1. TRAUMATIC AORTIC INJURY MI Zucker, MD

2. A dr Z Lecture on Aortic Injuries

3. Aortic Injuries: Defined They are TEARS not dissections, so best terminology would be: Traumatic Aortic Injury or TAI

4. Epidemiology Major deceleration force as in high speed MVA, auto vs pedestrian, fall from a height 80-85% die at scene, aortic root area tear 15-20% survive to ED, aortic isthmus tear

5. PATHOLOGY The lesion is an aortic wall TEAR, not a dissection. The tear is through the intima and media, with the thin but tough adventitia containing the blood volume as a pseudoaneurysm for a time. When the adventitia fails, the patient usually immediately expires.

6. Location of TAI (On a Conventional Angiogram)

8. TAI In TAI, the mediastinum is of abnormal size or contour. Abnormal mediastinum MAY be due to hemorrhage into the mediastinum. The hemorrhage is due to small vessel bleeding, rarely from the torn aorta itself.

9. But… If there has been enough deceleration force to rupture small vessels, then there has been enough force to tear the aorta.

10. However… Other things may and often do alter the mediastinum size and contour: Supine position Portable film Poor inspiration Tortuous aorta Fat, non-trauma diseases

11. And so… The chest film is very sensitive, but not specific for TAI. If fact, 90-95% of patients with trauma and abnormal mediastinum DO NOT have TAI. But, only 1 % with normal mediastinum DO have TAI.

12. CHEST FILM FINDINGS of TAI Abnormal shape or size of aortic arch Indistinct aortic arch or aortopulmonary window Abnormally wide right paratracheal stripe Deviation of trachea or esophagus (NGT) to right Left apical cap Abnormal paraspinal line Wide mediastinum (over 8 cm)

13. And: “I don’t know why, but the mediastinum just don’t look right.” (You need a little experience to use this one.)

14. Of these, NONE is any better or worse than any other. ONE abnormality makes the mediastinum abnormal.

15. First, the NORMAL Mediastinum Young Middle aged Elderly

19. An “abnormal” mediastinum in a normal patient Caused by portable technique, supine position, and poor inspiration

21. Abnormal mediastinum Caused by Traumatic Aortic Injury. The subtle and the unsubtle. We are going to look for the mediastinum abnormalities we just talked about on each film.

28. So, Chest Film is Abnormal: What’s Next? CT TEE Angiography MRI With contrast bolus CTA. Multidetector unit Unstable patient. Operator dependent Invasive. Labor intensive Slow. Harder to manage patient. Availability

29. ANGIOGRAPHY Invasive Labor intensive The “gold standard”

32. CTA Universally available Quick Accurate The new “gold standard”

35. TREATMENT of TAI Operate emergently Graft placement

36. Prognosis Without surgery, classical data show 99% death rate With surgery, 70% survival. Most of post- operative deaths due to associated injuries, especially head trauma, not to TAI. But…

37. A Case to Think About: Code Trauma Young man, MVA, stable, but multiple injuries, including chest.

38. The Chest Film Multiple injuries, abnormal mediastinum

40. The CTA Called “suggestive” of TAI, but technically limited examination

42. The Angiogram Done because of uncertain CT. Called “normal”

44. So: Chest film: Abnormal CT: Abnormal, but uncertain for TAI Angiogram: Normal

45. The Outcome: No surgery on aorta Patient recovered from other injuries Discharged Still alive, as far as we know

46. But: Was the Aorta Injured?

47. ???? Were the chest film and the CT results correct and the angiogram, the so-called “Gold Standard,” wrong? Is MDCT the new “Gold Standard”?

48. “MINIMAL AORTIC INJURY” There are patients with aortic injury who have survived without surgery. There may be a subtype of Minimal Intimal Injury with a more benign outcome, where the injured intima heals without intervention. So, the 99% death rate without surgery may be an overestimate.

49. Goodbye Copyright 2004 MI Zucker