Penetrating injuries to the aorta and great vessels require operative management. This needs to be performed immediately if the patient is hemodynamically unstable. However, if the patient is hemodynamically stable, diagnostic arteriography is used to determine whether there is a significant vascular injury. Patients with penetrating injuries within the area bordered by the sternal notch, the xiphoid process, and the nipples laterally, or who have evidence of transmediastinal missile passage, are at risk of these injuries. The arteriography findings will delineate the optimal operative approach.
In blunt trauma, the aorta is most commonly injured at the level of the ligamentum arteriosum, close to the take-off of the left subclavian artery. The possibility of blunt aortic injury should be considered in patients who have had a major deceleration injury, such as occurs with a head-on motor vehicle crash at a high rate of speed or a fall from a long distance. Aortography is the definitive diagnostic test for blunt aortic injury, and should be obtained in patients who have a highly suspicious mechanism or a suggestive chest radiograph. The most sensitive radiographic sign of an aortic laceration is mediastinal widening of more than 8 cm at the level of the aortic knob. However, as many as 28 per cent of patients with a proven aortic injury may have a normal chest radiograph, and 90 per cent of patients with mediastinal widening will have a negative aortogram (Rosenthall,aDldll..EllJjlS 1,9.9.5). Alternative screening techniques, such as the chest CT, have been advocated, but these have not yet been proven to be sufficiently sensitive to eliminate the need for arteriography ( Durham etal 1994).
Transesophageal echocardiography is being successfully performed instead of aortography in selected patients. This technique appears to be quite sensitive for detecting injuries of the descending aorta. Transesophageal echocardiography may be particularly useful for patients requiring ongoing resuscitation or other intensive care management, since it does not require transport to an angiographic suite. However, transesophageal echocardiography does not adequately visualize the upper ascending aorta or aortic arch. While not nearly as common as injuries at the aortic isthmus, injuries to the root of the aorta or to the innominate artery can be missed by transesophageal echocardiography.
Most aortic injuries should be surgically repaired. However, non-operative management, similar to that used in patients with aortic dissections, has been successfully utilized in carefully selected patients in whom only an intimal injury is identified. Some details of the operative procedure, such as the use of a graft versus direct repair of the aorta and the use of a shunt while the aorta is cross-clamped, are still controversial.
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