Thoracic aotic injury

thoracic aortic injuries are very rare, this presentation will give a brief idea regarding the presentation of Thoracic aortic injury and its management

1. Thoracic Aortic Injury Awaneesh Katiyar Senior Resident M.Ch . Trauma Surgery & Critical Care AIIMS, Rishikesh

2. Case Scenario A 25 year-male driving car @140km/hour collided to a wall, arrived in ED within 25min of car crash. Airway patent with full GCS. HR 134/min, BP 112/48, complaining of severe chest pain. O/E pattern abrasion of steering noted over sternum and left chest with sign of sternum fracture. Right Patella fracture , right both bone leg fracture also noted. PCT positive. EFAST –pericardial fluid( no tamponade ) with left hemothorax noted , abdomen - no fluid. P/A soft nontender. What are the differential diagnosis ? How you proceed ? Thoracic Aortic Injury 1

3. Introduction Incidence <1% of all blunt trauma ( > 70% HMV collision) 1 80% - on scene death or transfer – counts for 10-15% MVC related deaths 2 Sign and symptoms are non-specific – often associated with distracting injuries Akhmerov A, DuBose J, Azizzadeh A. Blunt thoracic aortic injury: current therapies, outcomes, and challenges. Annals of Vascular Diseases. 2019 Jan 22:ra-18. Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521. 2 Thoracic Aortic Injury

4. Deaths – untreated Duration Deaths First hour 10-15 % Within 6 hours 20-30% Within 24hours 30-50% Within a week 60-70% Parmley et. al 1958 Jahnke et al 1964 Gotzen , Hetzer et al 1982 Hartford et al 1986 Death Percentage Duration (days) 3 Thoracic Aortic Injury Most deaths are Preventable death -Depends on preparedness

5. Deaths * * Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521. 4 Thoracic Aortic Injury

6. Hunt JP, Baker CC, Lentz CW, Rutledge RR, Oller DW, Flowe KM, Nayduch DA, Smith C, Clancy TV, Thomason MH, Meredith JW. Thoracic aorta injuries: management and outcome of 144 patients. Journal of Trauma and Acute Care Surgery. 1996 Apr 1;40(4):547-56. Parmley LF, MATTINGLY TW, MANION WC, JAHNKE JR, MAJ EJ. Nonpenetrating traumatic injury of the aorta. Circulation. 1958 Jun;17(6):1086-101. 1. 144 Emergency Cases ( Hunt et. al 1996) 2. 275 Post-Mortem Cases ( Parmley et. al 1958) AA DTA DTA 5 Thoracic Aortic Injury

7. Mechanism of Injury Rapid decelerating injury Direct impact Fall from height 6 Thoracic Aortic Injury

8. Rapid deceleration - Pathophysiology Rapid deceleration 7 Thoracic Aortic Injury Thoracic Aortic Injury – common in high velocity crash Head injury Cervical spine – whiplash injury Knee, Hip – acetabulum Retroperitoneal injury Shearing force between static and mobile parts of Aorta Tear – distal to LSCA ( fixed)

9. Osseous Pinch - Pathophysiology Blunt trauma chest – osseous pinch 8 Thoracic Aortic Injury

10. Water hammer effect - Pathophysiology Water- Hammer effect 9 Thoracic Aortic Injury

11. Clinical presentation Hypotension (clinical suspicion) Upper extremity hypotension Expanding hematoma at thoracic out Intra-scapular murmur sternum fracture Left flail chest Associated thoracic spine fracture Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521. 10 Thoracic Aortic Injury

12. Chest radiograph – large hemothorax 11 Thoracic Aortic Injury

13. Foreign body (FB) in proximity of great vessels 12 Thoracic Aortic Injury

14. Trajectory with confusing course / distal embolization 13 Thoracic Aortic Injury

15. Funny looking mediastinum 14 Thoracic Aortic Injury Loss of Aortic Knuckle Sign of contained aortic rupture

16. Mediastinal clues * Aortic knob – obliteration or double Mediastinal widening > 8cm Depression of left main bronchus >140 from trachea Loss of paravertebral stripe * Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521. 15 Thoracic Aortic Injury

