TRAUMA
Review Article
Imaging of thoracic trauma
Benjamin Holloway, Helen Mathias and Peter Riley
Abstract
The purpose of this article is to demonstrate the commonly encountered findings in all types of thoracic trauma. It is not
intended to be a systematic review of the literature, but will discuss and illustrate the differing imaging techniques which
are used to diagnose common traumatic injuries in the thorax. Interventional radiology-based therapeutic interventions
will be demonstrated.
Keyword
Trauma, thorax, imaging
Introduction
Thoracic trauma, most specifically aortic injury, is the
second most common cause of mortality in the ser-
iously injured patient after head injuries.1 Imaging
has become a central part of the evaluation of these
patients and is often used after the patient has been
initially stabilised in the resuscitation department.
There is increasing evidence that minimally invasive
interventional radiology can be used to effectively
treat severe internal thoracic injuries such as acute
aortic injury and localised bleeding.
Imaging modalities
The principle imaging techniques used for the diagnosis
of thoracic trauma are plain radiography and com-
puted tomography (CT). Other modalities including
ultrasound, invasive angiography and magnetic reson-
ance imaging (MRI) are less frequently used, princi-
pally as specific problem-solving tools.
Plain chest radiography (CXR) is readily available in
the resuscitation department making it ideal for very
early assessment immediately after the initial stabilisa-
tion of the patient. Often chest radiographs are
performed with the patient supine and in the antero-
posterior (AP) projection in acutely ill patients
(Figure 1). Because the film is supine, a pneumothorax
is more difficult to detect as it will be anterior (making
the lung edge absent).2 While rib fractures and lung
contusion are often detected on CXR their extent are
frequently under diagnosed.2 Nonetheless, the CXR is
particularly useful in the unstable patient to diagnose
Trauma
2014, Vol. 16(4) 256–268
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DOI: 10.1177/1460408614532050
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large haemothoraces, pneumothoraces, lung collapse
and mediastinal shift, which could require emergent
chest tube insertion. In addition, it allows the rapid
assessment of support lines and tubes. Contrary to
CT, the radiation dose from a CXR is very small
being in the order of 0.02 millisieverts (mSv) equivalent
to around 3 days of background radiation in the UK.
CT use in the severely injured patient has increased
significantly in the UK in recent years. This is in the
context of increasing evidence as to its accuracy for
diagnosing significant injury and enabling the guidance
of therapeutic surgery or radiological intervention.
Description of the various protocols, including scan
pitch, slice thickness, contrast delivery and timing are
beyond the scope of this article but it is important to
emphasise that there are a number of ways that a CT
can be performed depending on the clinical question
posed. CT delivers high radiation dose to the patient
in the order of 20–30 mSv depending on the extent
covered. This is of particular concern to the radio-
logical community and became more widely discussed
following a review article in 2007.3 The potential for
imaging radiation to induce malignancy is most rele-
vant in young patients. Furthermore, several studies
have shown that CT is being frequently performed in
Department of Radiology, Queen Elizabeth Hospital Birmingham,
Birmingham, UK
Corresponding author:
Benjamin Holloway, Department of Radiology, Queen Elizabeth Hospital
Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK.
Email: ben.holloway@uhb.nhs.uk
Holloway et al.
Figure 1. AP supine chest radiograph in a patient that was
subsequently shown to have no significant intrathoracic injury on
CT. The projection results in an apparent widening of the
mediastinum which can be mistaken for mediastinal haematoma.
those that turn out to have minor or no injury and
could be limited by employing a strict clinical decision
making tool.4 Because of the high radiation, judicious
use of CT limited to trauma patients in whom there is
either clinical evidence of significant injury or a high
index of suspicious is needed.
MRI is difficult to perform in acutely ill or poten-
tially unstable patients due to incompatibility of moni-
toring and support equipment with the magnet, and the
enclosed gantry. Nonetheless MRI provides the best
contrast resolution for soft tissues and has an estab-
lished role in the assessment of spinal trauma.
Elsewhere in the thorax, MRI has a limited role,
except in cases of equivocal great vessel injury on CT
(such as possible acute intramural haematoma which
can be difficult to characterise on a post-contrast CT
when pre-existing atheroma is present).
In most centres, the principle role for ultrasound in
thoracic trauma is the assessment of pleural or pericar-
dial fluid. Dedicated echocardiography has a role in the
assessment of cardiac injury. Ultrasound is unrivalled
in the differentiation of fluid, septation and sediment
identification. More recent evidence suggests that ultra-
sound is potentially superior to clinical examination
and chest radiography in the detection of pneumo-
thorax and lung contusion when using CT as a refer-
ence standard.5 In the author’s experience, ultrasound
use in this context is generally limited to centres where
there are individuals with particular expertise. In the
