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Traumatic thoracic aortic injury

Key sources
The following summarized guidelines for the evaluation and management of traumatic thoracic aortic injury are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2022), the American College of Radiology (ACR 2020), the Society of Interventional Radiology (SIR 2020), the Society of Critical Care Medicine (SCCM 2016), the Eastern Association for the Surgery of Trauma (EAST 2015), the European Society of Cardiology (ESC 2014), and the Society for Vascular Surgery (SVS 2011).
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Guidelines

1.Diagnostic investigations

Chest imaging
As per ACR 2020 guidelines:
Obtain a CXR and chest CT with IV contrast or chest CTA as complementary first-line imaging modalities in hemodynamically stable patients with suspected cardiac injury following blunt chest trauma.
B
Obtain a CXR, chest CT with IV contrast, chest CTA, and cardiac CT with IV contrast as complementary imaging modalities in hemodynamically unstable patients with suspected cardiac injury following blunt chest trauma.
B
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  • Cardiac imaging

2.Medical management

Setting of care: manage and treat patients with blunt TTAI at a trauma center with the facilities and expertise to treat aortic pathology.
B

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  • Expectant management

  • Anti-impulsive therapy

3.Nonpharmacologic interventions

Physical activity: provide education and guidance about avoiding intense isometric exercises (such as heavy weightlifting or activities requiring the Valsalva maneuver), burst exertion and activities, and collision sports in patients with significant aortic disease.
B

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  • Psychosocial support

4.Perioperative care

Choice of anesthesia: consider administering general anesthesia for TEVAR.
C

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  • Thromboprophylaxis

5.Surgical interventions

Resuscitative thoracotomy
Consider performing emergency department thoracotomy in patients presenting pulseless to the emergency department with signs of life after blunt injury.
C
Avoid performing emergency department thoracotomy in patients presenting pulseless to the emergency department without signs of life after blunt injury.
D

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  • TEVAR (indications)

  • TEVAR (timing)

  • TEVAR (choice of approach)

  • TEVAR (technical considerations)

  • Left subclavian artery revascularization

6.Specific circumstances

Patients with penetrating injury, bedside echocardiography: obtain bedside echocardiography in hemodynamically stable patients with penetrating chest trauma.
B

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  • Patients with penetrating injury (emergency department thoracotomy)

7.Follow-up and surveillance

Surveillance imaging
Consider obtaining surveillance imaging at intervals appropriate for the repair approach and location after aortic repair in patients with blunt traumatic aortic injury.
C
Consider obtaining surveillance CT at 1 month, 6 months, and 12 months after the diagnosis and, if stable, at appropriate intervals thereafter (depending on the type and extent of the injury) in patients with unrepaired blunt traumatic aortic injury.
C