Blunt abdominal aortic injury

Department of Surgery, Division of Vascular Surgery, University of Washington, Seattle, Wash., USA.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (Impact Factor: 3.02). 02/2012; 55(5):1277-85. DOI: 10.1016/j.jvs.2011.10.132
Source: PubMed


Blunt abdominal aortic injury (BAAI) is a rare injury with less than 200 cases in the current reported world literature, mostly in case report format. We sought to describe the experience of a high-volume trauma center and to provide a contemporary review of the literature to better understand the natural history and management of this injury.
This was a retrospective review of patients with BAAI between 1996 and 2010. Data collected included demographics, mechanism of injury, associated injuries, type of intervention, subsequent imaging, and follow-up. BAAI was classified by the presence of external aortic contour abnormality noted as an intimal tear, large intimal flap, pseudoaneurysm, or free rupture. Abdominal aorta zones of injury were classified by possible surgical approaches as zone I (diaphragmatic hiatus to superior mesenteric artery [SMA]), zone II (includes SMA and renal arteries), and zone III (from the inferior aspect of the renal arteries to the aortic bifurcation).
We identified 28 individuals (68% male) with BAAI (median age, 28.5; range, 6-61 years). The median injury severity score was 45 (range, 16-75), and 39% were hypotensive at presentation. BAAI presented as intimal tear (21%), large intimal flap (39%), pseudoaneurysm (11%), and free rupture (29%). Zone III was the most common location of injury. Management depended on the location and type of injury: nonoperative (32%), open aortic repair (36%), endovascular repair (21%), and multimodality (10%). Overall mortality was 32%. Most deaths occurred during the initial operative exploration. The mortality rate of free aortic rupture was 100%. Intimal tears resolved or remained stable. Median follow-up was 15.5 months (range, 8 days-7.5 years). Vascular complications due to repair included a thrombosed access femoral artery during an endovascular repair and death of a patient who underwent a hybrid repair.
This is the largest BAAI series described in the English literature at one institution. BAAIs range from intimal tears to free rupture, with outcomes and management correlating with type and location of injury. Nonoperative management with blood pressure control using β-blockers coupled with antiplatelet therapy and close follow-up is successful in individuals with intimal tears with minimal thrombus formation because they remain stable or resolve on follow-up. Free rupture remains a devastating injury, with 100% mortality. For all other categories of aortic injury, successful repair correlates with a favorable prognosis.

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    ABSTRACT: Blunt abdominal trauma with major vascular involvement is found to be rare. Although few series have been reported in the literature, the true incidence of blunt abdominal aortic injury is unknown. Different modalities of blunt trauma may occur among civilians with steering wheel and seat belt injury secondary to motor vehicle accident the most frequent. Mechanical forces produce variable patterns of injury; therefore, the onset of signs and symptoms can be different. Dissection and thrombosis of the abdominal aorta have been frequently described among seat-belted adult patients with major vascular involvement. The associated abdominal viscus and/or vertebral lesions must always be taken into account. Prompt diagnosis allows adequate surgical treatment. We present the case of a 66-year-old woman, restrained front passenger involved in a motor vehicle collision, who had small bowel transection, vertebral fractures, and aortic partial occlusion below inferior mesenteric artery with bilateral iliac artery involvement. Along with the case reported, the purpose of this study is to highlight and compare features and management of the previous cases described in the English literature.
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    ABSTRACT: Blunt abdominal aortic injury (BAAI) is historically associated with significant morbidity and mortality. Our institutional experience was analyzed to define current patterns of injury and to help guide management. Adult patients with BAAI between January 2000 and July 2011 were identified from our trauma registry. Medical, radiographic, and autopsy records were reviewed for relevant clinical data. Management and outcomes were compared between patients with minimal aortic injury limited to the intima (MAI) compared to more significant aortic injury (SAI). Nine patients had MAI and 8 had SAI, including 2 dissections, 2 pseudoaneurysms, 2 branch avulsions, 1 thrombosis, and 1 transection. The MAI and SAI groups had similar demographics and patterns of injury, and all patients had significant polytrauma, with a mean injury severity score of 42. More MAI than SAI patients were managed nonoperatively (100% vs. 38%; P = 0.01). All observed patients underwent repeat imaging during the index admission, 85% within 72 hours, and no observed lesions led to malperfusion, death, or progression during the index admission. One MAI progressed to a pseudoaneurysm within 8 months. Five SAI patients underwent aortic-related repairs, including 2 endovascular stent grafts, 2 open primary repairs, and 1 axillobifemoral bypass. Overall, 15 (88%) patients underwent procedures for any injury-9 required laparotomy (53%) and 2 underwent thoracotomy. There were 6 (35%) deaths, 2 attributable to aortic injury-1 from hemorrhage and 1 from hyperkalemic cardiac arrest after prolonged ischemia from infrarenal aortic occlusion. Among patients who survived the initial resuscitation, SAI was associated with a significantly higher mortality rate compared to MAI (50% vs. 0%; P = 0.03). Patients with MAI are at low risk of complications and may be considered for observation. Patients with SAI requiring intervention manifest clinically and/or radiographically at presentation. Those not associated with bleeding, malperfusion, or thromboembolism may be observed with interval imaging. For all observed patients, long-term surveillance is required to document complete resolution or stability, because even MAI can progress to a more complex lesion.
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    ABSTRACT: Blunt injury of the abdominal aorta is highly fatal. We present an unusual case of an osteophyte impaling the abdominal aorta treated by endovascular repair. A 77-year-old man sustained a thoracolumbar fracture-dislocation with posterior aortic rupture between his celiac and superior mesenteric artery origins. His aortic injury was treated with a stent graft, excluding the celiac origin. He was dismissed on postoperative day 6. At 6 months, he had returned to most preinjury activities, and at 2-year follow-up, he continues to have good functional outcome. Endovascular repair may be successfully employed in select aortic injuries in hemodynamically stable patients.
    No preview · Article · Jun 2013 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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