1
|
Zoulati M, Bakkali T, Aghoutane N, Lyazidi Y, Chtata H, Taberkant M. [Acute post-trauma dissection of the descending thoracic aorta]. JOURNAL DE MÉDECINE VASCULAIRE 2019; 44:367-373. [PMID: 31761303 DOI: 10.1016/j.jdmv.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 08/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Traumatic injury to the descending thoracic aorta other than the isthmus is rare, and little known. Acute post-trauma rupture may occur in a context of multiple or rarely unique localizations. CASE REPORT We report the case of a young man who was the victim of multiple injuries with an isolated rupture of the descending thoracic aorta. Early diagnosis and adapted endovascular treatment led to favorable outcome. CONCLUSION In 90% of cases, acute post-trauma rupture of the aorta in a single localization involve the isthmus. Rupture of the descending aorta is more exceptional but must not be missed. The pathophysiological mechanism and appropriate management are discussed in light of a review of the literature.
Collapse
Affiliation(s)
- M Zoulati
- Service de chirurgie vasculaire, hôpital militaire d'instruction Mohammed V, Hay Riad, Rabat, Maroc.
| | - T Bakkali
- Service de chirurgie vasculaire, hôpital militaire d'instruction Mohammed V, Hay Riad, Rabat, Maroc
| | - N Aghoutane
- Service de chirurgie vasculaire, hôpital militaire d'instruction Mohammed V, Hay Riad, Rabat, Maroc
| | - Y Lyazidi
- Service de chirurgie vasculaire, hôpital militaire d'instruction Mohammed V, Hay Riad, Rabat, Maroc
| | - H Chtata
- Service de chirurgie vasculaire, hôpital militaire d'instruction Mohammed V, Hay Riad, Rabat, Maroc
| | - M Taberkant
- Service de chirurgie vasculaire, hôpital militaire d'instruction Mohammed V, Hay Riad, Rabat, Maroc
| |
Collapse
|
2
|
Patel AR, Caffarelli A, Pandian NG. Aortic Disorders. Echocardiography 2018. [DOI: 10.1007/978-3-319-71617-6_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
3
|
Garijo JM, Mashari A, Meineri M. Role of Transesophageal Echocardiography in General Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
4
|
Karalis DG, Tortella BJ, Chandrasekaran K. Role of Transesophageal Echocardiography in Blunt Chest Trauma. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925320200600210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients who suffer blunt chest trauma are at risk for injury to the heart, and the thoracic aorta and its branch vessels. Unrecognized injury to the heart or aorta may lead to life threatening complications. Therefore, the physician caring for the trauma patient must be able to accurately and rapidly diagnose cardiac and thoracic aortic injury. Transesophageal echocardiography is an ideal tool to diagnose cardiac and aortic injury in the patient with blunt chest trauma because it provides high quality images of the heart and thoracic aorta and can safely and rapidly be performed in the emergency department, operating suite or intensive care unit. To utilize transesophageal echocardiography most effectively, the echocardiographer must be familiar with the indications, limitations, and piffalls of transesophageal echocardiography in patients with blunt chesttrauma. This review describes the role of transesophageal echocardiography in evaluating the patient with blunt chest trauma for cardiac, thoracic aortic, and mediastinal injury.
Collapse
Affiliation(s)
- Dean G. Karalis
- Division of Cardiology, Drexel University College of Medicine, Philadelphia PA; Cardiology Consultants of Philadelphia, 227 North Broad Street, Suite 200, Philadelphia, PA 19107
| | | | | |
Collapse
|
5
|
Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:119-82. [DOI: 10.1016/j.echo.2014.11.015] [Citation(s) in RCA: 409] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
6
|
[Traumatic injuries of the descending thoracic aorta apart from the isthmus: diagnosis and therapeutic approach]. ACTA ACUST UNITED AC 2013; 32:799-802. [PMID: 24161295 DOI: 10.1016/j.annfar.2013.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/20/2013] [Indexed: 11/23/2022]
Abstract
Lesions involving the descending thoracic aorta apart from isthmus are rare and less known by anesthetists. We report the clinical course of two severely injured patients who sustained a thoracic aortic rupture in whom favorable outcome was achieved with endovascular treatment. Mechanisms, diagnosis and therapeutics aspects of these rare lesions are discussed according to literature.
