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Traumatic Aortic Rupture

Traumatic Rupture of Aorta

Traumatic aortic rupture refers to a condition in which there is a tear or rupture of the aorta. It is caused by motor vehicle accidents or severe falls and the majority of affected individuals dies at the scene.


Presentation

Patients who are admitted with TAR generally show symptoms of severe hemorrhage and cardiovascular failure. Symptom onset is often peracute and patients who reach the hospital relatively stable may suddenly decompensate if, for instance, tissue opposing an aortic hemorrhage breaks. Upon admission, these people may not show any symptoms at all or they may claim retrosternal chest pain, dyspnea, and cough resulting from a space-occupying intrathoracic hematoma. Systolic heart murmurs are often heard; blood pressure may differ between upper and lower limbs. Instable TAR patients usually have a systolic blood pressure of < 90 mm Hg, a barely palpable pulse, tachycardia and tachypnea. Their skin may be cool and damp, their mucosal membranes pale or cyanotic. Depending on the overall blood loss, they may loose conscience.

Due to the etiology of TAR, the vast majority of patients will present additional injuries. Fractures, further thoracic and abdominal injuries have been reported in 70, 50 and 40% of patients admitted with TAR [5]. Such lesions may significantly contribute to the poor overall condition of the patient. In the case of contained aortic hemorrhages, other injuries may even take priority over the TAR, e.g. neurosurgical and laparotomic interventions [6].

Asymptomatic
  • Asymptomatic chronic traumatic aneurysms are not always a risk for sudden death unless too large. Therefore, growing aneurysms, symptomatic or not, should be surgically removed due to the risk of rupture.[en.wikipedia.org]
  • […] splenectomy Talent Right femoral Early occlusion of left subclavian artery (2 Palmaz); local thrombosis of superficial brachial artery (medical treatment) 21 M 20 1 mo No Min Tec Left external iliac 20 M 21 8 mo No Talent Right femoral 3 M 18 7 mo No Asymptomatic[circ.ahajournals.org]
Intravenous Administration
  • We believe intravenous administration (0.5 to 2 micrograms/kg/min) of argatroban is a safe anticoagulant for left heart bypass in repairs of traumatic aortic rupture associated with multiple organ injuries.[ncbi.nlm.nih.gov]
Tachypnea
  • Instable TAR patients usually have a systolic blood pressure of 90 mm Hg, a barely palpable pulse, tachycardia and tachypnea. Their skin may be cool and damp, their mucosal membranes pale or cyanotic.[symptoma.com]
Hypotension
  • Each patient's chart was evaluated for chest pain, respiratory distress, thoracic back pain, hypotension, hypertension, and decreased femoral pulses.[ncbi.nlm.nih.gov]
  • Significant factors for paraplegia were intraoperative hypotension (p 0.000002), cross-clamp time longer than 30 minutes (p 0.008), pump versus no pump (p 0.008), and younger age group (28 /-11 versus 39 /-17 years) (p 0.03).[ncbi.nlm.nih.gov]
  • Despite 4 units of O -ve blood they remain hypotensive and shocked. You perform a FAST scan to investigate the hypotension but are unable to see anything due to severe subcutaneous emphysema. You perform an urgent TOE.[echopraxis.com]
  • Injury Prediction Rule Age 50 Unrestrained Hypotension Thoracic injury Abdominopelvic injury Extremity fracture Head injury The Probability of Aortic Rupture: Prevalence of Aortic transection in blunt chest trauma 4 studies (n 8772 pts), prevalence 1.4%[chestx-ray.com]
  • Abdominal aortic aneurysm (AAA) Ruptured AAA presents with a classical triad of pain in the flank or back, hypotension and a pulsatile abdominal mass; however, only about half have the full triad.[patient.info]
Chest Pain
  • Abstract Twenty-five years after a blunt chest trauma, sudden expansion of a traumatic aortic aneurysm induced a dysphagia and chest pain in a 57-year-old man.[ncbi.nlm.nih.gov]
  • Each patient's chart was evaluated for chest pain, respiratory distress, thoracic back pain, hypotension, hypertension, and decreased femoral pulses.[ncbi.nlm.nih.gov]
  • We present a patient who survived the initial injury, when the diagnosis of aortic rupture was not suspected. and presented 3 weeks later with chest pain.[ncbi.nlm.nih.gov]
  • When present, symptoms of an aortic rupture may include: Severe chest pain Severe back pain Severe abdominal pain Signs of external chest injury Causes and Risk Factors The condition is caused by trauma to the aorta.[cedars-sinai.edu]
  • Symptoms are often unreliable, but include: Severe tearing chest pain (sometimes) cough dyspnea dysphagia back pain hoarseness High upper body blood pressure Low lower body blood pressureBlood pressure is usually high in the upper body, but low in the[en.wikipedia.org]
Vascular Disease
  • VASCULAR DISEASE MANAGEMENT 2012:9(12):E217-E218 Key words: aortoiliac artery, stent graft, endovascular therapy, endovascular grafts _____________________________________ Case Report An 82-year-old female patient suffered multiple fractures from a fall[vasculardiseasemanagement.com]
Decreased Femoral Pulse
  • Each patient's chart was evaluated for chest pain, respiratory distress, thoracic back pain, hypotension, hypertension, and decreased femoral pulses.[ncbi.nlm.nih.gov]
Retrosternal Chest Pain
  • Upon admission, these people may not show any symptoms at all or they may claim retrosternal chest pain, dyspnea, and cough resulting from a space-occupying intrathoracic hematoma.[symptoma.com]
Meningism
  • Except for 2 patients with a history of heavy smoking, none of our patients presented risk factors other than those related to their previous trauma: paraplegia (n 1), splenectomy (n 1), past history of meningeal hemorrhage (n 1), pulmonary contusions[circ.ahajournals.org]

