Diseases of Aorta - Aortic Trauma

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AORTIC TRAUMA Aorta can be injured in variety of
accidents or trauma. A piercing or penetrating
injury by a sharp object can directly injure the
aorta in the thorax or abdomen. These injuries
are often instantly fatal due to severe bleeding.
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More commonly aorta is injured in blunt trauma
especially in high velocity deceleration
accidents. Typically the person is thrown from a
speeding bike and comes crashing. The relatively
fixed part of aorta (close to the position of
ligamentum arteriosum) takes the brunt of impact.
So commonest site of injury in these injuries is
opposite the left subclavian artery. Aorta may be
sustain partial tear of intima and/or media or a
complete tear. The complete tear is a devastating
injury accounting for heavy mortality- 20 of
victims die before reaching medical facility.
Untreated another 10 die every hour following
injury. Needless to say, this is a true surgical
emergency. Sometimes the extensive traumatic
dissection can cause malperfusion of the
visceral vessels or intercostals. Bleeding into
the chest can severe enough to cause hypotension
and shock.
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DIAGNOSIS
Blunt chest trauma or decelerating injury is an
indication for CT scan of chest with contrast.
Apart from identifying the bony or soft tissue
injuries, it can clearly demonstrate vascular
trauma including aortic tears.
TREATMENT
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Once the CT scan is done the extent and severity
of aortic injury becomes clear. Depending on the
type of injury the treatment varies. A small
hematoma on the aortic wall may be left alone.
Even a small tear in the aortic intima (inner
layer of aorta) may be treated conservatively
with caution and rigorous follow up. However,
more serious injuries need definitive
treatment. A full thickness tear in the aortic
wall is a potentially fatal injury. If the
bleeding continues. the victim may develop
hypovolemic (low blood volume in the
circulation) shock. Large volume of blood can get
collected in the thoracic cavity. Often after
the initial bleed, the blood clot in the vicinity
of injury prevents further bleeding. In these
circumstances proper treatment can save the
person fig(1).
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There are two types of definitive treatment. Open
Surgery and Endovascular Stenting. In open
surgery, the injured part of aorta is replaced
with artificial tubes or prosthetic grafts made
of PTFE, Dacron or Polyester fig(2).
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In Endovascular procedures, a folded tube with a
self-expanding stent in inserted into the aorta
from the femoral artery (Groin) and expanded
inside the injured portion to seal the area and
prevent bleeding. Sometimes a HYBRID technique is
employed. ie., a combination of surgery and
Endovascular procedure (fig 3)
FOLLOW UP It is important to keep a close watch
on these patients and get a CT aortogram at 3 and
12 months
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reserved.