Collapse
|
7
|
Aortic Disorders. Echocardiography 2009. [DOI: 10.1007/978-1-84882-293-1_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
8
|
Mahmood F, Christie A, Matyal R. Transesophageal echocardiography and noncardiac surgery. Semin Cardiothorac Vasc Anesth 2008; 12:265-89. [PMID: 19033272 DOI: 10.1177/1089253208328668] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of transesophageal echocardiography (TEE) for monitoring during cardiac and noncardiac surgery has increased exponentially over the past few decades. TEE has evolved from a diagnostic tool to a monitoring device and a procedural adjunct. The close proximity of the TEE transducer to the heart generates high-quality images of the intracardiac structures and their spatial orientation. The use of TEE in noncardiac and critical care settings is not well studied, and the evidence of the benefits of its use in these settings is lacking. Despite the widespread availability of TEE equipment in US hospitals, less than 30% of anesthesiologists are formally trained in the use of perioperative TEE. In this review, the safety and indications of TEE are reviewed and detailed analysis of the best available evidence in this regard is presented. Landmark trials evaluating the use of TEE and its therapeutic impact in noncardiac surgical setting are critically reviewed. This article details recommendations to familiarize anesthesiologists with TEE technology to exploit it to its fullest potential to achieve better patient monitoring standards and eventually improve outcome. Training of greater numbers of anesthesiologists in TEE is needed to increase awareness of the indications and contraindications. Until relatively inexpensive TEE equipment is available, the initial cost of equipment acquisition remains a significant prohibitive factor limiting its widespread use.
Collapse
Affiliation(s)
- Feroze Mahmood
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | |
Collapse
|
9
|
Cinnella G, Dambrosio M, Brienza N, Tullo L, Fiore T. Transesophageal echocardiography for diagnosis of traumatic aortic injury: an appraisal of the evidence. ACTA ACUST UNITED AC 2006; 57:1246-55. [PMID: 15625457 DOI: 10.1097/01.ta.0000133576.35999.00] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND An overview of the validity of transesophageal echocardiography (TEE) in patients suspected to have traumatic aortic injury (TAI). METHODS Computerized bibliographic search of trials from 1994 to 2002 evaluating the use of TEE to confirm the diagnosis of TAI. Seven relevant studies out of 204 were identified, involving 758 patients. The accuracy of TEE was analyzed by constructing summary receiver-operating characteristic (sROC) curves and computing areas under the sROC curve. RESULTS No prospective randomized trial was found. Although accuracy varied greatly, summary ROC curve found that TEE enjoyed a high diagnostic performance. Some study characteristics can affect accuracy. CONCLUSIONS Our findings seems to indicate that TEE is a valuable tool for diagnosing TAI, and its use as first-line evaluation of such patients can be supported; however, given the lack of randomized trials, no standard of care can be drawn from the present overview: future studies should look at this problem more carefully, and should be methodologically rigorous.
Collapse
Affiliation(s)
- Gilda Cinnella
- Departments of Anaesthesia and Intensive Care, University of Foggia, Foggia, Italy.
| | | | | | | | | |
Collapse
|
10
|
Kerut EK, Kelley G, Falco VC, Ovella T, Diethelm L, Helmcke F. Traumatic deceleration injury of the thoracic aorta. Echocardiography 2005; 22:697-704. [PMID: 16174130 DOI: 10.1111/j.1540-8175.2005.40150.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Edmund Kenneth Kerut
- Department of Pharmacology, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70072, USA.