sub-acute period, ultrasound allows the direct visualisa-
tion of catheter placement into pleural fluid collections.
257
Figure 2. Axial CT section with lung windows demonstrating
areas of ground glass opacity and consolidation consistent with
pulmonary contusion (arrows).
Invasive angiography is rarely used for diagnosis in
the era of modern multislice CT. There are examples
when the superior resolution of angiography relative to
CT can help resolve uncertainty, for example minor
intimal tears in aortic injury. Frequently, angiographic
imaging is performed just prior to intervention and can
aid stent positioning.
Common pathologies in thoracic
trauma
Lung parenchymal injury
The protection of the lungs by the ribs means signifi-
cant damage to the lung parenchyma is usually only
seen in major trauma, although it is relatively
common in this setting.
Lung contusion is defined as damage to the alveoli
and interstitium of the lung without significant lacer-
ation. Animal models have shown that immediately
after injury pulmonary contusion is shown invariably
on CT but it can take more than 30 min to, or never,
become visible on chest radiographs.6 This indicates
that airspace opacity developing on CT after the initial
period is unlikely to be due to contusion and is most
likely related to secondary infection or inflammation.
On CXR, contusion is seen as areas of patchy air space
opacity (vague increased density in the lungs). The cor-
responding abnormality on CT is typically areas of
ground glass opacity (increased lung density through
which vessels are still visible) or consolidation
(increased density through which the vessels are not
visible), which does not conform to one lobe or segment
(Figure 2). Frequently, this is on the side of trauma,
near to ribs fractures but can spare the sub-pleural
region. This abnormality is easily confused with the
258
Figure 3. CT section with lung windows demonstrating
pulmonary lacerations in a paraspinal location (arrow).
similar ground glass opacity or consolidation in the
lower lobes posteriorly, which is often due to under
aeration of normal dependent lung or aspiration.
Lung lacerations occur when there is a tear in the
lung interstitium and alveolar spaces with the adjacent
lung collapsing away from the area. These may be filled
with either air, blood or a mixture of the two. These are
generally seen in those with more severe trauma and
appear as ellipsoid well defined opacities on CT con-
taining air fluid levels often with adjacent pulmonary
contusion. Pulmonary lacerations have been classified
into four types depending of the mechanism by which
they occur and location on CT.7 More central and
para-vertebral lung lacerations are thought to be due
to blunt compression and shearing of the lung.
Peripheral lacerations are felt to relate to either direct
laceration by displaced rib fractures or secondary to
pre-existing pleural adhesion limiting the pleural move-
ment (Figure 3).
Pleural injury
Penetrating injury usually leads to collapse of the lung
and air or blood leaking into the space between the
parietal and visceral pleura. Pneumothorax is classic-
ally depicted as a lucent rim with a lung edge at the
apex of one hemithorax on erect chest radiographs.
Frequently, however, the seriously injured patient is
imaged when supine and detection of a pneumothorax
is difficult as there is usually only slightly reduced dens-
ity on the affected side. On CT, pneumothorax is easily
shown as a rim of low density around the lung, usually
anterior, with collapse of the adjacent lung (Figure 4).
When there has been a penetrating injury, air tracking
into the soft tissues can help identify the site of punc-
ture. Shift of the mediastinum can indicate the
Trauma 16(4)
Figure 4. Axial CT sections with lung windows showing a
moderate sized left pneumothorax.
pneumothorax is under tension and warrants immedi-
ate intervention.
Haemothorax is better appreciated on an erect chest
radiograph as increased density at the base of the hemi-
thorax with a superior meniscus. On the supine radio-
graph, relatively subtle increase in density of the
hemithorax is the only finding, which can also be
caused by rotation of the patient and diffuse lung
consolidation.
CT will show pleural fluid (blood or serous fluid) as
a rim of increased density posteriorly displacing the
adjacent lung. Usually, the higher density of blood in
the pleural space (Hounsfield units (HU) of >30) com-
pared to fluid (HU closer to 0) makes it straightforward
to distinguish between the two. Rarely ultrasound is
needed to help differentiate acute haemothorax from
pre-existing pleural fluid by demonstrating heterogen-
ous mixed echogenicity blood as opposed to
anechoic fluid.
Major airway rupture
Tracheal rupture is a rare condition that is difficult to
diagnose with imaging with few large series describing
the findings. Chest radiography can often raise the pos-
sibility of major airway injury by demonstrating pneu-
momediastinum and surgical emphysema tracking into
the neck.8 Pneumothorax is another predictor but is not
specific. CT often confirms the presence of mediastinal
air but in the absence of an endotracheal tube does not
normally detect the site of injury.8 When an endotra-
cheal tube is sited this often helps with detection of
tracheal injury. The main features on CT are the detec-
tion of an over distended balloon and displacement of
the tube outside the trachea.9 Potential bronchial injury
can be suggested on CT when air is seen around the
Holloway et al. 259

