Articles were classified as Class I, II or III according to the following definitions:

Class I: A prospective randomized clinical trial. There were no Class I articles reviewed.
Class II: A prospective noncomparative clinical study or a retrospective analysis based on reliable data.
Class III: A retrospective case series or database review.

III. Recommendations

The level of the following recommendations corresponds roughly to the class of references which support it.

A. Level I

There is insufficient evidence to support a standard of care on this topic.

B. Level II

  1. The possibility of a blunt aortic injury should be considered in all patients who are involved in a motor vehicle collision, regardless of the direction of impact.
  2. The chest x-ray is a good screening tool for determining the need for further investigation. The most significant chest x-ray findings include (but are not limited to): widened mediastinum, obscured aortic knob, deviation of the left mainstem bronchus or naso-gastric tube, and opacification of the aorto¬pulmonary window.
  3. Angiography is a very sensitive, specific and accurate test for the presence of blunt aortic injury. It is the standard by which most other diagnostic tests are compared.
  4. Computed Tomography of the chest is a useful diagnostic tool for both screening and diagnosis of blunt aortic injury. Spiral or Helical CT scanners have an extremely high negative predictive value and may be used alone to rule out blunt aortic injury. When these scanners are used, angiography may be reserved for patients with indeterminate scans.
  5. Prompt repair of the blunt aortic injury is preferred. If the patient has more immediately life-threatening injuries that require intervention such as emergent laparotomy or craniotomy, or if the patient is a poor operative candidate due to age or comorbidities, the aortic repair may be delayed. Medical control of blood pressure is advised until surgical repair can be accomplished.

C. Level III

  1. The presence of physical findings such as pseudocoarctation or intrascapular murmur should be investigated further.
  2. Trans-esophageal echocardiography is also a sensitive and specific test. There are several limitations to this test. It does require training and expertise which may not be as readily available as angiography.
  3. Repair of the aortic injury is best accomplished with some method of distal perfusion, either bypass or shunt. Neurologic complications appear to correlate with ischemia time, therefore this time should be kept to a minimum.

IV. Scientific Foundation

Blunt aortic injury (BAI) is the second most common cause of death in blunt trauma patients[2]. The majority of patients die at the scene with only 13-15% arriving at the hospital with signs of life[2][141]. The remainder of patients will die within the first few days of hospitalization if the BAI is not promptly diagnosed and treated[2].

The most common mechanism of BAI appears to be from a motor vehicle collision with frontal and lateral impacts occurring with approximately equal frequency[5][15]. The presence or absence of restraints does not appear to affect the incidence of BAI[147]. Other common mechanisms include pedestrian/vehicular incidents and falls[145]. Most patients who sustain BAI die at the scene or during transport. Of the patients who arrive alive to the hospital, there are many varied signs and symptoms they may present with. The most commonly noted signs in these patients are pseudocoarctation and intrascapular murmur[17][24][28][36]. Absence of any of these signs does not entirely rule out BAI, as it has been reported with a normal physical examination[22][23].

The chest radiograph (CXR) has been studied extensively as a screening test. There is some evidence that an erect postero-anterior view is better than a supine antero¬posterior view[25]. A widened mediastinum has been the most frequently cited CXR finding which triggers additional work-up for BAI[1][2][14][20][22][24][26]. The widened mediastinum may be defined as a measured width greater than 8 cm.[11][21][24][35], a mediastinal/chest width ratio of >0.38[11] or simply the physician’s impression that the mediastinum is widened[3][20]. Mediastinal abnormalities on the CXR which are considered strongly suggestive of BAI include: an obscure or indistinct aortic knob[1][3][13][14][25][27][30][34][35], depression of the left mainstem bronchus[6], deviation of the nasogastric tube[6][19] and opacification of the aorto-pulmonary window[1][4][25][30][35], Other commonly seen CXR findings include: widened paratracheal and paraspinous stripes[4][12][25][30] and apical capping[1]. Findings such as pneumothorax and hemothorax are very nonspecific[20] and there appears to be a negative association with fractures of the thoracic skeleton[19][20][36]. Although less likely, it is possible for BAI to occur in the face of a normal CXR, therefore patients with significant deceleration or acceleration mechanisms should undergo a screening test anyway[7][10].

Angiography has been used as the “gold standard” diagnostic test for BAI[41–43] . It is the test to which all others are compared. There is a small incidence of false positive angiograms resulting from anatomic abnormalities such as ductus diverticulum42 that the physician should be aware of. Various techniques have been studied in an attempt to reduce the required dye load. These include intravenous and intraarterial digital subtraction angiography[39][40][43][138], and there is some evidence that IA-DSA is as accurate as conventional angiography.