Workup

None of the above-mentioned symptoms and signs are characteristic for TAR; on the contrary, similar alterations may be presented by patients suffering from hypovolemic shock due to any other reasons. But any delay in adequate treatment may worsen the outcome and there may be no time for extensive diagnostic measures. The following may be considered:

  • Symptoms of hemorrhagic shock in patients older than 50 years who sustained an accident and did not wear a seatbelt, who are diagnosed with pneumothorax or have visible signs of thoracic injury and/or fractures of the vertebral spine are likely to suffer from TAR. Head injury and pelvic fractures may be further predictors of TAR [7].
  • Plain thoracic radiographic images can be obtained fast and may reveal hemothorax, pneumothorax, and mediastinal hematoma. The latter is related to an abnormally wide mediastinum that comprises more than a quarter of the diameter of the thorax. In the case of TAR, the space between the aortic arch and the pulmonary artery, i.e. the aortopulmonary window, is often poorly defined. Limited hemorrhages may be barely detectable in radiographic images.
  • In order to visualize aortic lesions despite the lack of radiographic findings, computed tomography scans or magnetic resonance imaging have to be carried out. With regards to computed tomography, detection of a luminal thrombus, intimal flap, pseudoaneurysm, periaortic extravasation of contrast agent and mediastinal hematoma are considered as direct signs of aortic injury [8]. Patients who present more than two direct signs of traumatic aortic lesions should be referred for surgery. Magnetic resonance imaging should be reserved for stable patients potentially considered for delayed surgery. In the case of an emergency, life-supporting devices cannot be disconnected long enough to allow for a time-consuming magnetic resonance scan.
  • Aortography is a very specific and sensitive diagnostic measure that should be omitted, though, if previous findings indicate TAR and call for an emergency surgery. Similar to magnetic resonance imaging, aortography may be too time-consuming in the case of life-threatening aortic injury. In TAR patients, aortography may reveal intraluminal or intimal anomalies, pseudoaneurysm or extravasation of contrast agent.
Atelectasis
  • In another patient, an atelectasis related to an increase of preexisting compression of the left main bronchus by the pseudoaneurysmal sac was successfully treated by temporary placement of an endobronchial silicone stent.[ncbi.nlm.nih.gov]
  • […] asymmetrical systolic pressures (150 mm Hg in the right arm versus 120 mm Hg in the left). (2) In 1 patient with a past history of severe septic context and neurological impairment, acute compression of the left main bronchus and homolateral pulmonary atelectasis[circ.ahajournals.org]
  • […] a chest radiograph: technical factors (supine vs erect) vascular ectasia mediastinal lipomatosis mediastinal masses Mimics of a mediastinal hematoma on CT include: artefact thymic tissue unopacified vessels pericardial recesses paramediastinal lung atelectasis[radiopaedia.org]
Chest X-Ray Abnormal
  • Chest x-ray abnormalities are common but may be absent and are often nonspecific; better aortic imaging studies include CT angiography, aortography, and transesophageal echocardiography.[merckmanuals.com]
X-Ray Abnormal
  • Chest x-ray abnormalities are common but may be absent and are often nonspecific; better aortic imaging studies include CT angiography, aortography, and transesophageal echocardiography.[merckmanuals.com]
Right Pleural Effusion
  • Right rib fractures, right pleural effusion, and right lung focal contusions are visible. Table 1.[circ.ahajournals.org]

Treatment

There are basically two treatment options: aortic repair during open surgery or endovascular stent placement. The latter has gained popularity in recent years and retrospective studies show endovascular treatment to be as effective but less invasive than open thoracic surgery [9] [10]. Endovascular aortic repair is not restricted to delayed surgery but can also be conducted as an emergency measure. This way, additional blood loss can be avoided, and systemic anticoagulation does not become necessary and thus does not interfere with other hemorrhages. It is also the faster alternative.