| | | | | | | | | | | |
Collapse
|
11
|
Vignon P, Martaillé JF, François B, Rambaud G, Gastinne H. Transesophageal echocardiography and therapeutic management of patients sustaining blunt aortic injuries. ACTA ACUST UNITED AC 2005; 58:1150-8. [PMID: 15995462 DOI: 10.1097/01.ta.0000169865.23229.58] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND No objective criteria have been described to help selecting patients with major blunt aortic injury (BAI) for postponed surgical repair. The efficacy of conservative management of minor BAI needs further evaluation. METHODS We studied 31 patients (Injury Severity Score, 48 +/- 15) who sustained a BAI diagnosed using transesophageal echocardiography (TEE). In patients with major BAI, the timing of surgery was made on the basis of clinical findings (grade 2) or TEE results (grade 3). We retrospectively separated patients into group I (rapid surgery, < or = 12 hours; n = 13) and group II (late or no surgery; n = 11). All major BAIs were confirmed by alternative imaging modalities or surgery. Patients with minor BAI (grade 1; n = 7) prospectively underwent conservative management with serial TEE follow-up. RESULTS All patients with grade 3 BAI (n = 4) were promptly operated on. No group II patient died as a result of aortic rupture, and all of them exhibited a small false aneurysm formation (ratio between the maximal diameter of the injured aortic isthmus and the diameter of the normal descending aorta < 1.4) and hemomediastinum (< 7.2 mm). TEE follow-up of group II patients (mean, 5 months) showed stable BAI, whereas follow-up of patients with minor BAI (mean, 15 months) disclosed total healing (n = 3) or stable lesions (n = 4). CONCLUSION Conservative management of minor BAI with serial follow-up appears to be appropriate. In patients with a grade 2 BAI and small false aneurysm formation and hemomediastinum, postponed surgical repair appears to be safe. However, these TEE criteria remain to be tested prospectively.
Collapse
Affiliation(s)
- Philippe Vignon
- Intensive Care Unit, Dupuytren University Hospital, 87042 Limoges, France.
| | | | | | | | | |
Collapse
|
12
|
Abstract
Blunt arterial injury provides a tremendous challenge to the emergency physician and traumatologist. The overall incidence of these injuries, even with more modern and aggressive screening, is low. Often, they are clinically occult on initial presentation, and untreated, they frequently result in devastating consequences. Great potential exists, however, for averting these deadly consequences by recognizing patterns of injury, prompting expedient diagnosis by rapidly obtaining the appropriate diagnostic study and providing opportunity for specific therapy under the direction of the trauma surgeon.
Collapse
Affiliation(s)
- William E Baker
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA 02118, USA.
| | | |
Collapse
|
13
|
Chen MYM, Miller PR, McLaughlin CA, Kortesis BG, Kavanagh PV, Dyer RB. The Trend of Using Computed Tomography in the Detection of Acute Thoracic Aortic and Branch Vessel Injury after Blunt Thoracic Trauma: Single-Center Experience Over 13 Years. ACTA ACUST UNITED AC 2004; 56:783-5. [PMID: 15187742 DOI: 10.1097/01.ta.0000063407.47520.f7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to review the trend of using chest computed tomography (CT) and aortography in evaluating patients with blunt thoracic trauma. METHODS A total of 85 patients who had blunt aortic injury diagnosed by chest CT, aortography, or both were included in this study. RESULTS Aortography was the dominant modality before 1998, and the use of chest CT has increased to 50% of patients with aortic injuries as of 2001. Isolated aortic, branch vessel, or combined injuries were found in 71 (84%), 11 (13%), and 3 (4%) patients, respectively. All 14 patients with branch vessel injuries were diagnosed by aortography. Ninety-eight percent of patients with aortography were true-positives, and 20% of patients with chest CT had indirect signs of aortic injury. CONCLUSION Our institution has increased the use of chest CT to evaluate blunt thoracic trauma. Patients with indirect signs of aortic injuries shown on chest CT require further evaluation. In our experience, angiography remains the optimal diagnostic modality for evaluating aortic branch vessel injuries.
