Chapter 56

Injury to the aorta and great vessels of the thorax may occur secondary to blunt or penetrating trauma, and appropriate management of immediate hemorrhage as well as that resulting from subsequent pseudoaneurysm rupture should be the primary goal of the treating surgeon.1 Blunt aortic injury is the most common thoracic vascular injury following blunt trauma and the second leading cause of death from motor vehicle collision, accounting for 15% of deaths.2–4 In 75 to 90% of cases, death occurs at the accident scene, typically in those with four or more serious injuries in addition to their aortic transection.2–5 After aortic transection at the isthmus, aortic disruption at the base of the innominate artery is the most common site of injury, followed by the base of the left subclavian artery, and the base of the left carotid.6 Central venous structures are rarely injured with blunt trauma,7 but this can occur with penetrating trauma.8 Traditionally, open surgical repair of these injuries has proved effective, but recent literature has demonstrated the safety and efficacy of endovascular interventions.9 This chapter examines trauma to each of the thoracic vessels and presents diagnostic modalities as well as treatment options.

### Mechanism of Injury

Descending thoracic aortic transection is the most common vascular injury resulting from blunt thoracic force; however, the ascending aorta and arch vessels may also be disrupted, commonly leading to dissection or pseudoaneurysm formation.10,11 Mechanistically, the transmission of force through the thoracic cavity from blunt injury is believed to cause torsion of the ascending aorta, leading to disruption of the wall with an associated shearing effect on the heart.12 Additionally, a water-hammer effect is described in which an aortic occlusion at the diaphragm occurs with impact and a high pressure wave is reflected back to the ascending aorta and aortic arch.1 The pathogenesis of blunt innominate artery rupture has been postulated to be the result of anteroposterior compression of the mediastinum between the sternum and vertebrae, displacing the heart posteriorly and to the left, thereby increasing the curvature of the aortic arch and increasing tension on all of its outflow vessels.13 Hyperextension of the cervical spine with head rotation provides additional tension on the right carotid artery, which is transmitted to the innominate artery, and can lead to rupture.13 The left carotid artery undergoes stretching injury with rapid deceleration, producing an intimal tear and subsequent dissection.10 Additional mechanisms of carotid artery injury include hyperflexion of the neck to cause compression between the mandible and cervical spine, basilar skull fracture transecting the artery, and strangulation injury.10 Blunt subclavian artery injuries are more common in the middle and distal third of the artery and are theorized to be caused by downward forces fracturing the first rib with the anterior scalene acting as a fulcrum so that the subclavian artery is pinched between the first rib and clavicle.14 The abrupt deceleration ...

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