17. Mediastinal clues * Calcium layering at aortic knob Deviation of NG tube Lateral displacement of the trachea. * Wall MJ, Tsai P, Mattox KL. Heart and thoracic vascular injuries. Trauma. New York, NY: McGraw Hill Medical. 2017:493-521. 16 Thoracic Aortic Injury

18. Associated organ injuries * 90% have other organ injuries 51% cerebral injury 62% other thoracic injury 22% intra-abdominal injuries 34% pelvic or extremities fracture * Smith RS, Chang FC. Traumatic rupture of the aorta: still a lethal injury. The American journal of surgery. 1986 Dec 1;152(6):660-3. 17 Thoracic Aortic Injury

19. Investigations Chest X rays – Initial investigation Aortography Thoracic CT (Investigation of choice ) * Thoracic MRI Transesophageal echo ( TEE) IVUS 18 * Kumar R, Raja J, Munirathinam GK, Mishra AK, Singh RS, Thingnam SK. A case of traumatic thoracic aorta rupture-A life threatening emergency. Journal of Cardiovascular and Thoracic Research. 2019;11(3):248. Helical CT is more sensitive than Aortogram and conventional CT * Thoracic Aortic Injury

20. Traumatic Aortic Injury classification Akhmerov A, DuBose J, Azizzadeh A. Blunt thoracic aortic injury: current therapies, outcomes, and challenges. Annals of Vascular Diseases. 2019 Jan 22:ra-18. 19 Thoracic Aortic Injury

21. AAST grading 20 Thoracic Aortic Injury

22. Aortogram: grade-I 21 Thoracic Aortic Injury

23. CT / Aortogram: grade-II 22 Thoracic Aortic Injury

24. X rays & Aortogram: grade-III 23 Thoracic Aortic Injury

25. CT thorax: grade-IV 24 Thoracic Aortic Injury

26. 25 Thoracic Aortic Injury

27. Management of Aortic Injury UpToDate 2020 - Management of Blunt Aortic injury Initial Management – ATLS Protocol Unstable Stable Operation theatre Grade – I Grade – II, III, IV Non– Operative Operative 26 Thoracic Aortic Injury

28. Non-operative Management – MAI Anti-impulse therapy ( Negative Inotropic therapy) : <100 SBP and HR < 100/min Beta blocker - IV Esmolol Calcium channel blocker – diltiazem Non achievable – add vasodilator - Nitroprusside 1. UpToDate 2020 - Management of Blunt Aortic injury 2. Malhotra AK, Fabian TC, Croce MA, Weiman DS, Gavant ML, Pate JW. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. Journal of Trauma and Acute Care Surgery. 2001 Dec 1;51(6):1042-8. Good clinical Practice – No Randomized control trial Initial Management – ATLS Protocol Minimal Aortic injury : <1 cm intimal tear with minimal or no peri-aortic hematoma 1,2 27 Thoracic Aortic Injury

29. Follow –up for NOM No Established protocol – lack of data First – CT follow up – 1 st three month after discharge. Exact timing depends Judgement of surgeon Anatomical lesion Patient status – age / renal functions Osgood MJ, Heck JM, Rellinger EJ, Doran SL, Garrard III CL, Guzman RJ, Naslund TC, Dattilo JB. Natural history of grade I-II blunt traumatic aortic injury. Journal of vascular surgery. 2014 Feb 1;59(2):334-42. 28 Thoracic Aortic Injury

30. Fate of MAI – NOM S.N. Author Study population Conclusion 1. Kepros et al 2002 5 - BOI <20 mm in hemodynamically stable patients treated with beta-blockade resolve within several days( 10 days ) – TEE monitoring ( 3 -19 days ) all Survived 6 month follow-up. 2. Malhotra et al 2001 Virginia 96 ( 9 with MAI) 33% - patient developed – pseudo aneurysm ( 56. 60. 70) 44% - healthy 10 weeks follow –up 22% - died ( MODS/PE) 1. Kepros J, Angood P, Jaffe CC, Rabinovici R. Aortic intimal injuries from blunt trauma: resolution profile in nonoperative management. Journal of Trauma and Acute Care Surgery. 2002 Mar 1;52(3):475-8. 2. Malhotra AK, Fabian TC, Croce MA, Weiman DS, Gavant ML, Pate JW. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. Journal of Trauma and Acute Care Surgery. 2001 Dec 1;51(6):1042-8. 29 Thoracic Aortic Injury

