Clinical communication: mature
A case of traumatic aortic transection with hemorrhagic shockFragments section
Case report
A 61-year-old male patient presented to the ER of our Level I Trauma Center by Emergency Medical Services (EMS) following a car-pedestrian collision. Vital signs recorded by EMS at the scene included a heart rate (HR) of 110 beats/min, Glasgow Coma Scale score of 14, and oxygen saturation (SpO2) 99%. A blood pressure of the scene was not recorded and exact details of the MVC were not provided. Initial vital signs on arrival to the ER include an HR in the 120s, manual blood pressure (BP)
Discussion
MVC is the most common cause of BAI. In a multicenter study, 81% of the 274 reported cases were caused by MVCs (3). Motor vehicle vs. pedestrian, such as the case presented, is a less common but well-known cause of BAI (4). The injury usually occurs due to rapid deceleration, with most cases of BAI occurring just distal to the left subclavian artery at the aortic isthmus, as shown in this case presentation (5).
BAI can be categorized by the severity of aortic injury. A type I aortic injury
Why should an emergency physician be aware of this?
Diagnosis of aortic injury can be challenging for the emergency physician, especially in trauma patients with hypotension. BAI is a potentially fatal condition that should be suspected in patients presenting to the ED after injury from a high velocity mechanism. Chest X-ray is an early diagnostic modality that may suggest BAI, but may be normal in a significant number of cases. CT of the chest is vital for determining the location and extent of BAI. Rapid diagnosis and surgical recovery are
Featured Articles (6)
Research article
(Video) Traumatic aortic injuryThe Association of Publication of Center for Medicaid and Medicare Services Guidelines for Carotid Artery Angioplasty and Stenting (CAS) and CREST Results on the Use of CAS in Carotid Revascularization
Annals of Vascular Surgery, Volume 29, Issue 8, 2015, pp. 1606-1613
Since the 2004 approval of angioplasty and carotid artery stenting (CAS), there have been 2 landmark publications on CAS reimbursement (Center for Medicaid and Medicare Various guidelines [CMSG]; 2008) and clinical outcomes (Carotid Revascularization Endarterectomy versus Stent Trial [CREST]; 2010). We examined trends in CAS usage following these publications at the national level.
The most recent datasets from the nationwide inpatient sample (NIS) were retrieved for patients undergoing carotid artery revascularization. CAS usage shares were calculated quarterly from 2005 to 2011 for NIS. Three time intervals related to CMSG and CREST publication were selected 2005-2008, 2008-2010 and after 2010. Logistic regression with piecewise linear trend for time was used to estimate different trends in CAS usage for common samples and for neurologically asymptomatic and symptomatic cases.
The majority (95%) of carotid artery revascularizations were performed in asymptomatic patients. Overall, CAS use made up 12.5% of carotid revascularization procedures with a significant period increase in CAS; from 9.4% to 14%;P<0.001. There was a small but significant decrease in the rate of CAS use after CMSG was published, corresponding to a 2% decrease in the quarterly odds ratio (OR) of CAS (OR, 0.98; 95% confidence interval, 0. 97-0.99;P=0.001). After CREST, CAS usage continued to increase in both NIS, but the rate of increase did not change significantly between the pre-publication and post-publication time intervals. The odds of in-hospital mortality and postoperative stroke were independent and significantly higher for CAS patients, both overall and within the symptomatic cohorts. In all 3 periods of the study, and compared to carotid endarterectomy, the risk of death and postoperative stroke was significantly higher in patients who underwent CAS.
While the overall use of CAS has increased since 2005, it was not uniformly associated with the publication of CMSG or CREST. Despite increased use, the likelihood of adverse outcomes was independently higher in CAS patients.
Research article
Clinical outcome of carotid artery stenting by provider specialty and volume
Annals of Vascular Surgery, Volume 44, 2017, pp. 361-367
(Video) Traumatic Aortic Injury (Carlos Bechara, MD)Several studies have shown better outcomes for carotid endarterectomy in major hospitals and health care providers. However, only a few studies have reported the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study analyzes the correlation between CAS results and provider specialty and volume.
