Injury to the aorta and great vessels of the thorax may occur secondary to penetrating or blunt trauma. The management strategy involves control of immediate hemorrhage with prevention of distal malperfusion or pseudoaneurysm development and rupture. Blunt thoracic aortic injury (BTAI) is the most common thoracic vascular injury and is the second leading cause of death in the United States from nonpenetrating trauma. Its incidence is estimated at 7500 to 8000 cases per year.1 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 Current data suggest that approximately 4% of patients die during transport from the scene, and an additional 19% die during the initial trauma evaluation.3 A meta-analysis in 2011 reported that in-hospital mortality of patients managed nonoperatively was as high as 46%, whereas mortality was 9% in patients treated by endovascular repair and 19% for open repair.4 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. Central venous structures are rarely injured with blunt trauma, but this can occur with penetrating trauma.5 Traditionally, open surgical repair of these injuries has proved effective. Since the first endovascular thoracic aortic device became commercially available in the United States in 2005, the treatment of BTAI has rapidly evolved as high-volume trauma centers applied the principles of endovascular aneurysm repair to BTAI in an off-label manner. With the growing shift from open repair to thoracic endovascular aortic repair (TEVAR) as the primary treatment in patients with BTAI, outcomes have improved with significantly reduced mortality and morbidity, including procedure-related paraplegia.6 This chapter describes the traumatic injuries to the thoracic aorta and its brachiocephalic branch vessels. The mechanism, clinical presentation, and treatment strategies are presented. The emphasis is directed to endovascular strategies which have emerged as the most commonly utilized intervention in blunt aortic and brachiocephalic branch vessel trauma. The chapter is divided into the ascending, arch, and descending zones and both open surgical and endovascular approaches are described with regard to the specific zones.
Zonal Divisions of the Thoracic Aorta
In order to facilitate international correspondence and a clinically more useful system with regard to anatomical identification of the thoracic aorta, an “anatomical endograft landing zone map” was advocated at the First International Summit on Thoracic Aortic Endografting held in Tokyo in 2001.7 We suggest using this landing zone map to classify not only the proximal deployment site of an endograft but also extent of open surgical repairs. In 2002, this landing zone map was expanded to include the position of the distal end of the endograft. Since then, the map (Fig. 51-1) ...