View source for Traumatic aortic transection

''Not to be confused with [[nontraumatic thoracic aortic dissection]]''
==Background==
[[File:Aorta segments.jpg|thumb|Aortic sebments.]]
[[File:Aorta branches.jpg|thumb|Branches of the aorta.]]
[[File:PMC3443276 13244 2012 187 Fig22 HTML.png|thumb|Aortic isthmus laceration with pseudoaneurysm (arrow), mediastinal hematoma, and bilateral hemothorax]]
*Blunt traumatic mechanism, rapid deceleration
*Most common location is isthmus (90%) just distal to the left subclavian artery<ref>Wojciechowski J et al. Traumatic aortic injury: does the anatomy of the aortic arch influence aortic trauma severity? Nov 2016. Surg Today. 2017; 47(3): 328–334.</ref>
**Where the ligamentum arteriosum tethers the aorta and pulmonary artery
**Other locations are:
***Ascending aorta (5%)
***Diaphragmatic hiatus (5%)
*Often asymptomatic but die without warning (80% die at scene)
*Do NOT have [[Hypotension]] (just die, but may have initial hypertension in upper extremities)
*Need high suspicion to diagnose

==Clinical Features==
''No signs or symptoms are sufficiently sensitive for dignosis<ref>Kram, H. B., Appel, P. L., Wohlmuth, D. A. and Shoemaker, W. C. (1989) ‘Diagnosis of traumatic thoracic aortic rupture: A 10-year retrospective analysis’, The Annals of Thoracic Surgery, 47(2), pp. 282–286</ref>''
===Symptoms===
*[[Chest pain]]
*[[Back pain]]
*[[Shortness of breath]]
*[[Dysphagia]]

===Physical exam===
*Seatbelt or steering wheel sign
*New [[murmur]]
*Subclavian hematoma
*Femoral pulse discrepancy
*Upper extremity [[hypertension]] if isolated traumatic aortic transection
**Aortic hematoma stretches sympathetic fibers, increasing systemic vascular resistance
**Patients either have moderately elevated BP or no blood pressure at all, as true rupture leads quickly to death

==Differential Diagnosis==
{{Thoracic trauma DDX}}

==Evaluation==
===Workup===
[[File:PMC4040866 rju05301.png|thumb|Blunt thoracic aortic injury on CXR showing widened mediastinum]]
[[File:PMC3874367 IJVM2013-797189.010.png|thumb|Acute  traumatic  aneurysm: small focal outpouching from the anterior aspect of the proximal descending thoracic aorta (curved arrow).]]
[[File:PMC3443276 13244 2012 187 Fig23 HTML.png|thumb|Traumatic dissection of the descending aorta. (a) Proximal border at the level of the isthmus. (b) Involvement of the abdominal part]]
*CT
**Diagnostic study of choice
**Good for aorta but not for branch vessels
*[[CXR]] (may be an initial screening study, but is not sensitive)
**Widened mediastinum (>8cm on supine film)
**Left apical cap
**Enlarged aortic knob
**Left hemothorax
**Rightward tracheal/esophageal deviation
**Depression of left mainstem bronchus
**Elevation of right mainstem bronchus
**Widened paratracheal stripe
**Widened paraspinal interfaces
*Aortography
**No longer routinely performed, although previously the gold standard
**25% have complications (i.e. infection & hematoma)

===Diagnosis===
====Classification<ref>Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408</ref>====
[[File:PMC4330229 13244 2014 380 Fig1 HTML.png|thumb|(a) Grade 1: Intimal flaps at the level of the proximal descending aorta and 10 cm distal to the subclavian artery (arrowheads) with accompanying mediastinal hematoma. (b) Grade 3: large pseudoaneurysm formation. (c) and (d) Traumatic aortic transection (grade 4) with massive para-aortic hematoma.]]
''Based on CT findings''
*Type I: Intimal tear
*Type II: Intramural hematoma
*Type III: Pseudoaneurysm
*Type IV: Rupture (free rupture, periaortic hematoma)

==Management==
*Management per [[ATLS]] for multiple injuries, hypotension
*Initial medical management similar to [[Nontraumatic thoracic aortic dissection]]
*Keep SBP <120, HR 60-80 with α/[[beta blockers|β-blockers]], [[calcium-channel blockers]]
*Type I injuries may be managed conservatively<ref>Azizzadeh, A., Keyhani, K., Miller, C. C., Coogan, S. M., Safi, H. J. and Estrera, A. L. (2009) ‘Blunt traumatic aortic injury: Initial experience with endovascular repair’, Journal of Vascular Surgery, 49(6), pp. 1403–1408</ref>
*Surgical management for type II and greater

==Disposition==
*Admission

==See Also==
*[[Thoracic trauma]]
*[[Nontraumatic thoracic aortic dissection]]

==References==
<references/>

[[Category:Cardiology]]
[[Category:Trauma]]