Prospectively collected data from CAS procedures performed at our institution over a 10-year period were analyzed. Major adverse events (MAEs; stroke at 30 days, myocardial infarction, and death) were compared by provider specialty (vascular surgeons [VSs], interventional cardiologists [ICUs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year).
Four hundred and fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographic/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between different specialties: 3.1% for ICU, 6.3% for US, 7.1% for IR, 6.7% for IVM (P=0.3121; 6.3% for US and 3.8% for others combined,P=0.2469). When physicians with <5 CAS/year were excluded: MAE rates were 3.1% for IC, 4.7% for US, and 6.7% for IVM (P=0.5633). When comparing US only with others, and excluding physicians with <5 CAS/year, MAE rates were 4.7% for US vs. 3.6% for non-US (P=0.5958). MAE rates for low volume providers, regardless of specialty, were 9.5% versus 4% for high volume providers (P=0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15–1.1,P=0.0674) for high volume providers, while the odds ratio for US was 1.3 (0.45–3.954,P=0,5969).
Perioperative MAE rates for CAS were comparable between different healthcare providers, regardless of specialties, especially for vascular surgeons with a similar volume to non-vascular surgeons. Low volume providers had higher MAE rates.
Research article
Trauma in CT: reviewing the role of serious injury in search satisfaction
Journal of the American College of Radiology, Volume 13, Issue 8, 2016, pp. 973-978.e4
(Video) Aortic Trauma by Jody Shen, MD, Stanford RadiologyThe satisfaction-of-search (SOS) effect occurs when an anomaly on an image is missed because another has been found. The aim of this experiment was to test whether severe distracting fractures control the magnitude of SOS on other fractures when both occur in a single CT image.
The institutional review board approved this study. The experimental (SOS) condition included 35 CT cases of the cervical spine, all of which showed severe injuries to the cervical spine. For each of these cases, a similar case was found with no injuries. Image fitting software has been developed to add simulated fractures to each pair of cases, with and without major injury. Sixteen different minor fractions were added to 16 of the 35 pairs of images. The 35 cases without congenital injuries formed a control condition (non-SOS), mixed in random order. Twenty radiologists read 35 mixed cases in each of the two sessions. False positive evaluations were only collected for cases without simulated fractures.
An SOS effect on the detection of simulated fractures was not observed. There was a non-significant (P= .07) finding of worse detection in the presence of severe injury cases. However, the magnitude of the effect was not greater than observed for less severe distraction injuries.
The outcome is consistent with the results of two previous experiments that showed no SOS effect associated with detecting severe injury, suggesting that the severity of a distracting injury does not determine whether a second injury is detected.
Research article
Hybrid treatment: expanding the armamentarium for infected infrarenal abdominal aorta and iliac aneurysms
Journal of Vascular and Interventional Radiology, Volume 28, Issue 4, 2017, pp. 564-569
To investigate the safety and efficacy of hybrid treatment for infected aortic and iliac aneurysms.
Between July 2007 and May 2011, hybrid treatment was performed in 6 male patients (mean age 67.7 years; range 57-76 years). Hybrid treatment consisted of extraanatomical bypass (EAB) and isolation of infected aneurysm with vascular plugs. Aneurysms were divided into primary and secondary infected aneurysms. Primary infected aneurysm refers to an aneurysm arising from a bacterial infection of the original arterial wall; secondary infected aneurysm refers to infection involving an aneurysm that has previously been treated with graft placement.
The infected aneurysm involved the infrarenal abdominal aorta in 4 patients and the common iliac artery in 2 patients. Hybrid treatment was successful in all 6 patients. The 3 patients with primary infected aneurysms only required hybrid treatment, while excision of the infected graft and placement of a new graft were performed in 2 of 3 patients with secondarily infected aneurysms. No mortality or complications were reported after 30 days. During the mean follow-up of 58.6 months (range 32.6-75.8 months), 1 patient (17%) with a secondarily infected aneurysm who did not undergo additional surgery died 32.6 months after hybrid treatment from hypovolemic shock secondary of recurrent aortoenteric fistula. Cumulative survival was 100%, 100%, 83% and 83% at 3 months, 1 year, 3 years and 5 years.