31. 145 – Thoracic aortic injury 30 – NOM 15 delayed repair 3days – 90 days 15 NOM 15 NOM – 5 expired due to severe head injury 10 NOM – (till 5 years follow up) 5 resolved completely 5 developed – stable pseudoaneurysm 30 Thoracic Aortic Injury

32. Conclusion – MAI MAI ( Grade 1) – should follow regularly once monthly Screened with – CT Angio or TEE While discharging patient – warning sign should be explained – severe chest pain ( MC) Counselled may required surgery within three months Even after 3 months 50% patient have probability to develop pseudoaneurysm 31 Thoracic Aortic Injury

33. Operative Management - Grade II,III,IV Unstable – Immediate repair ( Grade 4) Stable –– delayed repair Immediate repair associated with higher mortality and complications over delayed repair. Immediate repair – In Extremis. Pacini D, Angeli E, Fattori R, Lovato L, Rocchi G, Di Marco L, Bergonzini M, Grillone G, Di Bartolomeo R. Traumatic rupture of the thoracic aorta: ten years of delayed management. The Journal of Thoracic and Cardiovascular Surgery. 2005 Apr 1;129(4):880-4. 32 Thoracic Aortic Injury

34. Immediate Vs Delayed S.N Authors and Year Cases Conclusion 1. Davide Pacini el al 2005 69 21 Immediate(1) 48 delayed(2) Group 1 – 8 hrs (mean time) 4 died (19%) Group 2 – 3.4± 1.9 days( mean time) 2 died ( 4.2%) 33 Thoracic Aortic Injury

35. ORIGINAL ARTICLES Diagnosis and Treatment of Blunt Thoracic Aortic Injuries: Changing Perspectives AAST 1 – 1997 AAST 2 – 2007 Study 274 – 30 centers 193 – 18 centers Diagnosis CT 34.8%, Aortography 87.0%, and 11.9% TEE CT scan – 93.3% , 8.3% Aortography , 0.1% TEE Mean time ( injury to repair) 16.5 hours 54.6 hours Open Vs Endovascular 100% open 35.2% open repair 64.8% endovascular stent-grafts.  Bypass use 64.7% 83.8% Mortality ( excluded in-extremis presentation) 22% 13% Paraplegia 8.7% 1.6% Graft related complication 0.5% 18.4% Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy -Jones R, Teixeira PG, Hemmila MR, O’Connor JV, McKenney MO, Moore FO, London J. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. Journal of Trauma and Acute Care Surgery. 2008 Jun 1;64(6):1415-9. 34 Thoracic Aortic Injury

36. Open Vs Endovascular Open thoracic repair -primary repair of the aorta or replacement of the diseased aortic segment with a prosthetic tube graft through a thoracotomy incision Endovascular thoracic aortic repair( TEVAR) - placement of modular graft components - via the iliac or femoral arteries to line the thoracic aorta and exclude the injury from the circulation 2020 35 Thoracic Aortic Injury

37. Comparative effectiveness of the treatments for thoracic aortic transection (Retrospective) J Vasc Surg. 2011 Author NOM Open TEVAR Murad MH et. al 2011 7728 pts Mortality 46% 19% 9% Paraplegia 3% 9% 3% End stage renal ds 3% 8% 5% Graft site infection NA 11% 3% Murad MH, Rizvi AZ, Malgor R, Carey J, Alkatib AA, Erwin PJ, Lee WA, Fairman RM. Comparative effectiveness of the treatments for thoracic aortic transaction. Journal of vascular surgery. 2011 Jan 1;53(1):193-9. 36 Thoracic Aortic Injury

38. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: A modern meta-analysis J Vasc Surg. 2011 Tang GL, Tehrani HY, Usman A, Katariya K, Otero C, Perez E, Eskandari MK. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. Journal of vascular surgery. 2008 Mar 1;47(3):671-5. Authors Open (370 ) Endo (329) Tang GL et. al 2008 699 pts Mortality 15.2 % 7.6 % Paraplegia 5.6% 0.% Stroke 0.85 % 5.3 % Specific RLN - 14.1% Procedure specific – 17% Iliac rupture – 5 Thrombosis – 2 Procedure related 13.3% 37 Thoracic Aortic Injury

39. Thoracic Aortic Injury 38

40. Immediate-open Approach S.N. Vessels Incision – approach 1. Ascending Aorta Median sternotomy 2. Transverse Aorta Median Sternotomy ± neck extension 3. Descending Thoracic Aorta Left posterolateral thoracotomy 4 th ICS 39 Thoracic Aortic Injury No Cardiopulmonary bypass associated with poor outcome – in terms of mortality, paraplegia, Nerve injury,

41. Conclusion S.N. Points Summary Recommendation 1. Initial resuscitation Two wide bore cannula Permissive hypotension Anti- Impulse therapy Grade 2C HR < 100 BP < 100 SBP Grade 2C 2. Unstable Patient Emergent exploration – identify source of bleeding GCP 3. Stable patient Grade I tear – NOM Grade 2C Grade II, III , IV injury – operative management Grade 1B 4. Operative Suitable anatomy and stable patient – preferred Endovascular management Grade 2C 1B – strong recommendation , 2C – poor recommendation UpToDate2020 40 Thoracic Aortic Injury

42. Author’s suggestion Don’t ignore – High index of suspicion – sinister badness beneath the surface. Properly evaluate aorta – distal to LSCA Don’t ignore – Abnormal CXR and mediastinal sign Guidelines for MAI ( not defined) – management & follow-up Monthly follow-up ( surgeon’s choice and patient condition ) 2-3 mo. CT follow-up 6 months mandatory ( for stable pseudoaneurysm 5 yrs F/U) 41 Thoracic Aortic Injury

43. In stable patient prefer – TEVAR over Open Consider safe transfer over Open repair in stable patients. Author’s suggestion 42 Thoracic Aortic Injury

44. Thoracic Aortic Injury 43 Thank You If you want to save 20% you need to screen 80% extra with same intention

45. Q.1 A 32 yrs / M is involved in a high-speed motor vehicle accident collided to the wall. A- patent , Breathing – Left CCT positive, C – Intact P 140, BP 124/78 all pulses palpable , D-GCS – 15 with signs of clavicle fracture .CXR confirmed left clavicle and multiple ribs fracture with Left hemothorax . Given the suspected diagnosis, which of the following vessels should be evaluated for injury? Right subclavian artery Proximal innominate artery Left common carotid artery Left subclavian artery 44 Thoracic Aortic Injury

46. Q.2 A 36 yrs /M is involved in a high-speed motor vehicle accident. He was wearing seat belt, and he decelerate rapidly to save a pedestrian and swerved into a ditch. At presentation vitals stable, he complained of severe chest pain. Physical examination reveals several bruises on the chest. His respiratory examination is unremarkable. A chest x ray shown below . What will be the next investigation? CT Angiography Aortogram 2D echo IVUS 45 Thoracic Aortic Injury

47. Q.3 A 36 yrs /M is involved in a high-speed motor vehicle accident. He was wearing seat belt, and he decelerate rapidly to save a pedestrian and swerved into a ditch. At presentation vitals stable, he complained of severe chest pain. Physical examination reveals several bruises on the chest. His respiratory examination is unremarkable. A Helical CT shown below . What will be the management ? NOM TEVAR REBOA Open repair 46 Thoracic Aortic Injury

48. Q.4 A 24 yrs /M is involved in RTI driving bike ( 120Km/Hr) collided to truck . He was wearing helmet At presentation- patient was in in-extremis, bike handle pattern noted over sternum. Left flail chest visible, E1V2M4 CXR shown below, not responding to IV fluids. What will be the management ? Resuscitate with fluid Explore for bleeding source REBOA TEVAR 47 Thoracic Aortic Injury

49. Q.5 What will be the grade of Thoracic great vessels injury ( AAST) Grade 4 Grade 5 Grade 6 Grade 3 48 Thoracic Aortic Injury