Traumatic aortic rupture

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Traumatic aortic rupture is a condition in which the aorta, the largest artery in the body, is torn or ruptured as the result of trauma.

Traumatic aortic rupture is a common killer of victims of automotive accidents and other traumas,^[1] with up to 18% of deaths that occur in automobile collisions being related to the injury.^[2]

The condition is frequently fatal due to the massive bleeding that results from the rupture. Since the aorta branches directly from the heart to supply blood to the rest of the body, the pressure within it is very great, and blood may be pumped out of a tear in the blood vessel very rapidly. This can quickly result in hemorrhagic shock and death. Death occurs immediately after traumatic rupture of the thoracic aorta 75% to 90% of the time since bleeding is so severe, and 80 to 85% of patients die before arriving at a hospital. Though there is a concern that a small, stable tear in the aorta could enlarge and cause complete rupture of the aorta and heavy bleeding, this may be less common than previously believed as long as the patient’s blood pressure does not get too high. Patients who survive to hospital admission generally have a partial tear with pseudoaneurysm formation.

Though not completely reliable, chest X-rays are sometime used to diagnose the condition.

The preferred method of diagnosis is aortography.

If a chest tube drains a large amount of bright red arterial blood, or if there is sustained drainage of over 200mls, then aortic rupture should be suspected and the patient should undergo thoracotomy.

Since a high blood pressure could exacerbate the tear in the aorta or even separate it completely from the heart, which would almost inevitably kill the patient, hospital staff take measures to keep a patient’s blood pressure low. Such measures include giving pain medication, administration of beta blockers, keeping the patient calm, and avoiding procedures that could cause gagging or vomiting.

Traumatic aortic rupture is treated with surgery. However, morbidity and mortality rates for surgical repair of the aorta for this condition are among the highest of any cardiovascular surgery. For example, surgery is associated with a high rate of paraplegia,^[3] because the spinal cord is very sensitive to ischemia (lack of blood supply), and the nerve tissue can be damaged or killed by the interruption of the blood supply during surgery.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The injury is usually caused by high speed impacts such as those that occur in vehicle collisions and serious falls. The location of the initial aortic tear is usually at the point in the proximal descending aorta with the greatest sheer where the relatively free and mobile aortic arch joins to the fixed descending aorta (ligamentum arteriousm). By far the most common site for tearing in traumatic aortic rupture is the aortic isthmus, near where the left subclavian artery branches off from the aorta.^[1][2] This junction of the free and fixed part of the aorta is at the greatest risk of transection as a result of the shearing forces due to sudden deceleration.^[3] Frontal or side impacts in motor vehicle accidents and falls from substantial heights pose the greatest risk of sheer.

The aorta may also be torn at the point where it is connected to the heart. The aorta may be completely torn apart from the heart, but patients with such injuries very rarely survive for very long after the injury; thus it is much more common for hospital staff to treat patients with partially torn aortas. When the aorta is partially torn, it may form a “pseudoaneurysm”. In patients who do live long enough to be seen in a hospital, a majority have only a partially torn blood vessel, with the layer called the adventitia still intact. In some of these patients, the adventitia and nearby structures within the chest may serve to prevent severe hemorrhage.

Extrinsic compression of the aorta between the sternum and the spine may contribute at least in part to aortic rupture.

A sudden, dramatic rise in intra-luminal aortic pressure at the time of impact may contribute to aortic rupture.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Blunt chest trauma
• Falling from a height
• Motor vehicle accidents

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Traumatic aortic rupture is a common killer of victims of automotive accidents and other traumas,^[1] with up to 18% of deaths that occur in automobile collisions being related to the injury.^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The condition is frequently fatal due to the massive bleeding that results from the rupture. Since the aorta branches directly from the heart to supply blood to the rest of the body, the pressure within it is very great, and blood may be pumped out of a tear in the blood vessel very rapidly. This can quickly result in hemorrhagic shock and death. Death occurs immediately after traumatic rupture of the thoracic aorta 75% to 90% of the time since bleeding is so severe, and 80 to 85% of patients die before arriving at a hospital. Though there is a concern that a small, stable tear in the aorta could enlarge and cause complete rupture of the aorta and heavy bleeding, this may be less common than previously believed as long as the patient’s blood pressure does not get too high. Patients who survive to hospital admission generally have a partial tear with pseudoaneurysm formation.

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