Figure 5. (A) Axial CT demonstrating a small contrast filled pseudo-aneurysm arising anteriorly from the isthmus of the aorta
(arrow). (B) Oblique maximum intensity projection.

injured bronchus but this usually requires bronchos-

copy to confirm.

Aortic injury
After head injury, thoracic aortic injury is the most
common cause of death in blunt trauma in the UK.1
Blunt aortic injury has a poor prognosis especially
when it is not treated with either open or endovas-
cular repair.10 The exact mechanism by which blunt
traumatic injures of the aorta occur is unknown,
although several theories have been postulated.11
The most common site of injury, at least in those
reaching hospital and having a CT, is at the isthmus
(distal arch). Plain radiography has poor accuracy at
detecting blunt aortic injury and should not be relied
upon.12 The direct signs of blunt aortic injury on CT
include intimal flap, pseudoaneurysm, vessel wall con- Figure 6. Mediastinal haematoma (asterix) anteriorly within
tour irregularity, and extravasation of contrast the mediastinum without aortic injury. This was attributed to the
material which are strongly associated with true sternal fracture and rupture of small vessels in the mediastinum.
injury at surgery (Figure 5). These features should
be actively sought when assessing the aorta in usually larger in blunt trauma than in penetrating
severely injured patients using multiplanar reconstruc- injuries and occur more commonly on the left
tions. Mediastinal haematoma alone is much less side.13 The smaller defects from penetrating wounds
sensitive and specific for major vessel injury and are often diagnosed at laparotomy whereas in blunt
should not be relied upon (Figure 6). Further discus- trauma, CT is the most common means of making
sion and examples of aortic injury are in the inter- the diagnosis. Plain radiography can highlight the
ventional radiology section below. diagnosis by demonstrating abdominal contents
(principally shown as gas within bowel) in the lower
hemithorax, but is not very sensitive. There are
Diaphragmatic trauma
numerous signs described on helical CT which when
Diaphragmatic rupture in blunt trauma is uncommon seen in combination makes CT very sensitive for dia-
but is well recognised and usually occurs in patients phragmatic rupture. These can be subdivided into
who have other severe injuries. The defects are direct signs (such as a waist-like constriction of
260 Trauma 16(4)

Figure 7. (A) AP supine radiograph demonstrating bowel contents in the left hemithorax which suggests diaphragm rupture.
(B) Coronal multiplanar CT reconstruction demonstrating a wide defect in the left hemidiaphragm, which is a direct sign of diaphragm
rupture. Arrow indicates the edge of the diaphragm.

