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Objectives: The aim of this study was to compare aortic diameters from admission computed tomography angiography (CTA) scans to postoperative aortic diameters in patients with traumatic aortic injury (TAI) and evaluate the influence of substantial blood loss on aortic diameter., Methods: The aortic databases of two tertiary university centers were retrospectively screened for patients with TAI between February 2002 and February 2019. Concomitant organ injuries, bone fractures, blood loss, and clinical outcomes were evaluated. Aortic diameters were measured in CTA upon admission and were compared with the CTA before discharge at three different aortic levels (mid-ascending, 5 cm distal to the end of the stent graft, and at the celiac trunk level)., Results: We identified 45 patients, aged 43 (first quartile; third quartile [26; 55]) years with a TAI treated by thoracic endovascular aortic repair. The most frequent cause of TAI was a car accident ( n  = 24). Concomitant injuries were seen in all but one patient. Bone and pelvic fractures were seen in 40 (89%) and 15 (33%) patients, respectively. Type III aortic injury was present in 25 patients (56%). Increase of aortic diameter after stabilization was +1.7 mm (-0.6 mm; 2.5 mm; p  = 0.004) at the mid-ascending aorta, +2.1 mm (0.2 mm; 3.8 mm; p  < 0.001) 5 cm distal to the stent graft, and +1.5 mm (0.5 mm; 3.2 mm; p  < 0.001) at the celiac trunk level., Conclusion: In patients with TAI, the aortic diameter is significantly reduced as compared with the aortic diameter at discharge. The reduction of aortic diameter might be caused by hemorrhagic shock and should be kept in mind for appropriate stent-graft sizing., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: The recently developed thoracic endovascular repair (TEVAR) technique seems to offer a good alternative for treating acute traumatic transection of the thoracic aorta (TTA). We reviewed our experience of TEVAR in cases of acute traumatic transection and analyzed the subsequent remodeling changes., Methods: The medical records of 17 patients who underwent TEVAR for TTA were reviewed. The trauma mechanisms, anatomical characteristics of the transected aortas, technical details of TEVAR, and postprocedural results were reviewed., Results: The overall mean injury severity score was 53 ± 12. On three-dimensional computed tomography (CT), the mean distance of transection from the left subclavian artery was 14 ± 9 (0-31) mm. Fifteen patients presented an aortic pseudoaneurysm and two patients had impending rupture. TEVAR was performed emergently under general endotracheal induction. Technical success was achieved and complete pseudoaneurysm sealing was confirmed with aortography in all 17 patients. Two patients (12%) died of hypovolemic shock and hyperkalemia; however, no late death or stent-related complication occurred during the 45 ± 32 (6-102) months of follow-up. During a mean CT follow-up of 35 months, the mean aortic diameter increased by 2 (0-5) mm and pseudoaneurysm lesions completely disappeared in all patients., Conclusions: TEVAR resulted in good early survival in patients with TTA. No late or stent graft-related event was encountered up to a maximum of 9 years after surgery. We recommend that patients with grade III or higher TTA should undergo emergency surgery. Moreover, we consider that long-term follow-up and blood pressure management are essential when the proximal aortic diameter is found to increase slightly after TEVAR on follow-up CT., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

A 46-year-old man presented with severe pain in our emergency department. In addition he had macrohematuria, the further medical history was inconspicuous. The pain showed to be resistant to therapy, therefore we performed a CT scan of the abdomen. The CT scan showed a partial embolism of the right renal artery, a thrombus of the aorta thoracica as well as partial infarction of the spleen and the liver. An immediately initiated therapy with implantation of an aortal stent graft for fixation of the thrombus and an Actilyse® therapy led to full recovery of the patient. Closer questioning of the patient showed that the patient undertook an extended abdominal and thoracic muscle training programme by letting an eight-kilogram bowling ball fall down onto his abdomen from about 80 cm height. The diagnosis embolism of the renal artery cannot be made without extended diagnostics in the emergency room. A good hint for perfusion disorders of the kidney can be obtained with duplex ultrasound. Therapy-resistant pain without hydronephrosis and concomitant arrhythmia of the patient can lead to the diagnosis. The initiation of an adequate diagnosis and therapy is essential as otherwise persisting perfusion disorders of the kidney may occur., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Aim of the study was to present the 10-year results after endovascular repair of acute traumatic rupture of the descending aorta in a single centre., Methods: Forty-eight consecutive patients (35 men and 13 women; mean age 39.8 +/- 18 years) with traumatic lesions of the descending aorta were treated between March 1999 and November 2008. All patients were treated within 24 hours of admission., Results: Thirty-one Gore TAG, 13 Medtronic Valiant, 6 Cook Zenith TX2 were used. The technical success rate was 100%, the conversion rate was 0%. Thirty-day mortality rate was 8.3%; overall procedure-related mortality was 2.1% due an acute stent graft compression syndrome. Infolding endografts were observed in 3 patients (6.25%). The left subclavian artery was covered in 35 cases (70%), in one patient revascularisation was necessary. No neurological deficit was reported. Mean follow-up was 51.9 months (4-116 months). No late complications occurred., Conclusion: Endovascular treatment of acute traumatic rupture of the thoracic aorta is a safe method, with a lower morbidity and mortality than open repair., (Georg Thieme Verlag KG Stuttgart New York.)