Collapse
Affiliation(s)
- Michael Y M Chen
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1088, USA.
| | | | | | | | | | | |
Collapse
|
14
|
Macura KJ, Szarf G, Fishman EK, Bluemke DA. Role of computed tomography and magnetic resonance imaging in assessment of acute aortic syndromes. Semin Ultrasound CT MR 2003; 24:232-54. [PMID: 12954006 DOI: 10.1016/s0887-2171(03)90014-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Acute aortic syndromes refer to the spectrum of aortic emergencies that include nontraumatic diseases of the aorta, such as aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, aortic aneurysm leak, as well as traumatic aortic transection. Patients presenting with nontraumatic acute aortic syndromes usually have a similar clinical profile; hence, clinical diagnosis is difficult. Computed tomography (CT) and magnetic resonance imaging (MRI) allow for specific diagnosis of the underlying condition. Traumatic rupture of the aorta is one of the most dreaded complications of blunt chest trauma; therefore, in patients with high-risk deceleration injuries, radiographic assessment of the aorta is crucial. Imaging methods should detect even subtle aortic wall disruption and should provide a mechanism for communicating the findings to the surgical team. Noninvasive, cross-sectional imaging techniques have proven efficacy in the diagnosis of aortic pathology and have largely replaced aortography. Both CT and MR imaging provide aortogram-like reconstruction of the original data sets, and in addition to assessing the aortic lumen, permit detailed evaluation of the aortic wall, as well as comprehensive assessment of thoracic and abdominal viscera. This article addresses the role of different imaging modalities in assessment of acute aortic syndromes, with focus on CT and MRI, and with discussion of the key imaging findings that allow distinction among the various aortic pathologies.
Collapse
Affiliation(s)
- Katarzyna J Macura
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21287-0750, USA.
| | | | | | | |
Collapse
|
15
|
Belkin RN, Kalapatapu SK, Lafaro RJ, Ramaswamy G, McClung JA, Cohen MB. Atherosclerotic pseudoaneurysm of the ascending aorta. J Am Soc Echocardiogr 2003; 16:367-9. [PMID: 12712020 DOI: 10.1016/s0894-7317(02)74478-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pseudoaneurysms in the ascending aorta most commonly occur as a complication of surgical procedures at this site. They have also been reported in association with trauma, infection, aortitis, and other disorders. Pseudoaneurysm formation in the descending aorta or arch may occur as a result of penetrating ulcers in the presence of severe atherosclerotic plaque. Pseudoaneurysm as a result of atherosclerotic disease has only rarely been noted in the ascending aorta, where complex plaque is less common. We report here the finding with transesophageal echocardiography of a pseudoaneurysm in the ascending aorta as a result of atherosclerotic disease and penetrating ulcer.
Collapse
Affiliation(s)
- Robert N Belkin
- Division of Cardiology, New York Medical College and Westchester Medical Center, USA
| | | | | | | | | | | |
Collapse
|
16
|
Zimmer GD, Brown DFM, Nadel ES. Blunt traumatic injuries. J Emerg Med 2002; 22:81-5. [PMID: 11809561 DOI: 10.1016/s0736-4679(01)00428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Gary D Zimmer
- Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | |
Collapse
|
17
|
Leone M, Portier F, Antonini F, Chaumoître K, Albanèse J, Martin C. [Strategies diagnosis of polytraumatized adult patients with coma]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:50-66. [PMID: 11878125 DOI: 10.1016/s0750-7658(01)00550-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review the diagnostic strategy of management of multiple trauma patient during the first hours. DATA SOURCES Extraction from Pubmed database of French and English articles on the management of multiple trauma patient published for ten years. DATA SELECTION The collected articles were reviewed and selected according to their quality and originality. The more recent data were selected. DATA SYNTHESIS The first hours of management of multiple trauma patients are a particular challenge. The first dilemma is to drive the patient toward an adequate structure. In case of poor haemodynamic tolerance, the patient will be drive in the nearest hospital. When haemodynamic parameters are restored, multiple trauma patient has to be receive in a high level hospital by a trained medical team with an anesthesiologist, intensivist, neurosurgeon, general surgeon and radiologist. The initial assessment may have two priorities: quality and speed. The total body CT scan is actually the answer to these priorities.
