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Vascular injuries after blunt chest trauma: diagnosis and management.

O'Connor JV, Byrne C, Scalea TM, Griffith BP, Neschis DG - Scand J Trauma Resusc Emerg Med (2009)

Bottom Line: Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries.More stable injuries can often be medically temporized in order to optimize definitive management.Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

View Article: PubMed Central - HTML - PubMed

Affiliation: R. Adams Cowley Shock Trauma Center, Baltimore, USA. joconnor@umm.edu

ABSTRACT

Background: Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Methods: A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise.

Discussion: Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

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Reconstructed computed tomography with contrast depicting aortic injury with pseudoaneurysm (arrow). Arrowhead indicates proximal left subclavian artery.
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Figure 1: Reconstructed computed tomography with contrast depicting aortic injury with pseudoaneurysm (arrow). Arrowhead indicates proximal left subclavian artery.

Mentions: Historically bi-planar angiography has been the diagnostic modality of choice for evaluating blunt great vessel and aortic injury based on the landmark study by Parmley [5]. However, aortography is invasive and requires a special team for its performance and is therefore not a good screening study. In the past, the risk of a missed injury in these cases had been considered too great by some and routine screening by aortography had been suggested[4]. This dilemma is now largely only of historical interest since the advent of modern computed tomagraphy (CT) technology[31,32]. CT has sensitivities of 97-99.3% and specificities of 87.1-99.8% and routine use before angiography resulted in cost savings of greater than $365,000 over a four year period[31]. CT is now the diagnostic test of choice (Figure 1) [31,33]. The same can not be said for the use of CT scanning for the diagnosis of blunt injury to aortic branch vessels. The small number of patients undergoing CT for aortic branch vessel trauma and questions as to its accuracy has limited its use as the diagnostic test of choice [34,35]. New generation, multiple detector CT technology, however, has clearly improved diagnostic quality and reduced the need for catheter based angiography. Our practice is similar to others as we use CT as a screening test and angiography as needed [35,36]. Magnetic resonance imaging, transesophageal echocardiography, and intravascular ultrasonography are alternative modalities in particular for diagnosis of blunt aortic injury.


Vascular injuries after blunt chest trauma: diagnosis and management.

O'Connor JV, Byrne C, Scalea TM, Griffith BP, Neschis DG - Scand J Trauma Resusc Emerg Med (2009)

Reconstructed computed tomography with contrast depicting aortic injury with pseudoaneurysm (arrow). Arrowhead indicates proximal left subclavian artery.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2749011&req=5

Figure 1: Reconstructed computed tomography with contrast depicting aortic injury with pseudoaneurysm (arrow). Arrowhead indicates proximal left subclavian artery.
Mentions: Historically bi-planar angiography has been the diagnostic modality of choice for evaluating blunt great vessel and aortic injury based on the landmark study by Parmley [5]. However, aortography is invasive and requires a special team for its performance and is therefore not a good screening study. In the past, the risk of a missed injury in these cases had been considered too great by some and routine screening by aortography had been suggested[4]. This dilemma is now largely only of historical interest since the advent of modern computed tomagraphy (CT) technology[31,32]. CT has sensitivities of 97-99.3% and specificities of 87.1-99.8% and routine use before angiography resulted in cost savings of greater than $365,000 over a four year period[31]. CT is now the diagnostic test of choice (Figure 1) [31,33]. The same can not be said for the use of CT scanning for the diagnosis of blunt injury to aortic branch vessels. The small number of patients undergoing CT for aortic branch vessel trauma and questions as to its accuracy has limited its use as the diagnostic test of choice [34,35]. New generation, multiple detector CT technology, however, has clearly improved diagnostic quality and reduced the need for catheter based angiography. Our practice is similar to others as we use CT as a screening test and angiography as needed [35,36]. Magnetic resonance imaging, transesophageal echocardiography, and intravascular ultrasonography are alternative modalities in particular for diagnosis of blunt aortic injury.

Bottom Line: Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries.More stable injuries can often be medically temporized in order to optimize definitive management.Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

View Article: PubMed Central - HTML - PubMed

Affiliation: R. Adams Cowley Shock Trauma Center, Baltimore, USA. joconnor@umm.edu

ABSTRACT

Background: Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Methods: A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise.

Discussion: Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

Show MeSH
Related in: MedlinePlus