Background: A left recurrent nerve palsy caused by left atrium hypertrophy, dilatation of the left pulmonary artery or a thoracic aortic arch aneurysma is named Ortner's syndrome., Case Report: We report the case of a 84-year old male patient with a posttraumatic aneurysm of the distal aortic arch known for 20 years, which became symptomatic by new presentation of an acute hoarseness caused by a left sided recurrent nerve palsy due to rapid aneurysma expansion. Because of the aneurysma localization, the advanced age and the patient?s morbidity he was treated by a hybrid procedure with an extrathoracic reconstruction of the supraaortic arteries by a right to left carotid-carotid bypass and transposition of the left subclavian artery followed by endovascular implantation of aortic stent grafts for aneurysma exclusion. The left recurrent nerve palsy remained unchanged until now., Conclusions: Aneursms of the distal aortic have to be considered as a rare cause of a left-sided recurrent nerve palsy. Recent advances in endovascular therapy combined with supraaotic vascular reconstruction offers a less invasive therapeutic option for some of these patients.

Tissue factor (TF), the initiator of coagulation, has been implicated as a critical mediator of arterial thrombosis. Previous studies have demonstrated that TF is rapidly induced in the normal rodent arterial wall by balloon injury, but is not associated with fibrin deposition. A second injury, however, performed 10-14 days after the first, is followed by small platelet-fibrin microthrombi. This study was undertaken to better localize active TF in balloon-injured rat arteries and to explore possible mechanisms underlying the apparent discrepancy between injury-induced TF expression and the lack of large platelet-fibrin thrombi. By immunohistochemistry, TF antigen was first detected in the media 24 h after injury to rat aortas, and subsequently accumulated in the neointima. Using an ex vivo flow chamber, no TF activity (Factor Xa generation) was found on the luminal surface of normal or injured aortas. Wiping the luminal surface with a cotton swab exposed TF activity in all vessels; levels were increased approximately 3-fold in arteries containing a neointima. The exposed TF activity was rapidly washed into the perfusate, rendering the luminal surface inactive. The loss of luminal TF into the circulation may attenuate thrombosis at sites of arterial injury.

Purpose: Evaluation of percutaneously implanted covered stents in acute vascular bleeding as therapeutic alternative to conventional surgical treatment., Materials and Methods: 8 patients aged 26 to 83 years with acute vascular lesions caused by traumas, and subsequent haemorrhage, were transferred to our department. Because of general inoperability or difficult surgical access, interdisciplinary evaluation favoured an interventional treatment. In 6 patients stents could be placed percutaneously to the aorta, subclavian and iliac arteries. In one case we had to implant three stents into the thoracic aorta., Results: In 7 interventionally treated patients the stents could be placed exactly on the lesions (88%). The bleeding could be stopped immediately in 6 cases (75%). In one patient we had to implant successfully two more stents in reintervention (12%). In another patient the available prosthesis was too short, so that the patient had to be referred to the OR for surgical treatment (12%). There were no complications during the treatment., Conclusion: First results in the use of covered stents as interventional treatment of acute vascular lesions are encouraging and may represent a possible alternative to surgical therapy in locally limited bleedings, presupposing that all different types and sizes of industrially produced covered stents are available. Further investigations to compare surgical and interventional techniques are warranted.