Computed tomography of the chest (CTC) appears to be a very useful diagnostic tool[44][48]. It’s use ranges from the screening of all patients with blunt chest trauma[37][61][62], to studying only those patients with a normal or low suspicion CXR[47][50–52]. If the CTC is performed with a conventional scanner, most authors recommend following an abnormal CTC with angiography[47][50][54]. A potential problem with the CTC is that it may delay the time to angiography, and thus to a definitive diagnosis[57]. This problem is resolved with newer generation scanners such as helical or spiral CT scanners. They are more sensitive[45][139], and appear to have 100% negative predictive value[50][143][144]. When helical or spiral CTC is used, angiography may be reserved for those patients with equivocal or indeterminate scans as there is more anatomic detail present on the angiogram[143][144].

Trans-esophageal echocardiography (TEE) has gotten a lot of attention in the past 6 years. It is also a very sensitive screening test[10][63][65][67][70][71] but many authors also follow an abnormal TEE with angiography[64][68][72]. Unfortunately, TEE requires specific training and expertise[140] and may not be as readily available as CTC or angiography. It’s usefulness may lie in the ability to follow small intimal injuries which are not seen on angiography[63] or for diagnosis in the patient too unstable to move to the angiography suite66. TEE does not visualize the ascending aorta or the aortic branches well and may miss injuries to these vessels[73][74].

Once the diagnosis of BAI is made, most authors agree that prompt surgical repair is the best approach[2][28][80][83]. Immediate repair may not be possible in all patients, however. These include patients who are unstable from intra-abdominal injuries who require laparotomy or patients with severe closed head injuries who require craniotomies[76][84][86]. Another subset of patients are those who are elderly or have comorbidities which prohibit emergency thoracic surgery[77][81][149]. These patients may be safely managed medically until these other factors have been resolved[143]. Pharmacologic control of blood pressure with beta-blockers or nitroprusside is extremely important when delayed or non-operative management is contemplated[78][79][82][88][91][143]. The use of specialized monitoring devices such as a pulmonary artery catheter may be useful, especially in the patient who has sustained a significant blunt cardiac injury as well[85]. Delay in repair of BAI may result in a longer length of stay and potentially an increased incidence of nosocomial infections[150].

Several different techniques of repairing the BAI have been reported. These include both direct suture repair[115][122] and placement of a prosthetic graft[128]. A recent report of endoluminal stenting of a BAI shows promise toward minimally invasive therapy[152]. The most feared complications of BAI repair are paraplegia and renal failure both of which result from ischemia during the repair. Ischemic complications correlate with the time the aorta is clamped[2][102][106][114]. In addition, there are more metabolic derangements resulting from reperfusion when the clamp and sew method is employed[124]. The clamp and sew method may be best left to the more experienced surgeons[151][155]. Various methods of distal perfusion ranging from heparin-bonded (Gott) shunts[78][79][90][96][109][127] to partial or full cardiac bypass with and without systemic heparinization[55][98][99][103][105][114][116][118][128][130][133][153][154] have been shown to be helpful in minimizing distal ischemia. Although there is a theoretical risk of increased bleeding from head or abdominal injuries with systemic heparinization, Pate[116] found no increase in hemorrhage in his series. These methods should be employed in all patients or at least in those patients in whom a prolonged clamp time is anticipated[2][97][107]. Other protective measures such as hypothermia may also be helpful[94][98]. A dedicated thoracic surgeon may be best qualified to repair BAI[92] although Kim[108] feels that full-time trauma surgeons have equally good results. Close communication between the surgical and anesthesia teams is essential[104][124].

V. Summary

In summary, blunt aortic injury is a lethal result of severe blunt trauma. It should be considered in all patient with a deceleration or acceleration mechanism, especially in the face of physical or radiographic findings suggestive of mediastinal injury. Angiography remains the “gold standard” for diagnosis, although CT scanning is taking more of a role, especially for screening. Diagnosis should be followed by prompt surgical repair utilizing some method of distal perfusion to minimize renal and spinal cord ischemia. If prompt repair is not feasible due to other injuries or comorbidities, medical control of blood pressure is warranted in the interim.

VI. Future Investigation

Less invasive diagnostic testing should be investigated as it becomes available in a prospective fashion. In addition, the optimal method of distal perfusion during surgical repair should also be investigated in a prospective fashion. As the number of patients who actually survive to surgery is relatively small, this may best be accomplished through a multi-center trial.

