Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma

Abstract

This experience suggests that deliberate, nonoperative management of carefully selected patients with traumatic blunt aortic injury may be a reasonable alternative in the polytrauma patient; however, serial imaging and long-term follow-up are necessary.

A new aortic injury score predicts early rupture more accurately than clinical assessment

“…More broadly, these results are consistent with the safety of delayed repair or nonoperative treatment for patients with limited pseudoaneurysms and minimal secondary signs of injury, particularly as a relatively large subgroup of stable patients was treated without aortic intervention. 9,10,16 In contrast, although higher lactate levels are associated with organ failure and death after major trauma, 27 the relationship among lactate, BTAI severity, and lesion stability is unclear. Short of frank rupture, large aortic lesions could potentially contribute to systemic malperfusion through altered flow dynamics 28 or result in tension or tamponade physiology from extensive mediastinal hemorrhage or hematoma.…”

“…9,[15][16][17] Although some scales incorporate BTAI size and secondary signs of aortic injury, such as mediastinal hematoma, none include patient physiology or assess the stability of the lesion. As such, none of the current systems quantify a lesion's risk of rupture.…”

Evolution of lesion-specific management of blunt thoracic aortic injury

“…24 Follow-up imaging of minimal aortic injuries indicates a high rate of resolution and low rate of progression to more severe injury. 23,[25][26][27][28][29][30] For example, in a series of 43 patients with low-grade lesions and medium-term followup imaging reported by Osgood et al, 55% of lesions resolved and 40% remained stable. Progression to a higher grade injury occurred in two patients, but late intervention was not required.…”

“…3,17,32,33 Whereas pseudoaneurysms are associated with aortic-related morbidity and mortality because of greater potential for progression to rupture, 3,10,17 some remain stable and have been successfully managed nonoperatively. 10,16,29,30,[34][35][36] For example, Rabin et al reported a nonoperative management rate of 28% (17/59) for uncomplicated pseudoaneurysms, with no aortic mortality. 35 Similarly, in preliminary data from Osgood et al, 24% (37/153) of patients with pseudoaneurysms were managed medically, although one patient with a larger lesion subsequently ruptured and died.…”

“…28,33,35 The spectrum of blunt aortic trauma is graded by several CT-based scales that describe the anatomic severity of the injury (Table I). 17,28,29,33,35,37 For example, the system described by Azizzadeh et al and subsequently adopted by the Society for Vascular Surgery has four grades: I, intimal tear; II, intramural hematoma; III, pseudoaneurysm; and IV, rupture. 31,37 Other schemes, such as those by the Vancouver, Presley, Stanford, and Maryland Shock Trauma groups, further stratify pseudoaneurysms according to size.…”