intra-abdominal contents passing through a defect)

which are very specific, to indirect signs which vary
in specificity (e.g. haemothorax) (Figure 7).14
Potential mimics of diaphragmatic rupture include
idiopathic elevation of the hemidiaphragm, diaphrag-
matic eventration (localised thinning of the dia-
phragm musculature resulting in alteration of the
diaphragmatic contour) and Bochdalek hernia.15
Using multi-planar reformats in coronal and sagittal
planes aids the evaluation of the diaphragm and the
correct detection of the signs of injury.
Recent evidence highlights the importance of deter-
mining the trajectory of penetrating injury to identify
small, often subtle, penetrating diaphragmatic injuries.
This involves reconstructing a multi-oblique plane in
line with the trajectory to determine if it crosses the Figure 8. Axial oblique CT reconstruction demonstrating a
diaphragm.16 right-sided chest tube which has been placed in the chest wall
outside the ribs (arrow).
Support line assessment
Frequently, the severely injured patient will undergo CT offers the opportunity to assess the position of
endotracheal intubation and have chest drains placed the endotracheal tubes, central lines and chest drains
either at the scene of the incident or early on admis- accurately and can highlight malposition of these which
sion to the emergency department resuscitation room. could otherwise go unnoticed. CT has been shown to be
Chest radiography enables rapid and serial assess- more accurate at assessing the malposition of chest
ment of the position of endotracheal tube drains when compared with ultrasound and chest
immediately after placement. Ideal position for the radiographs (Figure 8).18,19 Endotracheal tubes placed
tip of the endotracheal tube is 5  2 cm above the into either bronchus can be shown clearly on CT with
carina or if the carina is not visible at T3/4 level the secondary effects of partial collapse of the under-
on the CXR.17 aerated lung often apparent (Figure 9).
Holloway et al.
Figure 9. (a) Minimum intensity coronal CT reconstruction demonstrating the mal-position of an endotracheal tube down the right
main bronchus (arrow). (b) Axial CT sections in the same patient showing collapse of the left lower lobe (arrow head) likely related to
under-aeration of this lung which is not being properly ventilated.
Cardiac and pericardial trauma
Cardiac and pericardial injury can be encountered in
the setting of penetrating or blunt chest trauma.
Cardiac trauma in particular is associated with a high
mortality.
In blunt injury, cardiac trauma is usually due to
either compression of the heart between the rigid struc-
tures of the sternum and thoracic spine20 or in relation
to a sudden deceleration injury where there is a shear-
ing effect between relatively mobile and fixed cardiac
and thoracic vascular structures.
In penetrating trauma, the site of injury will
clearly depend on the position of the wound; how-
ever, in both penetrating and blunt trauma, the right
ventricle, being the most anterior structure, is the
most commonly injured if the heart is involved. In
some cases, the injury will be confined to the
pericardium.
The mechanism of the high mortality in cardiac
trauma is related to either cardiac tamponade or
exsanguination.
Chest radiography is of limited utility in the detection
of the cardiac injury. Given that a CXR is often taken
supine, in the AP projection, heart size is difficult to
assess as the cardiac silhouette is exaggerated. Even so,
in acute tamponade, only a relatively small amount
of pericardial fluid (blood) is needed to cause
haemodynamic compromise due to its rapid
accumulation and therefore the cardiac silhouette may
be normal.
261
Echocardiography can be useful given its ease of
access at the bedside. It can accurately detect a haemo-
pericardium and the physiological signs of tamponade
and may be all that is required in the unstable patient to
indicate that emergent surgery is required. Potential
findings on echo suggestive of cardiac injury in addition
to haemopericardium include increased myocardial
echogenicity and focal wall motion abnormality, indi-
cating myocardial contusion. Echo is also of value
when valvular injury is suspected.
CT is sensitive in the detection of cardiac and peri-
cardial injury and is often performed in these patients
as there is concern regarding other significant chest
injuries.
Cardiac injury varies in extent from myocardial con-
tusion, the most common cardiac injury in blunt
trauma,21 to frank rupture, a rare finding in those reach-
ing hospital. There are no specific diagnostic features of
myocardial contusion on CT22 and stranding of the peri-
cardial and extrapericardial fat with or without a hae-
mopericardium may be the only findings. The diagnosis
should, however, be considered in the presence of sug-
gestive clinical findings particularly when there are sig-
nificant associated chest injuries.
A haemopericardium is an important indicator of
significant cardiac, pericardial or proximal aortic
injury and as with a haemothorax, is indicated by
fluid of higher density than simple fluid (Figure 10).
A pneumopericardium may also be present in the con-
text of penetrating injury (Figure 11).
The diagnosis of cardiac tamponade is essentially a
clinical one, with echocardiography being the accepted
262 Trauma 16(4)

Figure 10. Two axial slices of a contrast enhanced CT chest in a patient with a stab wound to the left lower chest showing dense
fluid around the heart consistent with a haemopericardium (left image). Right image also illustrates stranding of the extra-pericardial
fat (arrow) indicating haematoma.