References

  1. 1. Dalldorf PG, McCarthy MC, Tarver RD, et al.: Traumatic rupture of the aorta: Indications for aortography. Am Surg: 56; 500–3.
  2. Fabian TC, Richardson JD, Croce MA, et al.: Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma 1997: 42; 374–80.
  3. Gundry SR, Burney RE, MacKenzie JR, et al.: Assessment of Mediastinal Widening associated with Traumatic Rupture of the Aorta. J Trauma 1983: 23; 293–9.
  4. Heystraten FM, Rosenbusch G, Kingma LM, et al.: Chest radiography in acute traumatic rupture of the thoracic aorta. Acta Radiol 1988: 29; 411–7.
  5. 5. Katyal D, McLellan BA, Brenneman FD, et al.: lateral impact motor vehicle collisions: significant cause of blunt traumatic rupture of the thoracic aorta. J Trauma 1997: 42; 769–72.
  6. Marnocha KE and Maglinte DD: Plain-film criteria for excluding aortic rupture in blunt chest trauma. Am J Roentgen 1985: 144; 19–21.
  7. Marsh DG and Sturm JT: Traumatic aortic rupture: roentgenographic indications for angiography. Ann Thorac Surg 1976: 21; 337–40.
  8. Plewa MC, Stavros M, Boorstein JM and Weaver E: Cervical prevertebral soft-tissue measurements and chest radiographic findings in acute traumatic aortic injury. Am J Emerg Med 1997: 15; 256–9.
  9. Shackford SR, Virgilio RW, Smith DE, et al.: The significance of chest wall injury in the diagnosis of traumatic aneurysms of the thoracic aorta. J Trauma 1978: 18; 493–7.
  10. Vignon P, Lagrange P, Boncoeur MP, et al.: Routine Transesophageal echocardiography for the diagnosis of aortic disruption in trauma patients without enlarged mediastinum. J Trauma 1996: 40; 422–7.
  11. Woodring JH and King JG: Determination of normal transverse mediastinal width and mediastinal-width to chest-width (M/C) ratio in control subjects: implications for subjects with aortic or brachiocephalic arterial injury. J Trauma 1989: 29; 1268–72.
  12. Woodring JH, Pulmano CM and Stevens RK: The right paratracheal stripe in blunt chest trauma. Radiology 1982: 143; 605–8.
  13. Ayella RJ, Hankins JR, Turney SZ and Cowley RA: Ruptured thoracic aorta due to blunt trauma. J Trauma 1977: 17; 199–205.
  14. Barcia TC and Livioni JP: Indications for angiography in blunt thoracic trauma. Radiology 1983: 147; 15–9.
  15. Ben-Menachem Y: Rupture of the thoracic aorta by broadside impacts in road traffic and other collisions: further angiographic observations and preliminary autopsy findings. J Trauma 1993: 35; 363–7.
  16. Clark DE, Zeiger MA, Wallace KL, et al.: Blunt aortic trauma: signs of high risk. J Trauma 1990: 30; 701–5.
  17. DeMeules JE, Cramer G and Perry JF: Rupture of aorta and great vessels due to blunt thoracic trauma. J Thorac Cardiovasc Surg 1971: 61; 438–42.
  18. Feczko JD, Lynch L, Pless JE, et al.: An autopsy case review of 142 nonpenetrating (blunt) injuries of the aorta. J Trauma 1992: 33; 846–9.
  19. Gerlock AJ, Muhletaler CA, Coulam CM and Hayes PT: Traumatic aortic aneurysm: validity of esophageal tube displacement sign. Am J Roentgen 1980: 135; 713–8.
  20. Gundry SR, Williams S, Burney RE et al.: Indications for aortography in blunt thoracic trauma: a reassessment. J Trauma 1982: 22; 664–71.
  21. Kram HB, Wohlmuth DA, Appel PL and Shoemaker WC: Clinical and radiographic indications for aortography in blunt chest trauma. J Vasc Surg 1987: 6; 168–76.
  22. Kram HB, Appel PL, Wohlmuth DA and Shoemaker WC: Diagnosis of traumatic thoracic aortic rupture: a 10-year retrospective analysis. Ann Thorac Surg 1989: 47; 282–6.
  23. Lee J, Harris JH, Duke JW and Williams JS: Noncorrelation between thoracic skeletal injuries and acute traumatic aortic tear. J Trauma 1997: 43; 400–4.
  24. Mattox KL, Pickard L, Allen MK and Garcia-Rinaldi R: Suspecting thoracic aortic transection. JACEP 1978: 7; 12–5.
  25. Mirvis SE, Bidwell JK, Buddemeyer EU, et al.: Value of chest radiography in excluding traumatic aortic rupture. Radiology 1987: 163; 487–93.
  26. Pastershank SP and Chow KC: Blunt trauma to the aorta and its major branches. J Can Assoc Radiol 1974: 25; 202–10.