Collapse
Affiliation(s)
- M Leone
- Département d'anesthésie-réanimation et centre de traumatologie, CHU Nord, bd P-Dramard, 13915 Marseille, France
| | | | | | | | | | | |
Collapse
|
18
|
Malhotra AK, Fabian TC, Croce MA, Weiman DS, Gavant ML, Pate JW. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. THE JOURNAL OF TRAUMA 2001; 51:1042-8. [PMID: 11740248 DOI: 10.1097/00005373-200112000-00003] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND With the increasing use of high-resolution diagnostic techniques, minimal aortic injuries (MAI) are being recognized more frequently. Recently, we have used nonoperative therapy as definitive treatment for patients with MAI. The current study examines our institutional experience with these patients from July 1994 to June 2000. METHODS All patients suspected of blunt aortic injury (BAI) by screening helical CT (HCT) underwent confirmatory aortography with or without intravascular ultrasound (IVUS). MAI was defined as a small (<1 cm) intimal flap with minimal to no periaortic hematoma. RESULTS Of the 15,000 patients evaluated by screening HCT, 198 (1.3%) were suspected of having BAI. BAI was confirmed in 87 (44%), and 9 (10%) of these had MAI. The initial aortogram was considered normal in five of the MAI patients. The correct diagnosis was made by IVUS (four patients), and video angiography (one patient). One MAI patient had surgery, and two (22%) died of causes not related to the aortic injury. Follow-up studies were done on the six MAI patients that were discharged. In two, the flap had completely resolved, and in one it remained stable. The remaining three patients formed small pseudoaneurysms. CONCLUSION Ten percent of BAI diagnosed with high resolution techniques have MAI. These intimal injuries heal spontaneously and hence may be managed nonoperatively. However, the long-term natural history of these injuries is not known, and hence caution should be exercised in using this form of treatment.
Collapse
Affiliation(s)
- A K Malhotra
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
| | | | | | | | | | | |
Collapse
|
19
|
Chen MY, Regan JD, D'Amore MJ, Routh WD, Meredith JW, Dyer RB. Role of angiography in the detection of aortic branch vessel injury after blunt thoracic trauma. THE JOURNAL OF TRAUMA 2001; 51:1166-71; discussion 1172. [PMID: 11740270 DOI: 10.1097/00005373-200112000-00024] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The occurrence of aortic arch branch vessel injury as an isolated occurrence or in association with aortic injury after blunt chest trauma has not been emphasized in the literature. The imaging evaluation is also controversial. METHODS We reviewed thoracic aortograms of 166 patients examined at our institution from May 1995 to May 1999 performed after blunt thoracic trauma. We evaluated the aortograms for aortic and arch branch vessel injuries. Twenty-four injuries were detected and all patients had either a wide mediastinum demonstrated on plain radiographs (22 patients) or mechanism of injury conducive to aortic injury. RESULTS Of the 166 patients, 24 (14%; 16 men, 8 women; mean age, 50 years) had aortic or arch branch vessel injuries. Isolated aortic injury occurred in 15 (9%) of 166 patients. Branch vessel injury occurred in 9 (5%) of 166 patients; seven patients (10 branch vessels) had isolated branch vessel injury and two patients (three branch vessels) had branch vessel injury associated with aortic injury. The injured branch vessels were brachiocephalic artery (four), left common carotid artery (four), left subclavian artery (three), right internal mammary artery (one), and left vertebral artery (one). The types of branch vessel injuries included intimal tears (nine vessels; 69%), and transection causing a pseudoaneurysm (four vessels; 31%). Revised Trauma Scores in patients with branch vessel injuries were 12 in seven patients and 11 and 4 in one each. CONCLUSION We emphasize the angiographic findings in these patients that can at times be quite subtle. Awareness of the incidence of such injuries either in isolation or associated with aortic injury has implications regarding evaluation of this patient population with less invasive techniques such as CT or transesophageal echocardiography.
Collapse
Affiliation(s)
- M Y Chen
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
| | | | | | | | | | | |
Collapse
|
20
|
Nagy K, Fabian T, Rodman G, Fulda G, Rodriguez A, Mirvis S. Guidelines for the diagnosis and management of blunt aortic injury: an EAST Practice Management Guidelines Work Group. THE JOURNAL OF TRAUMA 2000; 48:1128-43. [PMID: 10866262 DOI: 10.1097/00005373-200006000-00021] [Citation(s) in RCA: 131] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In summary, BAI is a lethal result of severe blunt trauma. It should be considered in all patients who sustained injury by a deceleration or acceleration mechanism, especially in the face of physical or radiographic findings suggestive of mediastinal injury. Angiography remains the "gold standard" for diagnosis, although CT scanning is taking more of a role, especially for screening. Diagnosis should be followed by prompt surgical repair using some method of distal perfusion to minimize renal and spinal cord ischemia. If prompt repair is not feasible because of other injuries or comorbidities, medical control of blood pressure is warranted in the interim.