Figure 11. Axial slices of a contrast enhanced CT chest in a patient with a stab wound to the anterior chest wall showing small
locules of gas within the subcutaneous tissues of the anterior chest wall and a shallow anterior haemopericardium (arrow). Gas within
the mediastinum and soft tissues is often better seen using lung windows (right image).

best imaging modality. However, there are several signs
on CT such as dilatation of the SVC, IVC and hepatic
veins, periportal oedema and deformity of the cardiac
chambers, which, although non-specific in isolation, in
the presence of a pericardial effusion are suggestive of
tamponade.23
A specific site of cardiac injury may or may not be
visible depending on the size of the defect and the
extent of cardiac motion artefact (which may be signifi-
cant as the patients are often tachycardic).
Extravasation of dense intravenous contrast, if present,
confirms a specific site of injury but is not frequently
seen and surgical exploration may be required. In the
presence of haemopericardium, other injuries such as
injury to the SVC or IVC, the proximal aorta or a cor-
onary artery should also be considered.
Other potential cardiac injures that should be sought
are traumatic ventricular septal defects and valve inju-
ries. A VSD can occur in either penetrating or less com-
monly in blunt trauma and may be visible on CT
depending on the size of the defect and the relative con-
trast densities in the ventricles. TOE may be needed to
Holloway et al.
further assess these defects (or alternatively ECG-gated
CT or MRI depending on stability of the patient).
Valvular injury due to blunt trauma is relatively
rare. The aortic valve followed by the mitral valve is
most commonly injured.24 The mechanism of injury is
an abrupt increase in pressure within a cardiac chamber
against a closed valve creating a large pressure drop
across the valve.25 Injury can involve the valve leaflets
with a tear or avulsion from the annulus (aortic valve)
or to the accessory apparatus of the valve (e.g. mitral
valve papillary muscle rupture). These findings can
occasionally be seen on MDCT but are more accurately
assessed on echocardiography.
An isolated pericardial laceration may not be easily
visualised although may be suspected in the presence of
a pneumopericardium or haemopericardium. In the
presence of a large pericardial injury, cardiac herniation
or luxation may be seen which can be life-threatening
but is readily identified on CT with findings of cardiac
displacement and ‘entrapment’ of the heart between the
ascending and descending aorta.26
Chest wall injuries
Rib fractures are the most common injury in blunt
thoracic trauma, occurring in 50% of cases.27
Isolated rib fractures are rarely clinically significant
alone, other than being an explanation for pain,
although signs of associated injury (e.g. pneumothorax
haemothorax, upper abdominal visceral injury) should
be sought. When multiple rib fractures are present, these
Figure 12. Volume rendered CT image showing multiple right sided anterior rib fractures.
263
are more significant for a number of reasons. Firstly,
they indicate more significant force and therefore an
increased likelihood of associated significant injury. In
particular, fractures of the upper ribs, particularly the
first rib, should raise the suspicion of other intrathoracic
injuries (e.g. aortic or other vascular injury) as these
signify a high energy force. The second important
point regarding multiple rib fractures is their effect on
respiratory function. This is particularly seen in the set-
ting of the flail chest where three or more contiguous
ribs are fractured in at least two places. This can result
in paradoxical movement of the flail segment, which
may compromise respiratory function.
Chest radiography is often used as the initial assess-
ment of possible rib injury and while fractures may be
visible, there is a high false negative rate. The main
utility of the chest radiograph in this setting is to
detect associated complications such as pneumothorax
or haemothorax. CT is very sensitive for assessing rib
fractures particularly when multiplanar reformats are
used (Figure 12). The extent of displacement of the
fractures should be assessed and the presence of any
flail segments. Associated thoracic and upper abdom-
inal injuries are also readily detected by CT.
Sternal injury is relatively rare but may occur in
blunt injury. It may be associated with cardiac injury.
Thoracic spinal fractures should also be considered in
the presence of a sternal fracture. CT is much more
sensitive than the lateral radiograph for detecting ster-
nal fractures, particularly when multiplanar reformats are
employed. Sternal fractures are often best seen on the
264
Figure 13. Volume rendered CT (posterior view) illustrating a
comminuted scapula fracture.
sagittal reformats where the degree of displacement of the
sternal fragments can also be assessed. Scapular injuries
are relatively uncommon and indicate high force trauma
(Figure 13). While they may require surgical fixation in
due course, their importance in the initial management of
a major trauma patient, lies in their presence being an
indicator of other significant injury.28
Discussion of thoracic spinal injuries is beyond the
scope of this article but is frequently seen in patients
with other intrathoracic injuries and should be actively
sought.
Interventional radiology and
image-guided therapeutics in the chest
In this section, we shall discuss the role of
Interventional Radiology in the treatment of major
traumatic aortic injury.
Background
Injury to the thoracic aorta and its major branches is
one of the most important considerations following
either penetrating or blunt chest trauma. We shall con-
centrate on blunt chest trauma resulting in aortic tears
ranging from a minimal intimal tear (Figures 14 and 15)
to complete rupture with extravasation (Figure 16).
The most frequent site of injury is the aortic isthmus
(92%) at the point of attachment of the ligamentum
Trauma 16(4)
Figure 14. Contrast enhanced axial CT image at the level of
the aortic arch demonstrating a small filling defect in the distal
arch (arrow) indicative of an intimal flap (minimal tear).
Figure 15. Sagittal oblique reconstruction of contrast
enhanced CT of thoracic aorta demonstrating an intimal flap
arising from the greater curvature of the distal arch (arrow).
arteriosum, within 2 cm of the ostium of the left sub-
clavian artery. Other recognised sites of injury are the
arch (4%), aortic root (3%) (Figure 17) and the dia-
phragmatic hiatus (1%). These are all sites of relative
aortic anatomical fixation.
It has been estimated that 75–80% of thoracic aortic
injuries are a result of high-speed motor vehicle colli-
sions and are immediately lethal in 80–90% cases.29 Of
those that reach hospital alive, if untreated, the mortal-
ity is estimated at 1% per hour for the first 48 h. The
most common injury is a transverse tear which may be
segmental (45%) or circumferential (55%) and partial
(65%) or transmural (35%).
Diagnostic imaging has been discussed above but it
is important to re-iterate that multi-detector CT is the
most useful non-invasive modality in the acute setting.
Holloway et al. 265