  27. Petty SM, Parker LS, Mauro MA, et al.: Chronic posttraumatic aortic pseudoaneurysm: Recognition before rupture. Postgrad Med 1991: 89; 173–8.
  28. Richardson RL, Khandekar A and Moseley PW: Traumatic rupture of the thoracic aorta. South Med J 1979: 72 300–1.
  29. Richardson JD, Wilson ME and Miller FB: The widened mediastinum. Diagnostic and therapeutic priorities. Ann Surg 1990: 211; 731–6.
  30. Shaikh KA, Schwab CW and Camishion RC: Aortic Rupture in blunt trauma. Am Surg 1986: 52; 47-8.
  31. Smith RS and Chang FC: Traumatic rupture of the aorta: Still a lethal injury. Am J Surg 1986: 152; 660–663.
  32. Spouge AR, Burrows PE, Armstrong D and Daneman A: Traumatic aortic rupture in the pediatric population. Role of plain film, CT and angiography in the diagnosis. Pediatr Radiol 1991: 21; 324–8.
  33. Sturm JT, Perry JF, Olson FR and Cicero JJ: Significance of symptoms and signs in patients with traumatic aortic rupture. Ann Emerg Med 1984: 13; 876–8.
  34. Sturm JT, Marsh DG and Bodily KC: Ruptured thoracic aorta: evolving radiological concepts. Surgery 1979: 85; 363–367.
  35. Sturm JT, Olson FR and Cicero JJ: Chest roentgenographic findings in 26 patients with traumatic rupture of the thoracic aorta. Ann Emerg Med 1983: 12; 598–600.
  36. Trachiotis GD, Sell JE, Pearson GD, et al.: Traumatic thoracic aortic rupture in the pediatric patient. Ann Thorac Surg 1996: 62; 724–31.
  37. Vloeberghs M, Duinslaeger M, Van den Brande P, et al.: Posttraumatic rupture of the thoracic aorta. Acta Chir Belg 1988: 88; 33–8.
  38. Woodring JH and King JG: The potential effects of radiographic criteria to exclude aortography in patients with blunt chest trauma. Results of a study of 32 patients with proved aortic or brachiocephalic arterial injury. J Thoracic CV Surg1989: 97; 456–60.
  39. Mirvis SE, Pais SO and Gens DR: Thoracic aortic rupture: advantages of intraarterial digital subtraction angiography. Am J Roentgen 1986: 146; 987–91.
  40. Eddy AC, Nance DR, Goldman MA, et al.: Rapid diagnosis of thoracic aortic transection using intravenous digital subtraction angiography. Am J Surg 1990: 159; 500–3.
  41. Sturm JT, Hankins DG and Young G: Thoracic aortography following blunt chest trauma. Am J Emerg Med 1990: 8; 92–6.
  42. Morse SS, Glickman MG, Greenwood LH, et al.: Traumatic Aortic rupture: False-positive aortographic diagnosis due to atypical ductus diverticulum. Am J Roentgen 1988: 150; 793–796.
  43. Pozzato C, Gedriga E, Donatelli F and Gattoni F: Acute posttraumatic rupture of the thoracic aorta: the role of angiography in a 7-year review. CV Intervent Radiol 1991: 14; 338–41.
  44. Fisher RG, Chasen MH and Lamki N: Diagnosis of injuries of the aorta and brachiocephalic arteries caused by blunt chest trauma: CT vs aortography. Am J Roentgenol 1994: 162; 1047–52.
  45. Gavant ML, Menke PG, Fabian T, et al.: Blunt traumatic aortic rupture: detection with helical CT of the chest. Radiology 1995: 197; 125–33.
  46. Gavant ML, Flick P, Menke P, and Gold RE: CT aortography of thoracic aortic rupture. Am J Roentgenol 1996: 166; 955–61.
  47. Madayag MA, Kirshenbaum KJ, Nadimpalli SR, et al.: Thoracic Aortic Trauma Role of dynamic CT. Radiology 1991: 179; 853–5.
  48. Durham RM, Zuckerman D, Wolverson M, et al.: Computed tomography as a screening exam in patients with suspected blunt aortic injury. Ann Surg 1994: 220; 699–704.
  49. Miller RB, Richardson JD, Thomas HA, et al.: Role of CT in diagnosis of major arterial injury after blunt thoracic trauma. Surgery 1989: 106; 596–603.
  50. Mirvis SE, Shanmuganathan K, Miller BH, et al.: Traumatic aortic injury: diagnosis with contrast-enhanced thoracic CT - five-year experience at a major trauma center. Radiology 1996: 200; 413–22.
  51. Richardson P, Mirvis SE, Scorpio R and Dunham CM: Value of CT in determining the need for angiography when findings of mediastinal hemorrhage on chest radiographs are equivocal. Am J Roentgen 1991: 156; 273–9.
