Aortic injury is the most serious injury. Aortic ruptures of traumatic origin appear exceptionally isolated in penetrating trauma.
In closed injuries, they are considered to be directly responsible for the deaths on-site between 16 and 40% of deaths, only surpassed by the head brain trauma. They are associated with severe CNS lesions, constituting along with them (including cardiac lesions) the first cause of early and immediate post-traumatic mortality.
Regarding the aetiology of the aortic lesion, traffic accidents are among the most frequent. Also the precipitations, especially when the impacts are lateral.
Only 15% of the aortic lesions, according to the studies, they reach the hospital alive and the mortality without treatment is 90% at three months. The chances of survival will be determined by the severity of the aortic lesions themselves, the associated ones and the treatment applied.
Classification of the aortic lesion
In clinical practice guidelines, a classification is proposed that only recognizes 3 degrees of injury in the face of treatment:
- Grade I: these are the lesions that are indicated as control with medical treatment with beta-blockers and follow-up until the lesion stabilizes or disappears.
- Grade III: are the injuries that require immediate surgery. Also included are those that show free rupture or those with rupture contained by pseudoaneurysm but that associate secondary signs of severe injury.
Finally, an intermediate group that they denominate degree II that are the injuries type LIT. The treatment will depend on other parameters such as stability of the lesion, absence of those secondary signs of severity and the other associated injuries of the patient.
The proposals of these classifications simple to reproduce and concordant allows to standardize the language and communication of the findings.
Symptoms of aortic injury
The symptoms that the patient presents also will influence the choice of treatment. We can highlight the associated signs of severe injury and the concept of stability of the lesion over time.
Regarding the secondary signs of severe injury we can mention:
- Pseudocoarctation: it is an anomaly of the aorta artery.
- Severe bruising
- Massive left hemothorax.
- The size of the pseudoneurysm or the involvement of more than 50% of the circumference.
These are factors that increase the degree of injury. Thus, indicate the need for urgent repair, while its absence allows an elective treatment. Another factor with the same meaning is hypotension prehopsitalaria.
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How can it be diagnosed?
In recent years there has been a revolution in both diagnosis and treatment options for aortic injuries. In this way, it has evolved in parallel with the improvement of multidetector technology and the introduction of new endovascular repair techniques.
It was achieved, on the one hand, that the small injuries do not go unnoticed and on the other hand, a decrease in mortality which appears directly related to the choice of procedure and the time of treatment.
The natural evolution of aortic injuries depends on different variables, the degree being a determining factor, but it is not the only one, which will condition the need or not and the most appropriate moment of repair or conservative treatment.
Definitely, There has been a revolution in the diagnosis of aortic injury from the suspicion of indirect signs in the portable chest x-ray to the identification of minimal intimal lesions that previously remained hidden since they are not always accompanied by mediastinal hemorrhage.
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Treatment of aortic injury
Nowadays there are three therapeutic modalities:
- Medical treatment with beta blockers, calcium chain blockers and vasodilators to reduce the blood pressure frequency associated with anti-aggregating agents / anticoagulants.
- Endovascular repair.
- Repair with open surgery.
Either of the two interventions can be carried out in an urgent, semi-elective or programmed manner. Regarding the endovascular repair that has been developed in recent years, shows a marked decrease in operating room times, transfusion needs and hospital stay compared to those undergoing open surgery.
These data suggest that is proposed as the treatment of choice in those with a favorable anatomy and even in children with thoracic aortic injury.