Natural history of grade I-II blunt traumatic aortic injury

Abstract

Introduction Endovascular aortic repair has revolutionized the management of traumatic blunt aortic injury (BAI). However, debate continues about the extent of injury requiring endovascular repair, particularly with regard to minimal aortic injury (MAI). Therefore, we conducted a retrospective observational analysis of our experience with these patients. Methods We retrospectively reviewed all BAI presenting to an academic Level I trauma center over a ten-year period (2000–2010). Images were reviewed by a radiologist and graded according to Society for Vascular Surgery (SVS) guidelines (Grade I–IV). Demographics, injury severity, and outcomes were recorded. Results We identified 204 patients with BAI of the thoracic or abdominal aorta. Of these, 155 were deemed operative injuries at presentation, had grade III-IV injuries, or aortic dissection and were excluded from this analysis. The remaining 49 patients had 50 grade I–II injuries. We managed 46 grade I injuries (intimal tear or flap, 95%), and 4 grade II injuries (intramural hematoma, 5%) nonopertively. Of these, 41 patients had follow-up imaging at a mean of 86 days post-injury and constitute our study cohort. Mean age was 41 years and mean length of stay was 14 days. The majority (48 of 50, 96%) were thoracic aortic injuries and the remaining 2 (4%) were abdominal. On follow-up imaging, 23 of 43 (55%) had complete resolution of injury, 17 (40%) had no change in aortic injury, and 2 (5%) had progression of injury. Of the 2 patients with progression, one progressed from grade I to grade II and the other progressed from grade I to grade III (pseudoaneurysm). Mean time to progression was 16 days. Neither of the patients with injury progression required operative intervention or died during follow-up. Conclusions Injury progression in grade I–II BAI is rare (∼5%) and did not cause death in our study cohort. Since progression to grade III injury is possible, follow-up with repeat aortic imaging is reasonable.

Treatment of blunt thoracic aortic injury in Germany—Assessment of the TraumaRegister DGU®

“…Furthermore, in contrast to previous studies, our survey showed considerable increased risk assessment scores for the pre-hospital phase for all subgroups. Du Bose et al and Demetriades et al demonstrated lower values for the ISS and for GCS as well as lower rates of hypotension on admission compared to this study [7, 8, 20]. In addition, a higher rate of conservative treatment for grade IV injuries was observed, which might be evaluated as palliative therapy for fatal injured persons, finally resulting in a higher mortality rate.…”

“…This observation is surprising, as the risk for rupture for BTAI grade I and II is generally estimated low and previous studies recommended medical treatment for patients suffering from grade I and II BTAI [7, 20]. Osgood et al described a low progression rate of medical treated grade I and II BTAI within a follow up period of 86 days [20]. However, the patients in the present study who received medical treatment, displayed an AIS > 3 and a GCS <8 more frequently as well as a higher rate of CPR compared to those receiving surgical therapy.…”

Traumatic injuries of the thoracic aorta: The role of imaging in diagnosis and treatment

“…The approach to treatment varies from one unit to another, in spite of several attempts to bring practices in line [17].…”

The Acute Abdominal Aorta

“…44 Although precise classification of an ATAI into one of these types based on CT may be difficult, radiologists should be aware of this classification scheme because it can inform prognosis, guide treatment, and determine the need for follow-up imaging. 45 What the Referring Clinician Needs to Know: Traumatic Aortic Injury Classification …”