  52. Agee CK, Metzler MH, Churchill RJ and Mitchell FL: Computed Tomographic Evaluation to Exclude traumatic aortic disruption. J Trauma 1992: 33; 876–81.
  53. Biquet JF, Dondelinger RF and Roland D: Computed tomography of thoracic aortic trauma. Eur Radiol 1996: 6; 25–9.
  54. Brooks AP, Olson LK and Shackford SR: Domputed tomography in the diagnosis of traumatic rupture of the thoracic aorta. Clin Radiol 1989: 40; 133–8.
  55. Franchello A, Olivero G, DiSumma M, et al.: Rupture of thoracic aorta resulting from blunt trauma. Int Surg 1997: 82; 79–84.
  56. Heiberg E, Wolverson MK, Sundaram M and Shields JB: CT in Aortic Trauma. Am J Roentgen 1983: 140; 1119–24.
  57. Hills MW, Thomas SG, McDougall PA, et al.: Traumatic thoracic aortic rupture: investigation determines outcome. Aust NZ J Surg 1994: 64; 312–8.
  58. Kawada T, Mieda T, Abe H, et al.: Surgical experience with traumatic rupture of the thoracic aorta. J Cardiovasc Surg 1990: 31; 359–63.
  59. Mirvis SE, Kostrubiak I, Whitley NO, et al.: Role of CT in excluding major arterial injury after blunt thoracic trauma. Am J Roentgen 1987: 149; 601–5.
  60. Morgan PW, Goodman LR, Aprahamian C, et al.: Evaluation of traumatic aortic injury: does dynamic contrast-enhanced CT play a role? Radiology 1992: 182; 661–6.
  61. Raptopolous V, Sheiman RG, Phillips DA, et al.: Traumatic aortic tear: screening with chest CT. Radiology 1992: 182; 667–73.
  62. Wilson D, Voystock JF, Sariego J and Kerstein MD: Role of computed tomography scan in evaluation the widened mediastinum. Am Surg 1994: 60; 421–3.
  63. Brooks SW, Young JC, Cmolik B, et al.: The Use of Transesophageal Echocardiography in the Evaluation of Chest Trauma. J Trauma 1992: 32; 761–8.
  64. Buckmaster MJ, Kearney PA, Johnson SB, et al.: Further experience with transesophageal echocardiography in the evaluation of throacic aortic injury. J Trauma 1994: 37; 989-95.
  65. Catoire P, Orliaguet G, Liu N, et al.: Systematic transesophageal echocardiography for detection of mediastinal lesions in patients with multiple injuries. J Trauma 1995: 38; 96–102.
  66. Cohn SM, Burns GA, Jaffe C, et al.: Exclusion of aortic tear in the unstable trauma patient: The utility of transesophageal echocardiography. J Trauma 1995: 39; 1087–90.
  67. Kearney PA, Smith DW, Johnson SB, et al.: Use of transesophageal echocardiography in the evaluation of traumatic aortic injury. J Trauma 1993: 34; 696–703.
  68. Minard G, Schurr MJ, Croce MA, et al.: A prospective analysis of transesophageal echocardiography in the diagnosis of traumatic disruption of the aorta. J Trauma 1996: 40; 225–230.
  69. Saletta S, Lederman E, Fein S, et al.: Transesophageal echocardiography for the initial evaluation of the widened mediastinum in trauma patients. J Trauma 1995: 39; 137–41.
  70. Shapiro MJ, Yanofsky SD, Trapp J, et al.: Cardiovascular evaluation in blunt thoracic trauma using transesophageal echocardiography (TEE). J Trauma 1991: 31; 835–40.
  71. Smith MD, Cassidy JM, Souther S, et al.: Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. NEJM 1995: 9; 356–62.
  72. Vignon P, Gueret P, Vedrinne JM, et al.: Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption. Circulation 1995: 15; 2959–68.
  73. Ahrar K, Smith DC, Bansal RC, et al.: Angiography in blunt thoracic aortic injury. J Trauma 1997: 42; 665–9.
  74. Mollod M and Felner JM: Transesophageal echocardiography in the evaluation
    of cardiothoracic trauma. Am Heart J 1996: 132; 841–9.
  75. Sparks MB, Burchard KW, Marrin CA, et al.: Transesophageal echocardiography. Preliminary results in patients with traumatic aortic rupture. Arch Surg 1991: 126; 711–3.
  76. Borman KR, Aurbakken CM and Weigelt JA: Treatment priorities in combined blunt abdominal and aortic trauma. Am J Surg 1982: 144; 728–32.
  77. Camp PC, Shackford SR, et al.: Outcome after blunt traumatic thoracic aortic laceration: Identification of a high-risk cohort. J Trauma 1997: 43; 413–22.
