The diagnostic problem associated with blunt traumatic azygous vein injury: delayed appearance of right haemothorax after blunt chest trauma

An isolated azygos vein rupture from blunt chest trauma

We report a case of isolated traumatic rupture of the azygous vein. A 33-year-old female suffered blunt chest injury from the airbag explosion in a car accident. Initial examination revealed decreased breath sounds in the right chest. Computed tomography showed a massive right hemothorax without evidence of rib fracture or great vessel injury. An emergency exploratory thoracotomy was performed due to massive hemothorax with unstable vital signs. A laceration in the anterior wall of the azygos vein was identified. Bleeding was controlled by double ligation at the injury site. The patient was discharged on postoperative day 7 without any sequelae.

Injury to Azygos Venous System: A Co-Existing Injury in High-Impact Lethal Trauma

BACKGROUND

About 50 cases of azygos venous system injuries following civilian trauma have been published in current literature. The purpose of our study was to investigate the incidence of these injuries, the causative mechanism and type of trauma, the co-existing injuries, and the mortality rate in our institution.

METHODS

We performed a retrospective review of all trauma patients who were admitted to the surgical department of the General Hospital of Rethymno during an 11-year period. Our study included patients arriving at our institution dead or alive with an azygos venous system injury following blunt or penetrating civilian trauma.

RESULTS

Seven patients-five men and two women-were identified with azygos venous system injuries. Five had an azygos vein laceration, one suffered from both azygos and hemiazygos vein lacerations, and the last one had sustained hemiazygos and accessory hemiazygos vein injuries. All of them suffered from a blunt trauma. Three arrived at our hospital in extremis, and all died within 24 h despite our resuscitation attempts. All of our patients were polytrauma patients. All of them had co-existing torso injuries which were severe in all but one case, three of them suffered also from serious head injuries, and all but one had at least serious extremity's injuries.

CONCLUSION

Azygos venous system injuries are rare, although it seems that they are more frequent than current literature would indicate. Blunt trauma mechanism seems to be predominant in civilian trauma setting, and the patients have usually sustained a lot of serious and severe co-existing injuries with high resultant lethality.

Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation

Hemothorax is not an uncommon cardiopulmonary resuscitation(CPR)–related complication. But hemothorax related to azygos vein injury (AVI) is a rare condition following blunt chest trauma, with no report of CPR-related AVI in the literature. We present a case of azygosve in rupture in a middle-aged woman after repeated chest compression during 1 hour of CPR. She eventually presented with massive hemothorax due to azygos vein rupture diagnosed by computed tomography (CT). When faced with a patient with massive hemothorax after chest compression, azygos vein rupture should be considered as a complication.

Azygos vein injury in blunt chest trauma

Injuries to the azygos vein in a blunt chest trauma are uncommon and have previously been described in only 21 cases. The diagnosis is crucially based on massive right haemothorax with signs of shock, hypotension and altered mental status. The severity of the trauma, speed of transport and surgical intervention are often decisive for the survival of the patient. This is confirmed by the three cases we report below.

Injuries to the azygous venous system

BACKGROUND

Azygous venous system injuries are rare. Although not commonly classified as a thoracic great vessel, the azygous system manifests morbidity and mortality that is similar to that of other great vessel injuries.

METHODS

Over a 40 year period, data were retrospectively collected and charts reviewed from a vascular injury database.

RESULTS

A total of 22 injuries to the azygous venous system were identified with 21 to the azygous vein and 1 to the hemiazygous vein. All were secondary to penetrating trauma, with 19 from gunshot wounds and 3 from stab wounds. Eight of 22 patients died for an overall mortality of 36%. All patients had associated injuries, with concomitant injury to the lung noted in all cases.

CONCLUSIONS

Injuries to the azygous venous system have a significant associated lethality. As an azygous venous injury is not typically the indication for operation, anterior incisions are often employed, making exposure difficult. In the majority of injured patients, the azygous system injury was found after excluding injuries to the heart, lung, and great vessels. A key finding in detecting these injuries through an anterior incision is continued hemorrhage of dark blood from a posterior location in the thoracic cavity. The azygous venous system should be considered early as a source of significant hemorrhage from the posterior mediastinum.

Prevalence of Delayed Hemothorax in Blunt Thoracic Trauma

Delayed hemothorax (DHTX) is rarely seen. On an 8-year retrospective analysis of blunt thoracic trauma (BTT), hemothorax (HTX) was diagnosed in 167 patients: 18 children, 113 adults, and 36 elderly. No statistical differences were seen in any age groups regarding Injury Severity Score (mean ISS, 30.54), critical care length of stay (CLOS, 9.0), and hospital LOS (HLOS, 11.21). Mortality rate was 18 per cent in adults and 28 per cent in elderly ( P value < 0.0001). HTX was acute in 160 and delayed in 7 patients. Two-thirds of HTX patients were males and 75 per cent had rib fractures. All of our DHTX patients were males (5 adults and 2 elderly) and had rib fractures. Acute HTX was seen in younger patients (43.3 vs 56.1 years, P value 0.46), with higher ISS (31.44 vs 14.43, P value < 0.001), CLOS (7.19 vs 3.0 days, P value 0.511) and HLOS (11.9 vs 11.6, P value 0.468). Mortality was 22.5 per cent in AHTX and none in DHTX. Eighty-six per cent of DHTX and 49 per cent of AHTX patients went home on discharge. DHTX was rare (5%) in the current report with lower ISS, HLOS, and no mortality. Patients with rib fractures should be watched for development of DHTX as timely diagnosis and treatment is essential for favorable outcome.