Elsevier

Annals of Vascular Surgery

Volume 30, January 2016, Pages 34-39
Annals of Vascular Surgery

VESS Clinical Research
Observation May Be Safe in Selected Cases of Blunt Traumatic Abdominal Aortic Injury

https://doi.org/10.1016/j.avsg.2015.06.067Get rights and content

Background

Blunt traumatic abdominal aortic injury (BTAAI) is a rare lesion, often associated with extensive intraperitoneal injuries. Optimal management remains unclear, including the role of prosthetic aortic graft replacement with concomitant bowel injury and the management of small pseudoaneurysms.

Methods

We reviewed BTAAI cases occurring between 2000 and 2014. Thoracic and isolated iliac artery injuries were excluded. We included patient demographics, mechanism of injury, admission physiology, and reviewed available imaging to characterize aortic injury type and severity.

Results

BTAAI was noted in 16 of 8,751 (0.2%) blunt abdominal trauma patients admitted during the study period. Of these, 56% were males and the median age was 47 years (range, 5–80). Aortic repair was attempted in 7 patients, including 3 open prosthetic aortobi-iliac bypass grafts, 1 endovascular repair, and 2 primary repairs. One patient died before repair. The remaining patients were medically managed for their aortic injury, including 3 with pseudoaneurysm and 3 with large intimal flaps. There were 5 in-hospital deaths (31%) but only 1 attributed to aortic injury. Among patients surviving to discharge, there were no readmissions or delayed deaths. All nonoperative and surgically repaired patients seen in follow-up had stable aortic lesions. No patient with graft or endograft repair had evidence of graft infection on follow-up (median, 52 months; range, 21–121).

Conclusions

BTAAI is a rare entity and is associated with high in-hospital mortality, primarily due to associated injuries. Observation of selected small pseudoaneurysms and intimal flaps appear safe. Survival after hospital discharge is excellent, and aortic-related complications are rare. The indications for repair and the role of revascularization with in situ prosthetic graft in the setting of concomitant bowel injuries are not well defined.

Section snippets

Background

Blunt traumatic abdominal aortic injury (BTAAI) is rare lesion, most commonly associated with high-speed motor vehicle collisions. It occurs in 0.03% of all blunt traumas1 and represents <5% of all aortic injuries. A significant portion of patients sustaining aortic injuries die in the field, with reported mortality among those patients reaching the hospital as high as 30%.2

Characteristic BTAAI-related physical examination findings, such as seat belt sign and abdominal wall contusions,3 have

Methods

The local institutional review board, the Committee for the Protection of Human Subjects, approved this study with a waiver of patient-informed consent. The institutional trauma and departmental databases were queried for patients with BTAAI admitted between January 1, 2000 and January 31, 2014. Patients with primarily thoracic aortic and isolated iliac artery injuries were excluded. Aortic injuries were considered primarily abdominal when occurring at or below the T12 vertebral body. The

Results

During the study period, there were 70,143 trauma admissions, of which 58,031 were for blunt trauma; 8,751 patients had blunt injury to the abdomen, with 16 (0.2%) BTAAI. Among these BTAAI patients, there were 11 males (69%) and 5 females (31%), with a median age of 47 years (range, 5–80; Table I). Mean ISS was 33.6 ± 12.9. One patient died soon after arrival, before initiation of treatment and ISS was not calculated. Three patients did not have admission CT scan because of hemodynamic

Discussion

After initial stabilization, much of the morbidity associated with BTAAI consists of acute arterial insufficiency of the lower extremities, neurologic deficits, and bowel injury.4 A significant portion of these injuries are diagnosed at the time of emergency exploratory laparotomy. Up to 60% of patients may present in stable condition,3 however, and have their aortic injury identified by subsequent CT imaging. Contrast-enhanced CT in this setting provides for improved characterization of injury

Conclusions

BTAAI is rare and is associated with high in-hospital mortality, mostly due to associated injuries. It appears that selected patients, even with large intimal flaps and pseudoaneurysms, can be safely observed. When needed, revascularization with in situ prosthetic graft may be safe, despite concomitant bowel injuries. Available short-term and midterm follow-up data suggest that survival after hospital discharge is excellent and aortic-related complications are rare. The optimal treatment of

References (9)

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