  78. Kirsh MM, Behrendt DM, Orringer MB, et al.: The treatment of acute traumatic rupture of the aorta: a 10-year experience. Ann Surg 1976: 184; 308–16.
  79. Akins CW, Buckley MJ, Daggett W, et al.: Acute traumatic disruption of the thoracic aorta: A ten-year experience. Ann Thorac Surg 1981: 31; 305–9.
  80. Bodily K, Perry JF, Strate RG and Fischer RP: The salvageability of patients with post-traumatic rupture of the descending thoracic aorta in a primary trauma center. J Trauma 1977: 17; 754–60.
  81. Camp PC, Rogers RB, Shackford SR, et al.: Blunt traumatic thoracic aortic lacerations in the elderly: an analysis of outcome. J Trauma 1994: 37; 418–23.
  82. Fisher RG, Oria RA, Mattox KL, et al.: Conservative management of aortic lacerations due to blunt trauma. J Trauma 1990: 30; 1562–6.
  83. Fleming AW and Green DC: Traumatic aneurysms of the thoracic aorta. Report of 43 patients. Ann Thorac Surg 1974: 18; 91–101.
  84. Hudson HM, Woodson J and Hirsch E: The management of traumatic aortic tear in the multiply-injured patient. Ann Vasc Surg 1991: 5; 445–8.
  85. Kram HB, Appel PL and Shoemaker WC: Increased incidence of cardiac contusion in patients with traumatic thoracic aortic rupture. Ann Surg 1988: 208; 615–8.
  86. Maggisano R, Nathens A, Alexandrova NA, et al.: Traumatic rupture of the thoracic aorta: should one always operate immediately? Ann Vasc Surg 1995: 9; 44–52.
  87. McCollum CH, Graham JM, Noon GP and DeBakey ME: Chronic traumatic
    aneurysms of the thoracic aorta: an analysis of 50 patients. J Trauma 1979: 19; 248–52.
  88. Pezzella AT, Todd EP, Dillon ML, et al.: Early diagnosis and individualized treatment of blunt thoracic aortic trauma. Am Surg 1978: 44; 699–703.
  89. Plume S and DeWeese JA: Traumatic rupture of the thoracic aorta. Arch Surg 1979: 114; 240–3.
  90. Sharma S, Reddy V, Ott G and Cobanoglu A: Surgical management of traumatic aortic disruption. Am J Surg 1997: 173; 416–8.
  91. Warren RL, Akins CW, Conn AKT, et al.: Acute traumatic disruption of the thoracic aorta: Emergency department management. Ann Emerg Med 1992: 21; 391–6.
  92. Albrink MH, Rodriguez E, England GJ, et al.: Importance of designated thoracic trauma surgeons in the management of traumatic aortic transection. S Med J 1994: 87; 498–501.
  93. Allmendinger PD, Low HB, Takata H, et al.: Deceleration injury: laceration of the thoracic aorta. Am J Surg 1977: 133; 490–1.
  94. Antunes MJ: Acute traumatic rupture of the aorta: repair by simple aortic cross-clamping. Ann Thorac Surg 1987: 44; 257–9.
  95. Appelbaum A, Karp RB and Kirklin JW: Surgical Treatment for closed thoracic aortic injuries. J Thorac Cardiovasc Surg 1976: 71; 458–60.
  96. Avery JE, Hall DP, Adams JE, et al.: Traumatic rupture of the thoracic aorta. South Med J 1979: 72; 1238–40.
  97. Cernaianu AC, Cilley JH, Baldino WA, et al.: Determinants of outcome in lesions of the thoracic aorta in patients with multiorgan system trauma. Chest 1992: 101; 331–5.
  98. Chalant CH, Ponlot R, Tremouroux J, et al.: Surgical treatment of post-traumatic aneurysms of the thoracic aorta. J Cardiovasc Surg 1971: 12; 108–12.
  99. Contino JP, Follette DM, Berkoff HA, et al.: Use of carmeda-coated femoral-femoral bypass during repair of traumatic aortic pseudoaneurysms. Arch Surg 1994: 129; 933–9.
  100. Cowley RA, Turney SZ, Hankins JR, et al.: Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience. J Thorac Cardiovasc Surg 1990: 100; 652–60.
  101. DelRossi AJ, Cernaianu AC, Madden LD, et al.: Traumatic disruptions of the thoracic aorta: treatment and outcome. Surgery 1990: 108; 864–70.
  102. Eddy AC, Rusch VW, Marchioro T, et al.: Treatment of Traumatic Rupture of the Thoracic Aorta: A 15-year experience. Arch Surg 1990: 125; 1351–6.
  103. Forbes AD and Ashbaugh DG: Mechanical circulatory support during repair of thoracic aortic injuries improves morbidity and prevents spinal cord injury. Arch Surg 1994: 129: 494–7.