Furthermore, standard therapeutic measures have to be taken to compensate for aortic hemorrhages and to treat comorbidities. With regards to the former, fluid resuscitation, most likely transfusion of blood products, and thoracic drainage with chest tubes is generally indicated. If TAR has not been diagnosed before a chest tube is used, recovery of more than half a liter of blood is highly suggestive of aortic injury. In order to prevent further blood loss, beta blockers may be applied. Hemorrhages may also exacerbate if the patient is coughing or gagging, and these reflexes should be attenuated, for example by the use of intravenous lidocaine before endotracheal intubation.

Prognosis

As has been delineated above, TAR is fatal in the vast majority of cases. Due to rapid exsanguination, health caregivers are generally unable to reach the site of the accident before the victim dies. A minor share of patients reaches the hospital alive, but even among these individuals, mortality remains high. According to a recently published retrospective study, 50% of TAR patients suffered cardiopulmonary arrest shortly after arriving at the hospital; another 8% died after emergency operations [3]. Early surgical intervention is often the only chance for an affected person to survive TAR.

The outcome is somewhat better if aortic hemorrhages are contained in restricted anatomical spaces. The dense periaortic tissue, for instance, may serve as a life-saving barrier [4]. TAR may also refer to the mere dissection of aortic intima and media. In these cases, the aortic adventitia in conjunction with periaortic tissue may impede immediate exsanguination, which prolongs the time window for surgery and increases the chance of survival. The statement given above does not, however, apply to bleedings into the pericardial space. These most likely lead to cardiac tamponade, cardiogenic shock, and death.

Prognosis may be even worse in the case of life-threatening comorbidities, which are often observed in patients who sustained severe thoracic trauma.

Etiology

Blunt trauma, usually sustained in motor vehicle accidents or severe falls, is the main cause of TAR. The aortic wall is unable to withstand strong mechanical forces, namely those acting upon sudden deceleration. The risk of fatal TAR correlates with the magnitude of those forces and is thus increased if the patient impacts without being restrained by a seatbelt or similar safety installations.

Less frequently, penetrating lesions - either resulting from accidents or violent actions - account for transecting aortic injury [1].

Pre-existing aortic lesions, e.g., thoracic aortic aneurysm or abdominal aortic aneurysm, render patients more susceptible to TAR.

Epidemiology

In the majority of cases, TAR results from motor vehicle accidents. Most TAR patients are males, preferentially young adults in their third decade of life. This presumably results from an increased prevalence of risk behavior in that patient group.

Interestingly, overweight and obese people have been reported to be frequent victims in TAR patient cohorts.

Sex distribution
Age distribution

Pathophysiology

The left cardiac ventricle pumps blood into the aorta, from where it is distributed throughout the whole body. The aorta emerges from the left heart, ascends, gives rise to coronary arteries, and follows an arch in the posterior and left direction. The brachiocephalic artery, left common carotid artery and left subclavian artery emerge from this arch. The aortic arch narrows down, turns into the aortic isthmus, and re-expands as descending aorta, which passes the diaphragm through the aortic hiatus. At this point, the thoracic aorta turns into the abdominal aorta. The bifurcation into the left and right common iliac arteries constitutes the end of the aorta.

More than 50% of TAR victims suffer aortic isthmus rupture, i.e., vessel transection occurs in close proximity to the heart in the thoracic cavity [2]. The aortic isthmus is tightly connected to the left pulmonary artery. The ligamentum arteriosum, a remnant of the ductus arteriosus, consists of taut connective tissue and reduces the mobility of this part of the aorta. In the case of blunt trauma, other sections of the aorta may resist shearing forces to a limited extent by shifting. The aortic isthmus can't and ruptures rather easily. The second most frequently affected part of the aorta is even closer to its origin and comprises ascending aorta and aortic arch.