Collapse
Affiliation(s)
- K Nagy
- Department of Trauma, Cook County Hospital, Chicago, Illinois, USA.
| | | | | | | | | | | |
Collapse
|
21
|
Willens HJ, Kessler KM. Transesophageal echocardiography in the diagnosis of diseases of the thoracic aorta: part II-atherosclerotic and traumatic diseases of the aorta. Chest 2000; 117:233-43. [PMID: 10631223 DOI: 10.1378/chest.117.1.233] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Transesophageal echocardiography (TEE) has provided an accurate new window for the evaluation of diseases of the thoracic aorta. Experience with TEE has led to an increased recognition of atherosclerosis of the thoracic aorta as a source of cerebral and systemic embolism. Certain features of aortic plaque morphology detected by TEE may prove to have prognostic and therapeutic significance. The intraoperative assessment of thoracic aortic atherosclerosis by TEE may guide modifications in surgical techniques and aortic manipulations that reduce the incidence of perioperative neurologic complications. TEE has also become a valuable tool for the diagnostic evaluation of patients with blunt chest trauma. The precise role of TEE in the management of these disorders is currently under investigation.
Collapse
Affiliation(s)
- H J Willens
- Department of Medicine, Memorial Regional Hospital, Hollywood, FL 33021, USA
| | | |
Collapse
|
22
|
Adalia R, Sabater L, Azqueta M, Muntanyá X, Real MI, Riambau V, González FX, Zavala E. Combined left ventricular aneurysm and thoracic aortic pseudoaneurysm caused by blunt chest trauma. J Thorac Cardiovasc Surg 1999; 117:1219-21. [PMID: 10343278 DOI: 10.1016/s0022-5223(99)70265-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- R Adalia
- Surgical Intensive Care Unit, Department of Cardiology, Department of Angioradiology, University of Barcelona, Barcelona Spain
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Gavant ML. Helical CT grading of traumatic aortic injuries. Impact on clinical guidelines for medical and surgical management. Radiol Clin North Am 1999; 37:553-74, vi. [PMID: 10361546 DOI: 10.1016/s0033-8389(05)70111-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Helical CT is a reliable method for screening patients with blunt chest trauma for vascular and visceral injuries. Thoracic aortic injuries detected by CT examination affect the immediate clinical management and patient triage. This article describes the clinical indications and imaging protocols for helical CT of the chest used to detect aortic injuries, provides a grading system of the range of aortic injuries demonstrated by CT, and discusses the clinical management decisions that should be considered based on the CT grade of the aortic injury.
Collapse
Affiliation(s)
- M L Gavant
- Department of Radiology, University of Tennessee, Memphis, USA.
| |
Collapse
|
24
|
Vignon P, Lang RM. Use of Transesophageal Echocardiography for the Assessment of Traumatic Aortic Injuries. Echocardiography 1999; 16:207-219. [PMID: 11175142 DOI: 10.1111/j.1540-8175.1999.tb00805.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Acute traumatic lesions of the thoracic aorta or its branches (TLA) constitute highly lethal yet treatable injuries that are increasingly diagnosed in surviving patients. Traumatic disruptions are limited to the region of the aortic isthmus in approximately 90% of cases. Unlike aortography, usually referred as the gold standard diagnostic technique, transesophageal echocardiography (TEE) is a noninvasive imaging modality that can be rapidly performed at the patient bedside. Accordingly, TEE is being increasingly used as a first-line screening test for the evaluation of patients with suspected TLA. The TEE signs associated with TLA depend on the anatomic type of aortic disruption. After a period of validation, multiplane TEE allows accurate diagnosis of traumatic disruptions of the aortic isthmus, with a sensitivity of 88% (range, 57%-100%) and a specificity of 96% (range, 84%-100%). False-negative TEE results have been mainly attributed to lacerations of aortic branches. Accordingly, aortography must be routinely performed when a traumatic injury to brachiocephalic arteries is suspected. False-positive TEE findings have been associated with the presence of ultrasound artifacts or atherosclerotic changes that mimic TLA. Accurate determination of the depth of aortic wall tears and diagnosis of blunt cardiac injuries during the TEE study are crucial to guide patient management. The presence of TEE signs associated with imminent risk of adventitial rupture should lead to prompt surgery. The use of TEE as a first-line imaging modality simplifies the initial assessment of patients at high risk for TLA and helps guide acute management.
