Blunt Thoracic Aortic Injury and Contemporary Management Strategy

Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.

Applicability of Anatomic and Physiologic Scoring Systems for the Prediction of Outcome in Polytraumatized Patients with Blunt Aortic Injuries

Background: Most patients with blunt aortic injuries, who arrive alive in a clinic, suffer from traumatic pseudoaneurysms. Due to modern treatments, the perioperative mortality has significantly decreased. Therefore, it is unclear how exact the prediction of commonly used scoring systems of the outcome is. Methods: We analyzed data on 65 polytraumatized patients with blunt aortic injuries. The following scores were calculated: injury severity score (ISS), new injury severity score (NISS), trauma and injury severity score (TRISS), revised trauma score coded (RTSc) and acute physiology and chronic health evaluation II (APACHE II). Subsequently, their predictive value was evaluated using Spearman´s and Kendall´s correlation analysis, logistic regression and receiver operating characteristics (ROC) curves. Results: A proportion of 83% of the patients suffered from a thoracic aortic rupture or rupture with concomitant aortic wall dissection (54/65). The overall mortality was 24.6% (16/65). The sensitivity and specificity were calculated as the area under the receiver operating curves (AUC): NISS 0.812, ISS 0.791, APACHE II 0.884, RTSc 0.679 and TRISS 0.761. Logistic regression showed a slightly higher specificity to anatomical scoring systems (ISS 0.959, NISS 0.980, TRISS 0.957, APACHE II 0.938). The sensitivity was highest in the APACHE II with 0.545. Sensitivity and specificity for the RTSc were not significant. Conclusion: The predictive abilities of all scoring systems were very limited. All scoring systems, except the RTSc, had a high specificity but a low sensitivity. In our study population, the RTSc was not applicable. The APACHE II was the most sensitive score for mortality. Anatomical scoring systems showed a positive correlation with the amount of transfused blood products.

Blunt aortic injury: Surgical treatment of the ascending and descending aorta

Traumatic aortic injury is potentially fatal. Although uncommon, involvement of the aortic arch and the ascending aorta can occur. This case shows concomitant dissection of the ascending and descending sections of the aorta after blunt chest trauma where the open surgical approach was successfully performed to treat both aortic injuries.

P.224 A Case Report of Spinal Screws Penetrating the Pulmonary Artery

Background: Spinal instrumentation is commonly utilized to mechanically stabilize the spine in trauma, oncology and degenerative disease. Although several complications have been reported, this is the first case of screw penetration of the pulmonary artery. Methods: We present a case of a 74-year old gentleman who suffered from a thoracic spine chordoma. He underwent a T8 resection with T8-T12 instrumented fusion with subsequent radiation. Recurrence of his disease led to resection of his 3rd and 4th ribs and repeat radiation. He presented 6 years later with 2 episodes of massive hemoptysis. Review of the literature was conducted to search for similar complications. Results: A Chest Computed Tomography scan demonstrated the presence of a pedicle screw tip in the right pulmonary artery. Angiogram revealed no evidence of active arterial extravasation. In the operating room, the patient had a right lower lobectomy, with segmental pulmonary artery sacrifice, as well as replacement of the spinal fixation hardware. Literature review revealed multiple aortic injuries following spinal instrumentation. However, this was the first case of pulmonary artery erosion. Conclusions: Spinal instrumentation has been associated with screw migration and penetration of nearby tissues and vessels. A high incidence of suspicion is required when patients present with delayed and unusual complications.

Blunt Traumatic Aortic Injury

Traumatic aortic injuries represent a leading cause of death following motor-vehicular accidents. These injuries curry a very high mortality rate even though a significant number of patients reaches the hospital alive. These injuries are identified in the contest of a polytrauma work up and are almost always associated with multiple other severe traumatic injuries which makes the management of these patients very challenging. The technology advancements seen in recent years with radiologic imaging and the progress of the therapeutic options brought up by the uprise of endovascular therapy, along with the sophistication of the techniques of trauma resuscitation and intensive care management, have improved significantly the overall prognosis of these patients. Although traumatic aortic injuries need to be generally considered a life-threatening condition, their degree of severity may differ significantly from case to case requiring immediate repair in some patients, whereas their repair can be delayed in cases when the severity of the aortic injury does not represent an immediate threat to the patient life. Therefore, the challenge of treatment of the polytrauma patients with an aortic injury is to identify the best strategy of therapy able to prioritize the treatment of the injuries based on their lethal potential. In this contest, the ability of properly defining the severity of the aortic injury is the key-factor to allow the appropriate definition of a treatment strategy able to identify treatment priorities. In our experience, radiologic assessment of the aortic injury in correlation with the evaluation of clinical parameters and a comprehensive polytrauma assessment allows to optimize the ability of the trauma team to establish the most appropriate strategy for the care of this complex patients’ group.

Endoprosthesis replacement of the thoracic aorta for traumatic dissection and pseudoaneurysm

Aortic injury in closed chest trauma takes the second place in the structure of mortality in closed injuries. The type of aortic injury is a crucial factor in determining the optimal timing of the operation. For many years, the treatment strategy was reduced to immediate surgical intervention. The mortality rate in open operations is still high. The widespread introduction of endovascular technologies and aortic endoprosthetics has significantly reduced mortality and reduced the number of severe postoperative complications. With the advent of new endoprostheses, the possibilities of treatment have increased even more and its results have improved for various aortic injuries. A case of successful treatment of a patient with traumatic dissection and pseudoaneurysm of the thoracic aorta by endoprosthetics is presented.

Fluoroquinolone-Induced Aortic Injury

According to clinical studies, the use of fluoroquinolone antibacterial agents is associated with such rare, but serious adverse reactions as aortic injuries. The aim of the study was to analyse scientific literature data on the risk of aortic injury during fluoroquinolone treatment. The analytical review showed that the risk factors for fluoroquinolone-induced aortic injury are male gender, age over 45 years, underlying aortic disease, as well as smoking and associated atherosclerosis. Clinical and morphological forms of fluoroquinolone-associated aortic injuries include dilatation (aneurysm development), dissection, and rupture. The analysis of data on the association between aortic injuries and the use of most common fluoroquinolones (ciprofloxacin, levofloxacin, and moxifloxacin) showed that development of aneurysm and dissection was most often observed for levofloxacin, and least often for ciprofloxacin. The mechanism of aortic injury is due to fluoroquinolone-mediated activation of matrix metalloproteinases which damage elastic components of vascular walls, as well as reduction in lysyl oxidase expression and collagen synthesis. The ability of fluoroquinolones to form complexes with magnesium ions reduces the availability of magnesium to the cell enzyme systems, which delays synthesis of extracellular matrix structural proteins, leads to metalloproteinase activation and calcification of the vascular walls. Prevention, early detection, and timely management of the above-mentioned issues depend on the awareness of different medical specialists about the risks of aortic injury associated with the use of fluoroquinolone antibiotics.