  104. Frick EJ, Cipolle MD, Pasquale MD, et al.: Outcome of blunt thoracic aortic injury in a level I trauma center: An 8-year review. J Trauma 1997: 43; 844–51.
  105. Higgins RS, Sanchez JA, DeGuidis L, Dewar ML, et al.: Mechanical circulatory support decreases neurologic complications in the treatment of traumatic injuries of the thoracic aorta. Arch Surg 1992: 127; 516–9.
  106. Hilgenberg AD, Logan DL, Akins CW, et al.: Blunt injuries of the thoracic aorta. Ann Thorac Surg 1992: 53; 233–8.
  107. Hunt JP, Baker CC, Lentz CW, et al.: Thoracic aortic injuries: management and outcome of 144 patients. J Trauma 1996: 40; 547–55.
  108. Kim FJ, Moore EE, Moore FA, et al.: Trauma surgeons can render definitive surgical care for major thoracic injuries. J Trauma 1994: 36; 871–5.
  109. Kirsh MM, Kahn DR, Crane JD, et al.: Repair of acute traumatic rupture of the aorta without extracorporeal circulation. Ann Thorac Surg 1970: 10; 227–36.
  110. Kodali S, Jamieson WRE, Leia-Stephens M, et al.: Traumatic rupture of the thoracic aorta: A 20-year review: 1969-1989. Circulation 1991: 84; SIII40–6.
  111. Mattox KL, Holzman M, Pickard LR, et al.: Clamp/repair: a safe technique for treatment of blunt injury to the descending thoracic aorta. Ann Thorac Surg 1985: 40; 456–63.
  112. McCroskey BL, Moore EE, Moore FA and Abernathy CM: A unified approach to the torn thoracic aorta. Am J Surg 1991: 162; 473–6.
  113. Merrill WH, Lee RB, Hammon JW, et al.: Surgical treatment of acute traumatic tear of the thoracic aorta. Ann Surg 1988: 207; 699–706.
  114. Nicolosi AC, Almassi GH, Bousamra M, et al.: Mortality and neurologic morbidity after repair of traumatic aortic disruption. Ann Thorac Surg 1996: 61; 875–8.
  115. Orringer MB and Kirsh MM: Primary Repair of acute traumatic aortic disruption. Ann Thorac Surg 1983: 35; 672–5.
  116. Pate JW: Traumatic rupture of the aorta: Emergency operation. Ann Thoracic Surg 1985: 39; 531–7.
  117. Pickard LR, Mattox, Espada R, et al.: Transection of the Descending Thoracic Aorta Secondary to Blunt Trauma. J Trauma 1977: 17; 749–53.
  118. Read RA, Moore EE, Moore FA and Haenel JB: Partial left heart bypass for thoracic aorta repair. Survival without paraplegia. Arch Surg 1993: 128; 746–50.
  119. Reul GJ, Rubio PA and Beall AC: The surgical management of acute injury to the thoracic aorta. J Thorac Cardiovasc Surg 1974: 67; 272–81.
  120. Saylam A, Melo JQ, Ahmad A, et al.: Early surgical repair in traumatic rupture of the thoracic aorta. J Cardiovasc Surg 1980: 21; 295–302.
  121. Schmidt CA and Jacobson JG: Thoracic aortic injury: A ten-year experience. Arch Surg 1984: 119; 1244–6.
  122. Schmidt CA, Wood MN, Razzouk AJ, et al.: Primary repair of traumatic aortic rupture: A preferred approach. J Trauma 1992: 32; 588–92.
  123. Stiles QR, Cohlmia GS, Smith JH, et al.: Management of injuries of the thoracic and abdominal aorta. Am J Surg 1985: 150; 132–40.
  124. VanNorman GA, Pavlin EG, Eddy AC and Pavlin DJ: Hemodynamic and metabolic effects of aortic unclamping following emergency surgery for traumatic thoracic aortic tear in shunted and unshunted patients. J Trauma: 1991; 31; 1007–16.
  125. Vasko JS, Raess DH, Williams TE, et al.: Nonpenetrating trauma to the thoracic aorta. Surgery 1977: 82; 400–6.
  126. Vaughn GD, Crawford FA and Heath BJ: Blunt thoracic aortic injuries. J Miss State Med Assoc 1983: 24; 4–7.
  127. Verdant A, Mercier C, Page A, et al.: Major mediastinal vascular injuries. Can J Surg 1983: 26; 38–42.
  128. Von Oppell UO, Brink J, Hewitson J, et al.: Acute traumatic rupture of the thoracic aorta. A comparison of techniques. S Afr J Surg 1996: 34; 19–24.
  129. Wallenhaupt SL, Hudspeth AS, Mills SA, et al.: Current treatment of traumatic aortic disruptions. Am Surg 1989: 55; 316–20.
  130. Walls JT, Boley TM, Curtis JJ and Schmaltz RA: Experience with four surgical techniques to repair traumatic aortic pseudoaneurysm. J Thor Cardiovasc Surg 1993: 106; 283–7.
