1. William Beaumont Hospital Royal Oak, Michigan
Monzer Chehab, MD
William Beaumont Hospital
Royal Oak, Michigan

2. History of Present Illness:
Chief Complaint:
Left shoulder and chest pain
History of Present Illness:
44 year old female
Restrained passenger in motor vehicle collision (MVC)
Contrast enhanced chest CT showed extensive aortic injury
Patient remained hemodynamically stable and was transferred to level 1 trauma center with multiple injuries

3. Past Surgical History: Medications: Allergies Social
Past Medical History:
Hypertension
Past Surgical History:
None
Medications:
None on admission
Allergies
Social
Nonsmoker
Social drinker
No illicit drugs
Injuries noted on admission:
Multiple rib fractures
Small left pneumothorax
Left clavicle fracture
Splenic laceration
Right renal infarct
Left eye chemosis
Extensive subcutaneous emphysema overlying chest
Pneumomediastinum

4. Noninvasive Imaging ∧ E ∧ H A B C
40 year old female status post MVC- Mutidetector contrast enhanced CT images obtained during arterial phase prior to transfer. Axial (A), Coronal (B) and Sagittal (C) planes demonstrate aortic transection at level of aortic isthmus with intimal flap projecting into aortic lumen (red arrow), pseudoaneurysm (arrowhead) and periaortic hematoma (H). Note extensive subcutaneous emphysema (E).

5. Noninvasive Imaging C B A
Complex traumatic injury of Aorta in 44 year old female status post MVC. Repeat contrast enhanced multidetector CT obtained at our institution. Axial (A), Coronal (B) and Sagittal (C) images obtained during arterial phase demonstrates interval enlargement of pseudoaneurysm (arrow)

6. Diagnosis and Panel Discussion
Diagnosis: Acute Traumatic Aortic Injury
Intimal flap (transection)
traumatic pseudoaneurysm
contained rupture
intraluminal mural thrombus
abnormal aortic contour
sudden change in aortic caliber (aortic “pseudocoarctation”)
Treatment Options:
1. Open Thoracotomy
Resection of injured segment and reconstruction with Dacron graft
2. Endovascular Stent Graft
Fixed graft deployed via femoral access
3. Conservative management
Blood pressure control

7. Potential Complications of Treatment
Open Thoracotomy
Requires large posterolateral thoracotomy, aortic cross clamp,
Difficult in unstable patients
Results in long hospitalization times and postoperative pain
Risk of spinal ischemia and paraplegia especially in the absence of distal perfusion adjunct i.e. hepranized cardiopulmonary bypass
Endovascular stent graft
Stroke, puncture-site complications, device collapse/ endoleak, recurrent laryngeal nerve damage
Limited devices for small caliber aortas
Long term outcomes and complication data lacking
Conservative Management
Blood pressure control
High long term aortic complications with up to 40% requiring surgical or endovascular treatment
Typically reserved for the most minimal intimal injuries

8. Intervention
Bovine Arch
Nondeployed stent graft positioned in the descending thoracic aorta over a Lunderquist wire placed through a 20F sheath
Pseudoaneursym

9. Intervention
Gore graft placed intentionally covering left subclavian artery ostium
Balloon angioplasty avoided
Retrograde flow (steal phenomenon) into left subclavian artery predisposes to Type 2 endoleak

10. Intervention To treat steal phenomenon:
8 mm Amplatzer plug placed though 5F brachial artery sheath occlude origin of subclavian artery at its take off

11. Summary
44 year old female, status post endovascular stent graft of Acute Traumatic Aortic Injury
Covering of left subclavian artery
Bovine arch provided good landing zone
Balloon angioplasty avoided in traumatic scenario
Subclavian Steal recognized post deployment
Treated with amplatz plug of left subclavian take
No acute complication
No evidence of upper extremity ischemia
Patient discharged to rehabilitation facility post procedure day 20
Sagittal CT Angiogram 3 months post stent graft repair demonstrates interval resolution of intimal flap and pseudoaneurysm