Figure 16. Axial contrast enhanced CT image at the level of
the upper descending thoracic aorta. There is a defect in the
anterior wall of the aorta (arrow) with active extravasation of
contrast into the anterior mediastinal tissues (asterisk). Note
also a small intimal flap posteriorly.
Figure 17. Axial contrast enhanced CT at level of left coronary
artery ostium. There is a localised tear in the ascending aorta
immediately above the root (arrow) with contrast leaking into
the media.

Catheter angiography is almost always reserved as a

precursor for endovascular therapy.

Treatment of thoracic aortic injury

Treatment of aortic injuries is essentially either open
surgery via thoracotomy with resection and placement
of a Dacron graft or endovascular placement of a stent
graft (Figure 18). Both methods carry a risk of para-
plegia due to disruption of intercostal vessels that may
supply the spinal cord.
Surgery traditionally has involved three types of pro-
cedure, cross-clamp and sew the aorta together or inter-
position graft with either a passive shunt or active
perfusion i.e. left heart by-pass. In a meta-analysis of Figure 18. Stent graft prior to implantation.
1492 patients treated with surgery, the cross-clamp tech-
nique was associated with mortality of 16% and paraplegia aortic injury in 1997.32 The aim of stent graft repair is
rate of 19.2%, graft interposition with by-pass resulted in to prevent further rupture or extravasation by exclud-
zero mortality and 2.3% risk of paraplegia.30 A single ing the damaged segment from the systemic circulation
centre series of 138 patients repaired surgically over a 35- and has a technical success rate of 100%. Stent grafts
year period demonstrated 7.5% mortality for passive shunt are essentially a cylindrical meshwork of self-expanding
and 4% mortality with left heart by-pass.31 Of 97 patients metal (nitinol which expands to its original configur-
treated with by-pass, there were no cases of paraplegia. ation at body temperature) with surgical graft material
interwoven between the metal struts. The leading 1.5 cm
Interventional radiology and endovascular graft is uncovered to allow fixation against the vessel wall.
The procedure is usually performed under general
insertion
anaesthesia; in fact, very often the patient will have
The placement of endovascular stent grafts was first been intubated as part of the resuscitation process.
described in 1991 and was adopted for treating acute Access to the aorta is invariably gained via arteriotomy
266 Trauma 16(4)

