Traumatic Thoracic Aortic Transection After a High-Energy Trauma

Background: Deceleration trauma resulting in thoracic aortic contained rupture is uncommon and associated with a high prehospital mortality. Less than 25% of patients with blunt thoracic aortic injury survive long enough to reach a hospital. Radiological plays an important role in diagnosis and accurate classification of the type of dissection, in order to plan the intervention and optimize the outcome.

Objective: The authors aim to report a rare case of blunt thoracic aortic injury successfully corrected and share the correspondent unique imaging.

Case Report: A 17-year-old high energy accident victim with several traumatic lesions arrived in the emergency room. He was hemodynamically stable and had a Glasgow Coma Scale of 15/15. He presented diminished breath sounds on the left hemithorax and gross hematuria. Chest radiograph revealed left hemidiaphragmatic rupture with stomach herniation and mediastinal enlargement. A thoracic CT scan confirmed visceral herniation through the ruptured diaphragm, fracture of four left ribs and a contained aortic rupture located at the aortic isthmus, associated with perivascular hematoma – type IV. Endovascular treatment was considered unsuitable due to unfavorable anatomical characteristics. Therefore, the patient was submitted to open descending aorta replacement by a vascular prothesis. Distal aortic perfusion was maintained by a Gott shunt. Simultaneously, diaphragm laceration was directly sutured. Post-operative radiological revaluation revealed good resolution of both lesions.

Due to acute renal injury caused by severe rhabdomyolysis, continuous venovenous hemodiafiltration was required for 25 days. Regarding outcome, the adolescent was discharged home 44 days after hospital admission, without any severe sequelae.

Conclusion: This clinical case highlights the importance of considering different types of internal hemorrhage in cases of trauma, particularly life-threatening lesions resulting from blunt trauma. In this particular case, the patient was hemodynamically stable at all times, which was only possible due to the containment of the hemorrhage to the mediastinum.