Rupture of the aorta that usually occurs with major blunt trauma of the chest is associated with a high mortality, and only 2% of the patients survive long enough to develop a false aneurysm. Although symptom-free latent period is not rare, there is evidence of progression. Since 1970 we operated on 28 patients (24 male and 4 female, mean age 41.2 years) for chronic traumatic aneurysm of the descending aorta. A previous blunt trauma of the chest had certainly occurred in 23 cases (3 months to 20 years before) and was likely in 4 patients; in one young woman the aneurysm developed after percutaneous angioplasty of a coarctation. In 26 patients surgical repair consisted in a Dacron tube interposition, and in 2 cases patch repair was adequate. In 11 cases the "clamp and repair" technique was applied, while in 17 patients extracorporeal circulation was established to perform the reconstruction, two of these cases were operated with hypothermic circulatory arrest. Although there was no correlation between the occurrence of complications and the applied procedure, we lately turned to establish cardiopulmonary bypass in all cases with regard to a better control of the hemodynamics during clamping, the possibility of direct retransfusion of blood, and the option to extend the procedure, if necessary. In view of the facts, that traumatic thoracic aneurysms develop late complications in about 75% of the cases, and the morbidity in elective surgery is of a low figure, we conclude, that surgery of such lesions is mandatory, once the diagnosis has been established, and that an expectant attitude in the treatment is justified only in exceptional cases.

Between 1967 and 1994 48 patients have been treated at our institution for acute rupture. Two patients died before operation, in two cases the operative attempt had to be abandoned with irreversible cardiopulmonary arrest, and in 44 patients surgical correction could be performed, The rupture was complete in 14 cases and incomplete in 30. In 25 patients surgery consisted of direct suture, in one patient an aortoplasty was performed, and in 18 patients a dacron tube interposition was necessary. In 7 cases the clamp and repair technique was applied, and in 37 cases extracorporeal circulation was installed. The hospital mortality amounted to 18% and was mainly contributable to the concomitant injuries. Two patients presented with paraplegia at admission, both died; postoperative paraplegia occurred in two instances, once after 48 hours. The late results were in the majority of the cases influenced by orthopedic or neurological sequelae, only one patient had to be reoperated for a false aneurysm. Our results and the review of the literature lead to the following conclusions: In spite of an optimized emergency care system, many patients with aortic rupture die before any surgical intervention. The installation of extracorporeal circulation can decrease the incidence of postoperative paraplegia; in our experience the administration of heparin does not increase the risk of bleeding from concomitant injuries. Direct suture represents the correction of choice. The long-term results are excellent.

Immediate surgical treatment of traumatic aneurysms of the aorta is in our point of view in most cases problematic, also because of the combination with life threatening injuries of other organ systems. In our own patient-collection seven patients out of 44 with traumatic transsection were immediately operated. Six patients died in tabula, three of them due to uncontrollable hemorrhage. An analysis of over 5,000 post mortem findings from the department of forensic medicine in Hamburg revealed that injuries of the aorta lead in 98.3% to death in the first two hours after the accident. This shows that only a small number of injured victims survive. The danger of a two stage rupture is judged differently. We did not observe this problem in the patients with aortic lesion following blunt chest trauma and stable conditions who had first undergone treatment for other injuries and therefore operated in the interval period after two to ten weeks. With this strategy the lethality involving surgical management of aortic injuries in our unit decreased to 13%.

The behavior of 125I-labeled recombinant hirudin towards the uninjured and de-endothelialized rabbit aorta wall has been studied in vitro and in vivo to determine its usefulness as an indicator of thrombin activity associated with the aorta wall. Thrombin adsorbed to either sulfopropyl-Sephadex or heparin-Sepharose bound > 95% of 125I-r-hirudin and the complex remained bound to the matrix. Binding of 125I-r-hirudin to the exposed aorta subendothelium (intima-media) in vitro was increased substantially if the tissue was pre-treated with thrombin; the quantity of 125I-r-hirudin bound to the de-endothelialized intima-media (i.e. balloon-injured in vitro) correlated positively with the quantity of bound 131I-thrombin (p < 0.01). Aortas balloon-injured in vivo were measured for thrombin release from, and binding of 125I-r-hirudin to, the de-endothelialized intimal surface in vitro; 125I-r-hirudin binding correlated with the amount of active thrombin released (p < 0.001). Uptake of 125I-r-hirudin by the aorta wall in vivo was proportional to the uptake of 131I-fibrinogen (as an indicator of thrombin activity) before and after balloon injury. After 30 min in the circulation, specific 125I-r-hirudin binding to the uninjured and de-endothelialized (at 1.5 h after injury) aorta wall was equivalent to 3.4 (+/- 2.5) and 25.6 (+/- 18.1) fmol of thrombin/cm2 of intima-media, respectively. Possibly, only hirudin-accessible, glycosaminoglycan-bound thrombin is measured in this way.