Figure 19. Image of surgical cut-down onto right common femoral artery, a vascular sheath and guide wire can be seen positioned
within the lumen (arrow). The stent delivery system can be seen held by the operator with the stent contained within the plastic
covering, once this is withdrawn the stent will expand from the leading edge.

Table 1. Advantages and potential complications of endovas-

cular therapy.

Advantages Complications

Avoid single lung ventilation Stroke

Avoid aortic x-clamping damage Puncture site/access vessel
No cardio-pulmonary by-pass Recurrent laryngeal nerve
Limited anti-coagulation damage
Reduced blood loss

of the common femoral artery (Figure 19). A guidewire

and catheter are manipulated through the aorta into the
arch from where an angiogram (Figure 20) can be per-
formed to define the anatomy, confirm vessel diameter
and site for treatment although these have usually been
documented from multiplanar reconstruction of CT
images (Figures 21 and 22). The stent graft is then
deployed under direct fluoroscopic vision and an angio-
gram performed to check position and confirm exclusion Figure 20. Catheter angiogram in a patient with complete
of the leak (Figure 23). Given the position of the injury, transection and contained leak, the catheter has been inserted
via the left brachial artery to mark the position of the left
the ostium of the left subclavian artery will frequently be
subclavian artery osteum. There is a cuff of contrast surrounding
covered by the stent. This rarely leads to any complica-
the aortic lumen which is irregular.
tions although some patients may require subsequent
carotid-subclavian arterial by-pass.33 There are certain
requirements for stent graft delivery such as the femoral In a series of 41 patients treated with stent graft for
and iliac vessels being a suitable size to allow the device traumatic aortic injury, 98% of cases required only one
to pass through them (usually 7 mm). device, in hospital mortality was 2.4% and there were
The advantages and potential complications of no cases of paraplegia.34 These results are clearly very
endovascular therapy are listed in Table 1. favourable compared to surgical repair.
Holloway et al.
Figure 21. Contrast enhanced axial CT scan of chest just
below the level of the carina. There is contrast extravasating
outside the medial wall of the aorta (arrow) with two intimal
flaps visible more posteriorly.
Figure 22. Sagittal reformat of transection seen in Figure 21.
There is a cuff of contrast surrounding the descending thoracic
aorta at the point of the tear. The position of the injury with
respect to the left subclavian artery origin (arrow) can be seen
and distance between the two measured if necessary.
Clinical Practise Guidelines have been published in
North America by the Society for Vascular Surgery35
based on a systematic review of 7768 patients in 139
studies. Mortality rates for endovascular repair, open
repair and no intervention were 9%, 19% and 46%,
respectively. This review demonstrated improved survival
following endovascular repair with reduced rates of
spinal cord ischaemia, renal injury and graft and systemic
infection.
267
Figure 23. Catheter aortogram acquired following placement
of stentgraft. The left subclavian artery remains patent and the
leak has been excluded from the circulation (arrow).
They have made the following recommendations:
. urgent repair following stabilisation
. observe minimal aortic defects
. selective revascularisation of the left subclavian
artery
. spinal drainage is not routinely required.
Conclusion
Thoracic trauma is common and often has significant
associated morbidity and mortality. Imaging, particu-
larly CT, offers a rapid and accurate way of diagnosing
serious thoracic injury. Acute traumatic aortic injury
encompasses a spectrum of pathology within the
aortic wall, and has a high mortality if not treated in
a timely fashion. Endovascular stent graft repair rather
than surgery is now the preferred method of treatment
where possible.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
None declared.
268
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