  131. Weimann S, Balogh D, Furtwangler W, et al.: Graft replacement of post¬traumatic thoracic aortic aneurysm: results without bypass or shunting. Eur J Vasc Surg 1992: 6; 381–5.
  132. Young JN, Stallone RJ, Iverson LI, et al.: Surgical management of traumatic disruption of the descending aorta. West J Med 1989: 150; 662–4.
  133. Zeiger A, Clark DE and Morton JR: Reappraisal of surgical treatment of traumatic transection of the thoracic aorta. J Cardiovasc Surg 1990: 31; 607–10.
  134. Hartford JM, Fayer RL, Shaver TE, et al.: Transection of the thoracic aorta: assessment of a trauma system. Am J Surg 1986: 151; 224–9.
  135. Pezella AT: Blunt traumatic injury of the thoracic aorta following commercial airline crashes. Tex Heart Inst J 1996: 23; 65–7.
  136. Hill DA, Duflou J, and Delaney LM; Blunt traumatic rupture of the thoracic aorta: an epidemiological perspective. J R Coll Surg Edinb 1996: 41; 84–7.
  137. Stallone RJ: Management of ruptured thoracic aortic aneurysms. Am J Surg 1978: 136; 162–4.
  138. Johnson MS, Shah H, Harris VJ, et al.: Comparison of Digital Subtraction and Cut Film Arteriography in the Evaluation of Suspected Thoracic Aortic Injury. J Vasc Interv Radiol 1997: 8; 799–807.
  139. Wicky S, Capasso P, Meuli R, et al.: Spiral CT aortography: an efficient technique for the diagnosis of traumatic aortic injury. Eur Radiol 1998: 8; 828–833.
  140. Goarin JP, Catoire P, Jacquens Y, et al.: Use of Transesophageal Echocardiography for Diagnosis of Traumatic Aortic Injury. Chest 1997: 112; 71–80.
  141. Cameron PA, Dziukas L, Hadj A, et al.: Aortic Transection. Aust NZ J Surg 1998: 68; 264–267.
  142. Tripp HF, Robicsek F, Thomason M and Thubrikar: Transected thoracic aorta: age-specific differences in incidence and possible reasons. Cardiovasc Surg 1997: 5; 291–294.
  143. Fabian TC, Davis KA, Gavant ML, et al.: Prospective Study of Blunt Aortic Injury: Helical CT is Diagnostic and Antihypertensive Therapy Reduces Rupture. Ann Surg 1998: 227; 666–77.
  144. Mirvis SE, Kathirkamuganathan S, Buell J and Rodriguez A: Use of Spiral Computed Tomography for the Assessment of Blunt Trauma Patients with Potential Aortic Injury. J Trauma 1998: 45; 922–930.
  145. Brundage SI, Harrugg R, Jurkovich GJ and Maier RV: The Epidemiology of Thoracic Aortic Injuries in Pedestrians. J Trauma 1998: 45; 1010–1014.
  146. Dyer DS, Moore EE, Ilke DN, et al.: Thoracic Aortic Injury: How Predictive is Mechanism and Is Chest Computed Tomography a Reliable Screening Tool? A Prospective Study of 1,561 Patients. J Trauma 2000: 48; 673–683.
  147. Horton TG, Cohn SM, Heid MP, et al.: Identification of Trauma Patients at Risk of Thoracic Aortic Tear by Mechanism of Injury. J Trauma 2000: 48; 1008–1014.
  148. Pate JW, Gavant ML, Weiman DS and Fabian TC: Traumatic Rupture of the Aortic Isthmus: Program of Selective Management. World J Surg 1999: 23; 59–63.
  149. Camp PC, Rogers FB, Shackford SR, et al.: Blunt Traumatic Thoracic Aortic Lacerations in the Elderly: An Analysis of Outcome. J Trauma 1994: 37; 418–425.
  150. Wahl WL, Michaels AJ, Wang SC, et al.: Blunt Thoracic Aortic Injury: Delayed or Early Repair? J Trauma 1999: 47; 254–260.
  151. Sweeney MS, Young DJ, Frazier OH, et al.: Traumatic Aortic Transections: Eight-Year Experience with the “Clamp-Sew” Technique. Ann Thorac Surg 1997: 64; 384–389.
  152. Rousseau H, Soula P, Perreault P, et al.: Delayed Treatment of Traumatic Rupture of the Thoracic Aorta With Endoluminal Covered Stent. Circulation 1999: 99; 498–504.
  153. Attar S, Cardarelli MG, Downing SW, et al.: Traumatic Aortic Rupture: Recent Outcome With Regard to Neurologic Deficit. Ann Thorac Surg 1999: 67; 959–965.
  154. Szwerc MF, Benckart DH, Lin JC, et al.: Recent Clinical Experience With Left Heart Bypass Using a Centrifugal Pump for Repair of Traumatic Aortic Transection. Ann Surg 1999: 230; 484.
  155. Razzouk AJ, Gundry SR, Wang N, et al.: Repair of Traumatic Aortic Rupture: A 25-Year Experience. Arch Surg 2000: 135; 913–918.

« Back to guidelines