Management of thoracic trauma
Great Vessel and Cardiac Trauma: Diagnostic and Management Strategies

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Blunt and penetrating trauma to the chest can result in great vessel or cardiac injury. Both the diagnosis and management of these thoracic injuries have evolved from more invasive to less invasive strategies paralleling the advent of sophisticated imaging tools and the development of endovascular therapies. Despite these advances, conventional open repair and reconstruction techniques remain important and are often the definitive means toward effective management of these severely injured patients. The following review outlines the historical perspective, diagnosis, and management of blunt thoracic aortic, blunt cardiac, and penetrating cardiac injuries.

Section snippets

Pathology

Autopsy series demonstrate that 36% to 54% of blunt aortic injuries occur at the aortic isthmus, 8% to 27% involve the ascending aorta, 8% to 18% occur in the arch, and 11% to 21% involve the distal descending aorta.5, 6 Alternatively, surgical series demonstrate that 84% to 97% of ruptures occur at the isthmus, while only 3% to 10% occur in the ascending, arch, or distal descending aorta.2, 3, 5, 6 The discrepancy may exist because the periadventitial tissues around the isthmus provide some

Pathogenesis

Despite extensive analysis and debate, no consensus on the pathogenesis of aortic transaction has emerged. Popular opinion has perpetuated the “whiplash” theory posing that a combination of traction, torsion, shear, bending, and bursting forces secondary to differential deceleration of tissues within the mediastinum cause an appropriate stress to rupture the aorta at specific sites—the isthmus being the most common. The ligamentum arteriosum, the left mainstem bronchus, and the paired

Clinical Presentation

Aortic rupture presents with specific signs or symptoms in less than 50% of cases. Patients may develop dyspnea, back pain, or differential hypertension in the lower compared with the upper extremities. Identifying the character and mechanism of trauma is the critical first step in making the diagnosis of aortic disruption. If speeds or distances fallen suggest severe impact or significant deceleration forces, the possibility of aortic rupture exists, and it should be ruled out. There are often

Diagnosis

A standard supine anteroposterior (AP) chest X-ray (CXR) does not provide the diagnostic sensitivity to rule out aortic injury. Volumetric helical or spiral computed tomography (CT) has become the standard screening tool to rule out aortic disruption with sensitivity and negative predictive values approaching 100%.17, 18, 19 Its advantages over other sophisticated imaging techniques include its wide availability, its speed, its sensitivity, its reasonable cost, and its ease of interpretation.

Timing of Intervention

In hemodynamically stable patients without severe associated injuries who require emergent laparotomy, craniotomy, or pelvic stabilization, aortic repair is indicated immediately following the diagnosis of the aortic injury. Intracranial bleeding causing mass effect, and significant thoracic, abdominal, pelvic, or retroperitoneal hemorrhage should all be addressed before thoracotomy or endovascular stent grafting for contained aortic injury. Contained aortic injuries should be aggressively

Operative Strategies

Conventional open repair of traumatic aortic disruption via interposition grafting for replacement of the injured segment is safe, effective, and durable. Historically, open repair via thoracotomy is the standard with which all other management strategies should be compared. However, as endovascular strategies for treating abdominal and, more recently, thoracic aortic pathology have evolved, there is growing enthusiasm for endovascular stent grafting (EVSG) traumatic disruption because of its

Results

The mortality rate of patients with aortic rupture who reach the hospital ranges from 7% to 65% depending on whether or not the injury is repaired.2, 27, 31 The large discrepancy is likely due to under-reporting of patients who make it to the hospital but not to the operating room, as most series only report operative results. Among hemodynamically stable patients undergoing open repair or EVSG repair, the hospital mortality rate ranges from 0% to 24% in the modern era (Table 2).2, 27, 32, 33,

Conclusions

The diagnosis and management of thoracic aortic and cardiac trauma has evolved over the last several decades. Our ability to manage blunt aortic injuries safely and effectively has been significantly improved with the use of anti-impulse therapy preoperatively, the use of left heart bypass for open reconstructions, and the development of thoracic aortic stent grafts for endovascular repair. Operative timing should be based on hemodynamic status and the presence of other immediately

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