Traumatic Aortic Injury

Written on 13/08/2025
tok.ilman609
1

Blunt deceleration injury to the thoracic aorta ranging from intimal tears / intramural hematoma (a.k.a. “minimal aortic injury”) to pseudoaneurysm and free rupture. Most injuries occur at the aortic isthmus just distal to the left subclavian artery. Early anti-impulse therapy and grade-based management reduce rupture and mortality.
 


Quick Algorithm

High-risk mechanism ± concerning CXR → CTA chest

  • Grade I → Medical (β-blocker ± ASA) + surveillance.

  • Grade II → Medical vs TEVAR (multidisciplinary; flaps >1 cm higher risk).

  • Grade III → TEVAR (urgent; emergent if high-risk features).

  • Grade IV → Emergent TEVAR/Open.
     

At all grades: start anti-impulse therapy immediately; delay TEVAR in stable polytrauma/TBI to optimize physiology. 

 

 

1. Rapid Clinical Assessment & Stabilization

ABCDE with vascular risk control

  • Prioritize hemorrhage control and anti-impulse measures early (analgesia, anxiolysis, gentle handling).

  • Do not reassure yourself with a normal CXR—proceed to CTA when mechanism is high-risk.


     

2. Anti-Impulse Therapy (initiate immediately once TAI suspected/identified)

Targets:
SBP < 120 mmHg, MAP < 80 mmHg, HR < 90
Avoid hypotension in TBI

First-line:
Esmolol 500 µg/kg slow IV bolus (repeat once if needed) → 50 µg/kg/min infusion; titrate to targets.

Add-on (after β-blockade if further BP control needed):
Nicardipine (or nitroprusside where available/appropriate). Transition to oral β-blocker when stable. 

 

3. Imaging


> CXR (∼40% sensitivity). Suggestive findings:

  • Mediastinal widening (>8 cm)
  • Lost aortic knob
  • Left apical cap
  • Left pleural effusion,
  • Rightward tracheal/esophageal deviation.

Note: widened mediastinum has low PPV (~5%) but very high NPV (~99%) for excluding aortic transection. Use it to triage, not to rule in. 
 

> CTA chest (sensitivity 86–100%).

  • Intimal flap
  • Pseudoaneurysm
  • Luminal filling defect
  • Periaortic hematoma
  • Contrast extravasation (active bleed → immediate surgical response). ​

> TEE:

  • go-to for the unstable patient who cannot leave resus/OR; rapid bedside visualization.



4. Management by Grade (default pathway; individualize for polytrauma)


> Grade I (intimal tear) – Medical management

  • Anti-impulse therapy + low-dose aspirin if bleeding risk allows.

  • Surveillance CTA per local protocol (see Follow-up). 


> Grade II (intramural hematoma/large flap) – Individualize

  • Medical therapy vs TEVAR decided jointly by trauma + vascular based on lesion size (>10 mm flaps tend to progress), symptoms, and associated injuries. 


> Grade III (pseudoaneurysm) – TEVAR preferred

  • Urgent TEVAR (often within 24 h if stable); emergent if high-risk features present: arch involvement, large/posterior mediastinal hematoma (>10 mm), lesion/normal aortic diameter ratio >1.4, pseudo-coarctation, large left hemothorax, mass-effect mediastinal hematoma. 


> Grade IV (rupture) – Emergent repair

  • Resuscitate + immediate TEVAR (or open if anatomy precludes endovascular repair). 


Preference for TEVAR over open repair: lower perioperative morbidity and mortality in modern series/guidelines. 



5. Timing Strategy 

  • In otherwise stable patients, delayed (>24 h) TEVAR is associated with lower mortality than immediate repair; prioritize control of physiology and competing injuries (e.g., TBI, solid-organ bleeding). 


     

6. Special Considerations

  • Transfer early to a TEVAR-capable center; start anti-impulse therapy before transport. 

  • Left subclavian coverage: consider revascularization if ischemic risk (dominant left vertebral, prior LIMA graft, extensive coverage); risk–benefit is context-dependent. 

  • Antiplatelet/anticoagulation: Low-dose aspirin is commonly used in medically managed MAI and short-term post-TEVAR if bleeding risk allows; intra-op heparin during TEVAR is associated with improved outcomes when feasible. Balance against polytrauma bleeding.

     

7. Disposition & Follow-up

ICU for most patients until hemodynamics and pain are controlled.


Post-TEVAR: imaging surveillance is required; intervals vary (e.g., 6 weeks then per vascular surgery). Protocols are not standardized—follow local vascular service.


Medically managed Grade I–II (MAI):

  • Continue β-blockade targets until imaging resolution.

  • Follow-up CTA commonly at ~6 weeks (earlier imaging if Grade II or symptoms; many centers add short-interval scans for larger flaps). Most resolve within ~8 weeks.

​

References
  1. Brown, C. V. R., de Moya, M., Brasel, K. J., Hartwell, J. L., Inaba, K., Ley, E. J., … Martin, M. J. (2023). Blunt thoracic aortic injury: A Western Trauma Association critical decisions algorithm. Journal of Trauma and Acute Care Surgery, 94(1), 113–116. https://doi.org/10.1097/TA.0000000000003759 
  2. Fox, N., Schwartz, D., Salazar, J. H., Haut, E. R., Dahm, P., Black, J. H., … Scalea, T. M. (2015). Evaluation and management of blunt traumatic aortic injury: An EAST practice management guideline. Journal of Trauma and Acute Care Surgery, 78(1), 136–146. 
  3. Harper, C., & Acharya, S. (2024). Traumatic aortic injuries. StatPearls Publishing. 
  4. Kapoor, H., Lee, J. T., Orr, N. T., Nisiewicz, M. J., Pawley, B. K., & Zagurovskaya, M. (2020). Minimal aortic injury: Mechanisms, imaging manifestations, natural history, and management. RadioGraphics, 40(7), 1834–1847. 
  5. Lamarche, Y., et al. (2012). Vancouver simplified grading system with computed tomography in the assessment of blunt aortic injury. The Journal of Thoracic and Cardiovascular Surgery, 144(2), 347–354. https://doi.org/10.1016/j.jtcvs.2011.11.064 
  6. McGovern Medical School. (2023). Initial management of blunt thoracic aortic injury.
  7. Mazzaccaro, D., et al. (2023). Blunt thoracic aortic injury: Diagnostic modalities and treatment strategies—An update. Annals of Vascular Surgery, 91, 221–231. https://doi.org/10.1016/j.avsg.2022.08.040 
  8. Radiopaedia. (2024). Thoracic aortic injury; Minimal aortic injury. https://radiopaedia.org/ 
  9. Alarhayem, A. Q., et al. (2021). Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular era. Journal of Vascular Surgery, 73(5), 1589–1599. https://doi.org/10.1016/j.jvs.2020.10.076
  10. Firwana, M., et al. (2025). A systematic review supporting the development of the Society for Vascular Surgery clinical practice guidelines on the management of blunt thoracic aortic injury. Journal of Vascular Surgery. https://pubmed.ncbi.nlm.nih.gov/4048289/