Hybrid treatment appears to be a standalone, curative treatment for primary infected aneurysms and serves as a bridging therapy to subsequent surgery for secondary infected aneurysms.
(Video) Aortic Dissection | Etiology, Pathophysiology, Diagnosis, Clinical Features, TreatmentResearch article
The painstaking search for the optimal treatment of patients with asymptomatic carotid artery stenosis
Journal of Vascular Surgery, Volume 73, Issue 5, 2021, pp. 1834-1835
Research article
(Video) Aortic Trauma | Interesting Radiology CasesI may not be Southern by birth, but I'm proud to be an American: The Role of International Medical Graduates in Vascular Surgery and the Southern Association for Vascular Surgery
Journal of Vascular Surgery, Volume 62, Issue 1, 2015, pp. 241-250
Published by Elsevier Inc.
FAQs
What is a traumatic transection of the aorta? ›
Traumatic aortic transection, also known as aortic rupture, is the near-complete tear through all the layers of the aorta due to trauma such as that sustained in a motor vehicle collision or a fall. This condition is most often lethal and requires immediate medical attention.
What is the survival rate of traumatic aortic transection? ›Approximately 80% of patients with blunt thoracic aortic injury (BTAI) die before reaching the hospital. Most people who survive the initial injury eventually die without appropriate treatment.
What causes aortic transection? ›Blunt force trauma is the primary etiology of aortic transection. Penetrating trauma to the chest may result in aortic injury, though less commonly. In blunt thoracic injury, the rapid deceleration of the torso upon the impact of the encountered object causes shearing stress on the aortic wall.
What is the difference between aortic dissection and aortic transection? ›The most common categories are thoracic aortic aneurysm which is a ballooning of the aorta, traumatic aortic transection which is a tear in the aorta wall, and aortic dissection where a small tear occurs in the inner layer of the aortic wall.
Where is the aortic transection? ›It occurs from a near-complete tear through "all the layers" of the aorta due to trauma (e.g. motor vehicle collision or a severe fall). It can be associated with a sudden and rapid deceleration of the heart and the aorta within the thoracic cavity.
What is the most common site of aortic transection? ›The most common sites of injury are the following: Aortic isthmus. Just distal to the origin of the left subclavian artery. This is the transition zone between the mobile ascending aorta and the relatively fixed descending aorta.
Can you survive a wound to the aorta? ›Mortality after gunshot wounds to the thoracic aorta ranges from 92% to 100%. Survival is almost always in patients with injury from low-caliber, low-velocity bullets with hemorrhage contained by the wall of the aorta.
What are the grades of aortic transection? ›This grading system is based on anatomical layers of the aortic wall—intimal tear (grade I), intramural hematoma (grade II), pseudoaneurysm (grade III), rupture (grade IV)—and directly influences the management of blunt aortic injuries.
Has anyone survived an aortic rupture? ›The study finds nearly 96% of patients deemed eligible for surgery survive in the first 48 hours. The chance of a patient living after tearing their aorta has improved significantly, but the condition remains deadly if not recognized early and repaired surgically, a study finds.
Can you survive an aortic rupture? ›About 40% of patients die immediately from complete rupture and bleeding out from the aorta. The risk of dying can be as high as 1% to 3% per hour until the patient gets treatment.
What happens if the aorta of the heart is damaged? ›
If the coarctation of the aorta is severe, the heart might not be able to pump enough blood to the other organs. This can cause heart damage. It may lead to kidney failure or other organ failure. Complications are also possible after treatment for coarctation of the aorta.
What are the possible causes of death in aortic dissection? ›Aortic dissection is an acute process in which a tear in the internal face of the aorta leads to dissection through the laminas and formation of a new lumen (false lumen) and acute drop in systemic blood pressure, potentially leading to hemopericardium and cardiac tamponade [7] with sudden death.
What type of shock is aortic dissection? ›Clinically, the most common feature of aortic dissection is abrupt onset of sharp back or chest pain (>96% of cases). Septic shock, which is a frequent cause of death in the intensive care unit, is defined as severe sepsis combined with hypotension unresponsive to adequate fluid resuscitation [2].
