Endovascular treatment of traumatic thoracic aortic injury—should this be the new standard of treatment?

Abstract

Blunt trauma to the thoracic aorta is a potentially life-threatening condition that can lead to death in 75% of cases at the time of injury, as a result of either aortic transection or acute rupture. Although it accounts for 1% of adult admissions to level I trauma centers, blunt aortic injury represents the second most common cause of death due to blunt trauma, second to head injury. It is estimated that only 25% of patients who sustain aortic injuries due to blunt thoracic trauma remain alive upon arrival to the hospital. The prognosis for patients who survive the initial injury remains poor: nearly 30% will die within the first 6 hours, and 50% of these patients will not live beyond the first 24 hours after the injury. 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 to first manage other serious concomitant injuries and lessen the high surgical mortality rate associated with emergent aortic repair. Despite advances in modern trauma care, emergent operative intervention for blunt aortic injury is associated with significant cardiac, pulmonary, neurologic, and hemodynamic complications. The classic injury mechanism of blunt thoracic aorta 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. 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%). Patients with blunt trauma to the thoracic aorta typically have multiple associated injuries to