Traumatic Thoracic Aortic Injuries

T raumatic blunt injury to the thoracic aorta is one of the most formidable challenges surgeons face. This devastating condition can lead to immediate death at the time of injury in the majority of cases, due in part to either aortic transection or acute rupture.1 Although blunt aortic injury accounts for less than 1% of all adult level I trauma center admissions, this condition represents the second most common cause of death due to blunt injury, second only to head trauma.2 Approximately 7,500 to 8,000 cases of blunt aortic trauma occur annually in North America, and it is estimated that only 25% of patients who sustained aortic injuries due to blunt thoracic trauma remain alive upon arrival to the hospital.3 Although these patients survive the initial injury, their prognosis remains poor. Nearly 30% of them will die within the first 6 hours, and 50% of these patients will not live beyond the first 24 hours.4 This high mortality rate has previously prompted traditional management of blunt aortic injury to establish early diagnosis and rapid surgical intervention to prevent a catastrophic rupture. This belief has been modified to allow delay of the operative intervention in order to first manage other serious concomitant injuries and lessen the high surgical mortality rate associated with emergent aortic repair.5 Despite advances in modern trauma care, emergent operative intervention for blunt aortic injury is associated with significant cardiac, pulmonary, neurologic, and hemodynamic complications.5,6 The classic injury mechanism of blunt thoracic aortic rupture is related to the combination of sudden deceleration and traction at the relatively immobile aortic isthmus, which represents the junction between the relatively mobile aortic arch and the fixed descending aorta (Figure 1). The isthmus is the most common location for rupture (50% to 70%) followed by the ascending aorta or aortic arch (18%) and the distal thoracic aorta (14%).4 This article examines the role of endovascular aortic repair of traumatic blunt aortic injury, reviews current literature of this treatment, and analyzes the potential challenges of this treatment modality in blunt aortic injury.