Traumatic Injuries to Traumatic Injuries to the Aortathe Aorta

Amanda LawAmanda Law

AnatomyAnatomy Supplies body with oxygenated bloodSupplies body with oxygenated blood Three layersThree layers

– Tunica IntimaTunica Intima– Tunica MediaTunica Media– Tunica Adventitia Tunica Adventitia

Three major branchesThree major branches– Ascending AortaAscending Aorta– Aortic ArchAortic Arch– Descending Aorta Descending Aorta

Composed of connective tissue and elastic Composed of connective tissue and elastic fibersfibers

http://www.vcu.edu/hearts/images/aorta_anatomy.jpg

Different Forms of InjuryDifferent Forms of Injury

Incomplete Aortic RuptureIncomplete Aortic Rupture Severe Aortic InjurySevere Aortic Injury Traumatic Aortic DissectionTraumatic Aortic Dissection Traumatic and Iatrogenic Aortic Traumatic and Iatrogenic Aortic

DissectionDissection

Incomplete Rupture

Severe Aortic Injury

Traumatic Aortic Dissection

Mechanism of InjuryMechanism of Injury

Hardy, Shah, Kopacz, and Yang Hardy, Shah, Kopacz, and Yang studied mechanisms in 2006studied mechanisms in 2006

In situIn situ cadavers to test TRA cadavers to test TRA mechanismsmechanisms

Main Goal: further study potential Main Goal: further study potential TRA mechanisms and discover which TRA mechanisms and discover which movements might cause TRAmovements might cause TRA

ProcedureProcedure

5 tests5 tests Two tests pulled aortic arch in Two tests pulled aortic arch in

anterior directionanterior direction One test displaced the arch toward One test displaced the arch toward

the right sidethe right side Two tests displaced the arch Two tests displaced the arch

superiorly superiorly

Categories Categories

Side Impact Side Impact Frontal ImpactFrontal Impact Both Side and Frontal ImpactBoth Side and Frontal Impact

http://www1.istockphoto.com/file_thumbview_approve/2427726/2/istockphoto_2427726_car_crash.jpg

ResultsResults

Aortic tear in all situationsAortic tear in all situations TransverseTransverse 3 complete, 1 incomplete, and 1 3 complete, 1 incomplete, and 1

circumferential tear through intimacircumferential tear through intima Peri-isthmic regionPeri-isthmic region

Results Results

ConclusionsConclusions 56% of all clinical TRA 56% of all clinical TRA

occurs within the peri-occurs within the peri-isthmic region. isthmic region.

94% of all car accident-94% of all car accident-related injuries occur related injuries occur within this region, and within this region, and 93% of those tears are 93% of those tears are complete. complete.

Intimal tears were along Intimal tears were along the circumference and the circumference and were 6.9mm in length were 6.9mm in length and 33mm from the and 33mm from the subclavian arterysubclavian artery

http://www.jvascbr.com.br/03-02-03/03-02-03-197/fig02.jpg

MechanismsMechanisms

Straightening of the inferior archStraightening of the inferior arch Abnormal movement of the aortic Abnormal movement of the aortic

archarch Thoracic deformationThoracic deformation Stretch deformationStretch deformation Traction of superior vasculatureTraction of superior vasculature ““Shoveling”Shoveling” Motion of the sternumMotion of the sternum

TestsTests

Chest x-rayChest x-ray MRIMRI CT scanCT scan TEETEE

MRIMRI

http://hcd2.bupa.co.uk/images/factsheets/MRI_scan.gif

CT ScanCT Scan

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TEETEE

http://content.answers.com/main/content/img/medTest/f005007b.jpg

Surgical InterventionsSurgical Interventions

Stent-graft RepairStent-graft Repair Aortic repair using a “clamp and Aortic repair using a “clamp and

sew” approach or some form of sew” approach or some form of bypass bypass

Antihypertensive Therapy Antihypertensive Therapy

Stent-graft Repair Stent-graft Repair

http://www.medtronic.com/physician/aneurx/images/AAAdvantage3.jpg

Stent GraftsStent Grafts

Talent Talent Excluder Excluder Vanguard Vanguard

Advantages/DisadvantagesAdvantages/Disadvantages

Aortic cross Aortic cross clamping and clamping and single lung single lung ventilation is ventilation is avoidedavoided

