Endovascular stent grafts in urgent blunt and penetrating thoracic aortic trauma

A traumatic thoracic aortic injury is fatal in the majority of cases. Surviving the aortic injury in addition to the myriad of associated trauma requires comprehensive medical management from many medical services. Balancing these services and coordinating the medical care requires free and open communication between services. Although one might assume a thoracic aortic injury takes precedence over other injuries, an organized plan of care in which the morbidity of the injury as well as the consequences of treatment of each injury helps provide an appropriate rank order in the treatment process. A patient with a thoracic aortic injury can be observed for several days while additional injuries are treated, as long as appropriate blood pressure controls are observed. The treatment order for multiple injuries must be reevaluated on a regular basis to adjust for changes in the overall clinical condition. This rank order to treatment and scheduled treatment plan allows for appropriate imaging, evaluation, and coordination of services in preparation for the placement of a thoracic aortic stent graft. The goal of treatment is to reduce the risk of aortic rupture and subsequent fatal hemorrhage. Choosing an open surgical repair versus an endovascular stent graft depends upon physician expertise and clinical status of the patient. In the appropriate clinical setting, endovascular repair of the thoracic aortic injury has become the treatment of choice at the authors' institution in patients with significant operative risks and extensive comorbid injuries. Specific characteristics of the injured aorta also dictate the type of endovascular device required for repair. Case reviews of a patient with blunt trauma and a patient with penetrating trauma used to demonstrate clinical parameters, imaging options, and details of stent graft choice and placement, are presented followed by a review of the literature.