How severe is the pain with an aortic dissection? ›Pain: You may experience sudden severe pain in the chest, back or abdomen. A radiating pain in the chest or upper back is described as a tearing or ripping sensation. The pain can extend to the legs and make walking difficult. Difficulty breathing: You may feel short of breath or lose consciousness.
Is aortic dissection life threatening? ›As many as 40 percent of people who suffer from an aortic dissection die almost instantly, and the risk of death increases by 3-4 percent every hour the condition is left untreated.
Which part of aorta is mostly injured by blunt trauma? ›This topic last updated: May 31, 2022. Blunt thoracic aortic injury, which is a life-threatening injury, usually occurs at the aortic isthmus just distal to the left subclavian artery, but other sites can be affected.
What branch of the aorta takes blood to the left arm? ›Aortic arch branches
Left subclavian artery supplies your left arm and the back of your brain.
There are five arteries that branch from the abdominal aorta: the celiac artery, the superior mesenteric artery, the inferior mesenteric artery, the renal arteries and the iliac arteries.
How quickly does aortic root grow? ›Aortic root aneurysms grow at an average of 1–4 mm/year [5], with a faster rate of growth noted in patients with bicuspid aortic valves, Marfan syndrome, ESRD, male gender, and smokers [5, 67].
What is the most common finding in acute aortic dissection? ›The most common neurologic findings are syncope and altered mental status. Syncope is part of the early course of aortic dissection in about 5% of patients and may be the result of increased vagal tone, hypovolemia, or dysrhythmia.
How long does it take for a severed aorta to bleed? ›
3 minutes A victim who is bleeding from an artery can die in as little as three minutes. 30-40% Hemorrhage is the second leading cause of death for patients injured in the prehospital environment, accounting for 30-40% of all mortality.
How long does it take to bleed out from a ruptured aorta? ›“The normal rate of blood flow through the body is about six liters per minute. So, theoretically, it is possible for a person to bleed out his or her entire blood volume in one minute due to a ruptured aorta.”
Can aortic rupture cause immediate death? ›If the ruptures occur in the anterior areas, up to 90% of patients suddenly die within 48 hours if left untreated or treated improperly. If ruptures locate in the posterior areas, the risks of sudden death is substantially reduced to 30%.
What is the gold standard for aortic injury? ›Grade IV injuries, and any other injury in which there are signs of serious damage, require emergency invasive management. Endovascular stents are the gold standard treatment for traumatic injuries to the thoracic aorta.
What is the classification of aortic trauma? ›...
Classification of Blunt Traumatic Aortic Injury.
| Classification | Description | Notes |
|---|---|---|
| Grade 1 | Intimal tear | Minimal Aortic Injury |
| Grade 2 | Intramural hematoma or large intimal flap | |
| Grade 3 | Pseudoaneurysm | |
| Grade 4 | Rupture |
They often use CT scans to monitor the aneurysm size. Your provider may recommend surgery if the aneurysm is larger than 5.5 centimeters or has grown more than 0.5 centimeters in six months.
What is the mortality rate for AAA patients? ›Ruptured AAA is a catastrophic event associated with an overall mortality of 80–90%.
How long can you live with a ruptured aorta? ›When left untreated, ruptured aortic aneurysms are almost always fatal within several hours to a week, depending on the size of rupture. How quickly do aortic aneurysms develop? Aortic aneurysms grow slowly, typically 1 to 2 millimeters a year.
What is the quality of life after aortic dissection? ›Post-dissection, many patients wonder when it is appropriate to return to their previous lifestyle. With excellent blood pressure control and conscious limits to physical activity, you can continue to live a long, full life after a dissection. This would include returning to most jobs.
What is the most fatal aneurysm? ›The most common and deadly aneurysm is aortic. Two-thirds of aortic aneurysms are abdominal (AAA), and one-third is thoracic (occurring in the chest cavity). When the aneurysm occurs in both areas, it is called thoracoabdominal.
Can ruptured aorta cause brain damage? ›
In 18-30% of patients with aortic dissection, neurological signs often present as the onset of disease and ischemic stroke [5, 8, 9]. About 80% of patients with aortic dissection experience loss of consciousness and that symptom in patients with a brain stroke should turn doctors to further diagnosis [10].