The amount of blood passing the aorta corresponds to the cardiac output which in the condition of rest amounts to approximately five liters per minute. Consequently, complete TAR leads to rapid exsanguination and death. According to the number given above, and provided that death occurs after losing two or three liters of blood, a patient whose aorta ruptures proximal to the heart would die within half a minute. However, blood flow in the case of the rupture of the most distal part of the abdominal aorta is still high and survival times after complete rupture of this aortic part are somewhat longer than after proximal TAR.

Prevention

All possible efforts should be made to avoid this life-threatening injury. Since most TAR are sustained during motor vehicle accidents, the corresponding safety measures should be adhered to. As has been indicated above, failure to fasten the seatbelt significantly increases the risk of TAR in the case of an accident. Speed limits should be respected as well as the prohibition of dangerous overtaking. Similarly, appropriate security measures should be taken into account while realizing other, potentially dangerous activities.

Summary

Traumatic aortic rupture (TAR) is a life-threatening vascular injury usually sustained during motor vehicle accidents, severe falls or other situations that led to blunt thoracic trauma.

Large parts of the aorta are only loosely attached to adjacent tissues, with the exception of the aortic isthmus. This short section of the vessel is connected to the pulmonary artery and thus behaves differently than more proximal or more distal parts if exposed to severe mechanical forces. Consequently, most TAR affects the aortic isthmus.

Complete TAR generally causes rapid exsanguination and death; most affected individuals die at the scene within a few minutes. In some cases, aortic hemorrhages may be contained by periaortic tissues. Here, exsanguination may be delayed and health caregivers may have a chance to intervene and repair the artery before the patient decompensates. Emergency surgery - either performed as open thoracic surgery or endovascular vessel repair - have to be carried out.

Of note, TAR patients frequently suffer from several comorbidities, lesions to other organ systems. These may be life-threatening and require an urgent attention as the aortic injury itself.

Patient Information

Traumatic aortic rupture (TAR) refers to transection of the aorta, main artery of the human body. It is generally caused by motor vehicle accidents or severe falls and the majority of affected individuals dies at the scene. High mortality rates result from rapid exsanguination. About five liters of blood are pumped through the aorta every minute and blood losses exceeding two or three liters are generally fatal. Thus, health caregivers rarely have a chance to attend TAR patients before they fall victim to the causative accident.

Consequently, all possible measures should be taken to avoid TAR and because blunt trauma sustained in motor vehicle accidents account for the vast majority of cases, this basically refers to driving in a responsible way. Speed limits should be respected as well as a prohibition of dangerous overtaking and other traffic rules. Nobody should ride a car after drinking alcohol or consuming drugs. This way, the necessity for emergency surgery to repair a ruptured aorta is largely reduced.

References

Article

  1. Mohammed RK, Cheung S, Parikh SP, Asgaria K. Conservative management of aortic arch injury following penetrating trauma. Ann R Coll Surg Engl. 2015; 97(3):184-187.
  2. Feczko JD, Lynch L, Pless JE, Clark MA, McClain J, Hawley DA. An autopsy case review of 142 nonpenetrating (blunt) injuries of the aorta. J Trauma. 1992; 33(6):846-849.
  3. Okada M, Kamesaki M, Mikami M, et al. Evaluation of the outcome of traumatic thoracic aortic rupture in patients in a trauma and critical care center. Ann Vasc Dis. 2013; 6(1):33-38.
  4. Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras. 2007; 6(1):64-73.
  5. Antonopoulos CN, Sfyroeras GS, Kallinis A, Kakisis JD, Liapis CD, Petridou ET. Epidemiology of concomitant injuries in traumatic thoracic aortic rupture: a meta-analysis. Vascular. 2014; 22(6):395-405.
  6. Pate JW, Fabian TC, Walker W. Traumatic rupture of the aortic isthmus: an emergency? World J Surg. 1995; 19(1):119-125; discussion 125-116.
  7. Blackmore CC, Zweibel A, Mann FA. Determining risk of traumatic aortic injury: how to optimize imaging strategy. AJR Am J Roentgenol. 2000; 174(2):343-347.
  8. Ng CJ, Chen JC, Wang LJ, et al. Diagnostic value of the helical CT scan for traumatic aortic injury: correlation with mortality and early rupture. J Emerg Med. 2006; 30(3):277-282.
  9. Cindy M, Sabrina H, Kim D, Geert M, Inge F. Traumatic aortic rupture: 30 years of experience. Ann Vasc Surg. 2011; 25(4):474-480.
  10. Watanabe K, Fukuda I, Asari Y. Management of traumatic aortic rupture. Surg Today. 2013; 43(12):1339-1346.

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Last updated: 2019-06-28 10:19