Thoracic Vascular Injury

Thoracic Vascular Injury

David Ray Velez, MD

Table of Contents

Background
Initial Evaluation and Management
Definitive Management

See Also:
*See Blunt Thoracic Aortic Injury (BTAI)
*See Vascular Exposure: Thoracic
*See Vascular Exposure: Subclavian

Background

Thoracic Vascular Injury Has High Mortality and Cause 50% of All Trauma Deaths

Nearly All Thoracic Vascular Injuries Have Other Associated Injuries and Rarely Occur in Isolation

Etiology

  • Over 90% are Due to Penetrating Trauma or Iatrogenic Injury
  • Most Common Thoracic Great Vessel Injury by Mechanism:
    • Stab Wounds: Ascending Aorta
    • Gunshot Wounds: Descending Aorta
    • Blunt Thoracic Trauma: Aortic Isthmus (Just Beyond Left Subclavian Takeoff)

AAST Thoracic Vascular Injury Scale

Initial Evaluation and Management

Indications for Immediate Resuscitative Thoracotomy: *See Resuscitative Thoracotomy

Screening Techniques

  • History and Physical Exam
  • Chest X-Ray (CXR)
  • Focused Assessment with Sonography in Trauma (FAST)

CXR Findings Suggestive of Vascular Injury

  • Indistinct Aortic Knob
  • Wide Mediastinum > 8 cm
  • Left Main Bronchus Depression > 140 Degrees
  • Deviation of NG/ET Tubes to the Right
  • Massive Hemothorax

If History and Physical Exam is Suggestive of Blunt Thoracic Aortic Injury Start Anti-Impulse Therapy if Otherwise Stable, Even Before Definitive Diagnosis

Massive Hemothorax – Thoracotomy Indications

  • Initial Loss > 1,500 cc
  • Continual Loss > 200 cc/hr for 4 Hours
    • *Some Say 250 cc/hr for 3 Hours
  • CAUTION: A Dramatic Decrease in Volume Can Be Due to Complete Evacuation but Can Also Occur Due to Clotting within the Chest Tube
  • *See Hemothorax (HTX)

May Be Diagnosed on CT/CTA or Intraoperatively if Unstable or in Extremis

May Consider Catheter Angiography or Transesophageal Echocardiogram (TEE) if Initial Imaging is Equivocal

Thoracic Vascular Injury on CXR (Indistinct Aortic Knob and Widened Mediastinum 1

Definitive Management

Endovascular Techniques are Evolving and May Be Considered for Stable Patients with Select Injuries – Most Often Used for Small Partial Injuries but Have Also Been Used for Complete Transection or Thrombosis by Advanced Through-and-Through Snare Techniques

Blunt Thoracic Aortic Injury (BTAI)

Operative Sequence

  • Step 1. Temporary Bleeding Control
    • Manual Pressure
    • Wound Packing
    • Hemostatic Dressings (QuickClot Combat Gauze)
    • Foley Balloon Catheter Inserted into the Wound if Deep and Narrow
  • Step 2. Extensive Exposure
  • Step 3. Definitive Control (Proximal and Distal)
  • Step 4. Decision (Definitive Repair vs Damage Control)

Vascular Exposure

Surgical Management: Artery Injury

  • Small Injuries (< 50% Circumference): Arteriorrhaphy (Primary Repair)
  • Large Injuries (> 50% Circumference or Transection): Interposition or Dacron Bypass Grafting
  • May Consider Subclavian Artery or Internal Mammary Artery (IMA) Ligation in Damage Control

Surgical Management: Venous Injury

  • Simple Venous Injuries Can Be Repaired by Lateral Venorrhaphy
  • The Majority of Veins (Besides the SVC and Innominate) Can Be Managed by Simple Ligation if Complex or Hemodynamically Unstable
  • Decision is Made for Surgical Repair vs Ligation Based on Severity of Injury and Hemodynamic Status
  • Complex Injuries to the SVC or Innominate May Require PTFE Patch or a Dacron Interposition Graft

References

  1. Alameddine AK, Alimov VK, Alvarez C, Rousou JA. Unexpected traumatic rupture of left atrium mimicking aortic rupture. J Emerg Trauma Shock. 2014 Oct;7(4):310-2. (License: CC BY-NC-SA-3.0)