Acute traumatic tear of the thoracic aorta is extremely rare in childhood. Based upon our own experience with two children, the essential diagnostic and therapeutic measures are discussed with special reference to timing of surgery. Aortic disruption must be suspected in a child who sustains severe blunt chest injury and develops an abnormally wide mediastinum. Definite diagnosis is established by aortography or computed tomography. The appropriate therapeutic approach is determined by the clinical symptomatology and particularly by the severity of concomitant lesions. In the absence of a significant hemothorax and if no difference in pulse amplitude between upper and lower extremities is evident, the risk of free aortic rupture with intrathoracic exsanguination is presumed to be rather low if the patient reaches the hospital alive. In that situation, the continuity of the injured aorta is maintained by the adventitia and surrounding mediastinal structures. Therefore, these patients may derive the best benefit from an initially conservative management including pharmacological intervention to reduce the risk of free aortic rupture. This concept is particularly indicated if aortic disruption is associated with severe concomitant injury such as intraabdominal or intracranial lesions. Such injuries preclude safe aortic repair immediately after establishment of diagnosis. Delay of aortic repair until recovery from associated major injury allows heparinization and the use of a pump oxygenator, which is regarded as the most effective method to prevent spinal cord ischemia and to reduce the risk of paraplegia.

The early diagnosis of traumatic aortic dissections and aneurysms involving the thoracic aorta is of crucial importance for the outcome of patients suffering chest injuries. This subject is presented using two case reports; one illustrates the problems resulting from an overlooked traumatic aneurysm of the thoracic aorta and the second shows the possibilities of detecting such potentially lethal injuries early in patients with thoracic or multiple injuries, using the transesophageal Doppler echocardiography (TDE). The advantages and disadvantages of using TDE as compared to the more conventional methods such as the precordial Doppler echocardiography, computed tomography and angiography, are discussed. The particular advantage of this hardly invasive or burdening method is its immediate availability in the emergency room to assess patients with evident thorax trauma. In the intensive care unit TDE may be of value in screening polytraumatised patients who offered no primary evidence for chest injury upon arrival.

A retrospective study of plain radiographic findings in 11 patients with traumatic rupture of the aorta was conducted, and the results compared with the incidence of numerous chest x-rays signs previously described in 294 cases of angiographically proven thoracic aorta dissection. It is concluded that positive plain radiographic signs obtained from patients with blunt chest trauma reveal high sensitivity and may thus be used as an indication for emergency aortography. However, since this procedure lacks 100% specificity even those patients with normal x-ray findings but clinically and/or anamnestically adequate thoracic trauma should be submitted to aortography.

Traumatic rupture of the aorta isthmus is described in a patient with an aberrant right subclavian artery. While the aortic rupture could be diagnosed on plain films of the thorax, only an arch aortogram was able to demonstrate its location and the presence of the anomaly. Left anterior oblique views are to be preferred to the A.P. projection for the arch aortogram.

MRI with imaging in the frontal and axial planes can replace, in most cases, CT as well as angiography. By limiting oneself to these planes, the examination can be carried out on patients with acute symptoms. If the findings on MRI are indefinite due to movement or flow artifacts, angiography can be carried out immediately. This may not be possible after CT, due to limitation of contrast volumes. With the exception of patients being ventilated after multiple trauma, MRI should nowadays be the primary form of examination, particularly in high risk patients.

Between 1970 and 1987, 21 patients at St. Vincent Hospital and Medical Center underwent surgery for repair of a transected descending aorta. Nineteen of the transections were a result of trauma secondary to motor vehicle accidents, 1 was secondary to compression injury of the chest, and 1 was the result of a fall. All of the patients had diagnostic chest X-rays and all but one X-ray showed a widened mediastinum. Aortography was carried out in 20 cases. Atrio-femoral bypass was used for all but 2 patients, who had femoro-femoral bypass. The mean cross-clamp time was 53 minutes. Interposition graft was used in 16 patients, an intraluminal graft in 1 patient, and primary repair was performed in 2 patients. Survival was 71%, with 4 of the 21 patients expiring in the operating room (2 before the repair could be undertaken), one patient expiring during a laparotomy 2 days after the aortic repair, and one patient expiring 4 days after the repair. Fifteen patients were discharged alive. Survival and patient care could be improved by careful diagnostic assessment and by following a protocol agreed upon by a team of surgeons.

A case of subtotal circumferential rupture of the aorta is described which involved a woman who had sustained multiple injuries in a traffic accident. The rupture was discovered only during autopsy. As this type of injury is generally not diagnosed until after death, knowledge of some of the characteristics signs of rupture of the aorta is important, especially to the physician in charge of an intensive care unit. If there are suspicious signs aortography is essential. The only treatment likely to succeed is surgery, but postoperative mortality is still as high as 20--40 per cent.