Collapse
Affiliation(s)
- Philip Vignon
- The University of Chicago Medical Center, 5841 South Maryland Avenue, MC 5084, Chicago, IL 60637
| | | |
Collapse
|
25
|
Smith JC, Smith DC, Ahrar K, Bansal RC. Patent ductus arteriosus masquerading as traumatic aortic rupture at aortography: the complementary role of transesophageal echocardiography. J Vasc Interv Radiol 1999; 10:169-71. [PMID: 10082104 DOI: 10.1016/s1051-0443(99)70460-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- J C Smith
- Department of Radiology, Loma Linda University Medical Center, CA 92354, USA
| | | | | | | |
Collapse
|
26
|
Vignon P, Rambaud G, François B, Cornu E, Gastinne H. [Transesophageal echocardiography for diagnosis of traumatic injuries to the major intrathoracic vessels in 150 patients: the effect of the learning curve]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1999; 17:1206-16. [PMID: 9881188 DOI: 10.1016/s0750-7658(99)80026-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the role of transoesophageal echocardiography (TOE) in the management of patients with suspected traumatic lesions of the thoracic aorta (TLA) and its branches; to assess the influence of the learning curve on the diagnostic accuracy of TOE for the identification of TLA. STUDY DESIGN Retrospective study. PATIENTS The study included 150 patients (age: 41 +/- 17; Injury Severity Scale score: 31 +/- 17) who were admitted during a 4-year period for severe blunt chest trauma and who underwent a TOE study. METHODS TOE were performed with either a monoplane (n = 54) or a multiplane probe (n = 96). In all cases, TLA were confirmed by angiography, computed tomography, surgery, or necropsy. Initially performed routinely, angiography was subsequently indicated when the TOE study was inconclusive or when a disruption of supraaortic arteries was suspected. Echocardiographic studies were reviewed by an experienced reader who was unaware of the medical history and initial conclusions. To evaluate the influence of the learning curve on the diagnostic accuracy of TOE, these conclusions were compared with the initial interpretations. RESULTS A TLA was recognized in 25 patients out of 150 (17%), and evidenced using TOE in 22 of them. Three false negative and two false positive TOE results (needless thoracotomy) were recorded. After a learning period, the rate of inconclusive TOE studies decreased (18/150 vs 7/150: P < 0.05) and no false positive finding was recorded. The sensitivity and specificity of TOE for the diagnosis of TLA were 88 and 100%, and positive and negative predictive values were 100 and 97%, respectively. CONCLUSIONS TOE is an accurate imaging technique for the diagnosis of TLA located at the aortic isthmus. However aortography becomes essential when injuries of the aorta branches are suspected. A learning period is required to improve the specificity of TOE for this indication.
Collapse
Affiliation(s)
- P Vignon
- Service de réanimation polyvalente, CHU Dupuytren, Limoges, France
| | | | | | | | | |
Collapse
|
27
|
Habib G, Caus T, Avierinos JF, Richard D, Garcia M, Biou F, Maximovitch-Rodaminoff A, Ambrosi P, Luccioni R. Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression: An Echocardiographic Case Report. Echocardiography 1998; 15:665-668. [PMID: 11175097 DOI: 10.1111/j.1540-8175.1998.tb00666.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 69-year-old woman presented with chest pain and electrocardiographic evidence of subacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a posttraumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.
Collapse
Affiliation(s)
- Gilbert Habib
- Hôpital la Timone, Service de Cardiologie B, Boulevard Jean Houlin, 13005, Marseille, France
| | | | | | | | | | | | | | | | | |
Collapse
|