Can you survive being stabbed in the aorta? ›Penetrating injury of the aorta is rare and lethal. The reported mortality rate is very high. Few patients survive and present to the hospital. Some of these injuries are salvageable if treated in a timely and aggressive manner.
What happens to blood after the aorta? ›Supplying oxygen to the heart's muscle
These arteries branch off from the aorta so that oxygen-rich blood is delivered to your heart as well as the rest of your body. The left coronary artery delivers blood to the left side of your heart, including your left atrium and ventricle and the septum between the ventricles.
Aortic dissection most often happens because of a tear or damage to the inner wall of the aorta. This very often occurs in the chest (thoracic) part of the artery, but it may also occur in the abdominal aorta. When a tear occurs, it creates 2 channels: One in which blood continues to travel.
What is the survival rate of an aortic dissection? ›Acute type A aortic dissection (AAD) is a life-threatening emergency that carries a high mortality rate without surgical treatment [1,2]. Surgical mortality has been estimated to range from 9% to 30%, and survival rates of 51–82% at 5 years have been reported [3–9].
What is the most common cause of death in acute aortic dissection? ›Cardiac failure, postoperative stroke, and hemorrhage were the cause of death in nearly 70% of cases.
Are there warning signs of aortic dissection? ›Aortic Dissection Symptoms
Symptoms usually begin suddenly and may include severe chest or back pain that may be felt as sharp or stabbing or as a tearing. Sometimes, the pain moves to the neck, jaw, shoulder, arm, or abdomen. Acute aortic dissection can be life-threatening and requires immediate treatment.
Aortic dissection can occur spontaneously or secondary to blunt trauma.
What is the difference between an aneurysm and an aortic dissection? ›Develop the definitions for aneurysm and dissection to include: An aneurysm is a bulge in the aorta or a peripheral artery. A dissection of the aorta or its branches occurs when the inner lining of the artery is “torn” and begins to separate from the rest of the arterial wall.
What is the most common complication of aortic dissection? ›Possible complications of aortic dissection include: Death due to severe internal bleeding. Organ damage, such as kidney failure or life-threatening intestinal damage. Stroke.
Can aortic dissection pain resolve? ›
Patients with aortic dissection typically suffer sudden severe chest pain. The pain can settle completely and routine tests carried out in the Emergency Department can be normal. To make the diagnosis it is necessary to carry out an emergency CT scan.
What does aortic pain feel like? ›The most common symptom is general belly pain or discomfort, which may come and go or be constant. Other symptoms may include: Pain in the chest, belly (abdomen), lower back, or flank (over the kidneys). It may spread to the groin, buttocks, or legs.
What are the red flags of aortic dissection? ›Sudden, severe upper back or chest pain (often described as a “tearing” sensation from the neck down the back) Sudden, severe belly pain. Leg pain. Mild neck, jaw, or chest pain.
How long are you in hospital after aortic dissection? ›You can expect to remain in the hospital for two to three days after surgery. Because your aorta and heart need rest in order to heal, your doctor may recommend that you refrain from driving and lifting anything heavier than 10 pounds for 10 days after surgery.
What type of aortic dissection is worse? ›Type A is the most common type of aortic dissection and is more likely to be acute than chronic. This makes it more dangerous than type B dissections because it is more likely to cause the aorta to rupture, leading to a potentially fatal heart condition.
What is the cut off for aortic aneurysm? ›Thoracic aortic aneurysm is defined as a cross-sectional diameter exceeding the following cutoff: 4.5 cm in the United States. 4.0 cm in South Korea.
What happens to the blood after it goes to the aorta? ›The aorta is the main artery that carries blood away from your heart to the rest of your body. The blood leaves the heart through the aortic valve. Then it travels through the aorta, making a cane-shaped curve that allows other major arteries to deliver oxygen-rich blood to the brain, muscles and other cells.
Can you survive a ruptured aorta without surgery? ›Around 8 out of 10 people with a rupture either die before they reach hospital or don't survive surgery. The most common symptom of a ruptured aortic aneurysm is sudden and severe pain in the abdomen. If you suspect that you or someone else has had a ruptured aneurysm, call 999 immediately and ask for an ambulance.