Exposure of arch branches for repair following trauma can be difficult. Seven patients with blunt injuries and 5 with penetrating injuries underwent repair of the innominate, common carotid and subclavian arteries. Common associated injuries included head injury, hemopneumothorax, lung contusion, long bone fractures and brachial plexus injury. Widened mediastinum was seen in 5 patients. Six patients with innominate, right subclavian and right common carotid injuries were approached through sternotomy with extension into the right side of the neck. Posterolateral thoracotomy was used to reach the proximal left subclavian artery in 2. Combined supra- and infraclavicular incision were utilized for the distal subclavian artery in 4. Eleven patients are alive, one to 7 years after surgery. One died of an unrelated cause. Head injuries complicated the postoperative management in 4 of the 7 patients with blunt trauma. Two patients with brachial plexus injury continued to have neurologic deficits. All arterial repairs have remained patent and there have been no graft infections.

We report the case of a seven-year-old boy who sustained near-total transection of the aortic arch following apparently minor blunt injury. The radiological and operative findings and the successful outcome of urgent surgical repair support an aggressive approach to the diagnosis and management of suspected aortic injuries in children.

From 1970 to 1985, 49 patients were operated for traumatic aortic rupture (TAR) in 2 university hospitals. Protection of distal ischemia was performed 31 times with a left heart bypass (LHB), 5 times with a heparin coated shunt and, 13 times using simple aortic cross-clamping combined with pharmacological vasodilatation. Total mortality was 17 out of 49, 5 during and 12 after the operation, 2 of them being directly related to systemic heparinization during LHB. In the LHB and shunt groups there was one postoperative paraplegia out of 35 patients, while 4 from the 13 patients operated without a shunt developed paraplegia. If risk factors such as long cross-clamping time, hypotension, extensive laceration of the inner curvature of the aorta, or cross-clamping of the aortic arch at a high level are anticipated, LHB or the shunt technique must be considered to avoid paraplegia. A repair without a shunting procedure should be limited to those cases in which the individual surgeon believes that he can do the operation within 30 minutes aortic cross-clamping time.

A case of successful replacement of two coexistent chronic post-traumatic aneurysms of the thoracic aorta is presented. Presumably, these aneurysms at the aortic isthmus and the descending thoracic aorta resulted from two different deceleration traumas.

This is a case report of a 75 year old man who sustained a longitudinal rupture of the aortic arch in addition to cerebral and extremity trauma following a traffic accident. An emergency operation without the use of the heart-lung-machine could not save the patient's life. Possible mechanisms leading to this unusual damage to the aortic arch are discussed.

Between 1975 and 1980, 9 patients with traumatic rupture of the thoracic aorta were operated at our institution. All patients showed additional multiple limb and internal organ injuries. Leading symptoms of aortic rupture were mediastinal widening (8), left-sided hemothorax (6), and acute aortic coarctation (2). Aortic rupture was proven by angiography in 8 patients and during exploratory thoracotomy in another. The time interval between trauma and operation was one to 48 hours, in 6 patients less than 4 hours. Atrio-femoral bypass was used in 3 patients, TDMAC-heparin shunt in 4 patients and 2 patients were operated without bypass. Prosthesis interposition was required in 3 patients while direct suture was possible in 6 patients. Long-term survival was achieved in 7 patients, one patient died from shock sequelae and another had suffered inoperable multiple rupture along the ascending and transverse aorta. It is concluded that patients with traumatic aortic rupture have a relatively good prognosis if diagnosis is established immediately and if surgery is feasible. The operative result is influenced substantially by the degree of preoperative shock and the presence of additional injuries.

In the diagnosis of acute and chronic posttraumatic false aneurysms of the thoracic aorta the importance of imaging methods can't be overemphasized, especially, since clinical signs often are of no help. The findings in plain films and angiography in 17 patients with posttraumatic aortic rupture are described and discussed. The importance of angiography is stressed.

We tried to find out the validity of 16 wellknown signs indicating an acute traumatic aortic rupture on plain chest radiographs of 22 patients. Angiographically 11 of all patients had a tear at the aortic isthmus. It turned out that 7 of the 16 signs (widened mediastinum, loss of the aortic knob contour, opacification in the aortopulmonary window, bulging of the vascular pedicle predominantly to the left, left apical cap, depression of the left main stem bronchus and displacement of the right paraspinous interface) are of great diagnostic value.

The methods, indications and results of digital subtraction angiography in traumatology are presented, based on 56 examinations. The different use of intravenous or intraarterial DSA will be discussed with respect to expanding and localisation of traumatic vascular injury. DSA is recommended as the method of choice for follow-up after vascular reconstructive procedure.