Minimal Minimal anticoagulationanticoagulation

Less invasiveLess invasive Minimal blood lossMinimal blood loss

Annual CT scansAnnual CT scans

Direct aortic repair using a “clamp Direct aortic repair using a “clamp and sew” approach or some form and sew” approach or some form

of bypassof bypass

http://www.jvascbr.com.br/02-01-03/02-01-03-207/Fig5.jpg

Antihypertensive Therapy Antihypertensive Therapy

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/8693.jpg

ComplicationsComplications

ParaplegiaParaplegia HemorrhageHemorrhage TransfusionTransfusion Organ DysfunctionOrgan Dysfunction Long ICU staysLong ICU stays Extensive RehabilitationExtensive Rehabilitation

PredispositionPredisposition

GeneticsGenetics Connective Tissue DisordersConnective Tissue Disorders

– Marfan SyndromeMarfan Syndrome

http://www.cafamily.org.uk/pics/m15i1.jpg

Marfan SyndromeMarfan Syndrome

Connective Tissue DisorderConnective Tissue Disorder Connective Tissue is abnormal causing Connective Tissue is abnormal causing

weakened tendons, ligaments, blood weakened tendons, ligaments, blood vessel walls, cartilage, and heart valvesvessel walls, cartilage, and heart valves

Characteristics: slender, tapering Characteristics: slender, tapering fingers, long arms and legs, curvature fingers, long arms and legs, curvature of the spine, eye problems, mitral valve of the spine, eye problems, mitral valve prolapse, aortic root dilation, and aortic prolapse, aortic root dilation, and aortic dissection dissection

Fibrin-1 geneFibrin-1 gene

A Case StudyA Case Study

20-year female involved in motor vehicle 20-year female involved in motor vehicle accidentaccident

Sustained multi-system trauma Sustained multi-system trauma Unresponsive Unresponsive Slight bruise to left chest with no Slight bruise to left chest with no

instabilityinstability Pulse was 60-70 range (equal bilaterally)Pulse was 60-70 range (equal bilaterally) Systolic Blood Pressure was in 120sSystolic Blood Pressure was in 120s GCS - 3GCS - 3

TestsTests

Chest x-rayChest x-ray– Fractured ribs 4-8Fractured ribs 4-8– Possible mid-sternal fracturePossible mid-sternal fracture– Wide mediastinumWide mediastinum

CT scanCT scan– Mediastinal hematomaMediastinal hematoma– Left-pulmonary contusionLeft-pulmonary contusion– Collapse lungCollapse lung

LabsLabs Red Blood Cell Count – 4.25 x 10^12 cells/LRed Blood Cell Count – 4.25 x 10^12 cells/L Hemoglobin – 12.7 gm/dlHemoglobin – 12.7 gm/dl Hematocrit – 36.7%Hematocrit – 36.7% Glucose – 179Glucose – 179 Creatinine – 0.6 mg/dlCreatinine – 0.6 mg/dl

Na – 134 mEq/LNa – 134 mEq/L K – 3.2 mEq/LK – 3.2 mEq/L pH – 7.41pH – 7.41 pO2 – 456 mmHgpO2 – 456 mmHg pCO2 – 36 mmHgpCO2 – 36 mmHg

TreatmentTreatment

Stent Graft ProcedureStent Graft Procedure– AneuRx graftAneuRx graft

http://content.answers.com/main/content/wp/en/thumb/3/33/200px-Covered_Stent_Graft.jpg

Statistics Statistics

An estimated 15 to 20% of patients An estimated 15 to 20% of patients make it to the hospital alive and of make it to the hospital alive and of those 75% will die within 24 hours if those 75% will die within 24 hours if they do not receive surgical they do not receive surgical intervention. intervention.

ConclusionsConclusions

Aortic injuries are of serious concern Aortic injuries are of serious concern to medical professionals. There is a to medical professionals. There is a high mortality rate among patients high mortality rate among patients who sustain injuries to their aorta. who sustain injuries to their aorta.

The statistics make it apparent that The statistics make it apparent that researchers must pay extra attention researchers must pay extra attention to this problem so that the most to this problem so that the most effective treatments may be effective treatments may be developed. developed.

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