From the Guidelines
Vascular aortic injuries during trauma should be prioritized and fixed immediately, as they represent an immediate life-threatening emergency requiring urgent intervention, with the timing of repair dependent on the extent of aorta lesion and patient clinical status as assessed by a multidisciplinary team. The management of aortic injuries is guided by the principles outlined in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. According to these guidelines, the extent of aorta lesion and patient clinical status dictate the timing of therapeutic interventions.
- Minimal aortic injury (grades 1 and 2) may be managed medically along with strict clinical and imaging surveillance.
- Moderate aortic injury (grade 3) requires semi-elective repair (within 24–72 h) to allow patient stabilization, though in some patients urgent repair is needed.
- Severe aortic injury (grade 4) necessitates immediate repair. The preferred approach for repair is TEVAR (Thoracic Endovascular Aortic Repair), if feasible, due to its lower in-hospital mortality (7.9% vs. 20%) and 1-year mortality (8.7% vs. 17%) compared to open surgery 1. In cases where the left subclavian artery (LSA) needs to be covered during TEVAR, prior LSA revascularization is suggested to reduce the risk of paraplegia. The principle of addressing the most immediately life-threatening conditions first remains paramount in trauma care, with vascular control being crucial to prevent exsanguination.
From the Research
Vascular Aortic Injury Repair Timing
- The timing of repairing a vascular aortic injury during trauma depends on the severity of the injury and the presence of other injuries 2, 3, 4.
- For patients with low-grade injuries, non-operative management may be suitable, while high-grade injuries often require immediate intervention 4.
- The management of traumatic aortic injuries is guided by the severity of the injury, and treatment options include open surgical and endovascular approaches 2.
- Endovascular approaches with stent-graft placement are preferred due to their high clinical success and low rates of complications 2.
Associated Injuries and Treatment Prioritization
- Associated injuries, such as rib fractures, liver lacerations, and head injuries, are common in patients with aortic injuries 3, 5.
- The treatment of associated injuries may take priority over the repair of the aortic injury, depending on the severity and urgency of the injuries 3.
- In some cases, the repair of the aortic injury may be delayed to allow for the treatment of other life-threatening injuries 4.
Diagnostic and Treatment Considerations
- Diagnostic imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), play a crucial role in the diagnosis and treatment planning of aortic injuries 2.
- The choice of treatment approach, whether open surgical or endovascular, depends on the severity of the injury, the patient's overall condition, and the availability of resources 2, 3.