EURORAD ESR

Case 1336

Traumatic dissection of the aortic isthmus treated with an intravascular stent

Author(s)
Cademartiri F, Salamousas BV, Luccichenti G, Pavone P
 
Patient
female, 63 year(s)

Clinical History

Patient with deceleration car accident and blunt thoracic trauma.

Imaging Findings

The patient was involved in a car accident with a deceleration kinetic. Clinically there was a severe blunt thoracic trauma. A spiral CT scan was performed in another hospital and a traumatic rupture of the aortic isthmus was suspected. Then the patient was transferred to our institution for surgical treatment, but it was decided to use an intra-vascular approach.

Discussion

Most patients with traumatic lesions of the thoracic aorta die on the accident site, nevertheless 13-15% of these patients arrive at hospital with present vital signs present.
In patients who survive until they are admitted to hospital, the highest risk of complete rupture of the aorta is in the first 4 hours after the accident. Mortality can reach 80%. Later deaths are due to associated damage or to multiple organ failure.
An aortic lesion must be suspected if on admission the patient shows:
hypotension, left haemothorax, hypertension in the upper extremities or a left supra-clavicular haematoma.
The treatment is still controversial. Medical, endovascular or surgical procedures have been proposed, although the lack of wide and standardised studies prevent selection of the best protocol.
In this case the patient was treated with a stent. The result was therapeutically effective.

Final Diagnosis

Dissection of the aortic isthmus with endovascular treatment
 

MeSH

  1. Aorta, Thoracic [A07.231.114.056.372]
    The portion of the descending aorta proceeding from the arch of the aorta and extending to the diaphragm.

References

  1. [1]
    Parker MS, Matheson TL, Rao AV, Sherburne CD, Jordan KG, Landay MJ, Miller GL, Summa JA. Making the transition. The role of helical CT in the evaluation of potentially acute thoracic aortic injuries. AJR 176;1267-72: 2001..

  2. [2]
    Hunink MG, Bos JJ.Triage of patients to angiography for detection of aortic rupture after blunt chest trauma: cost-effectiveness analysis of using CT. AJR Am J Roentgenol. 1995;165(1):27-36..

  3. [3]
    Mirvis SE, Shanmuganathan K, Buell J, Rodriguez A. Use of spiral computed tomography for the assessment of blunt trauma patients with potential aortic injury. J Trauma. 1998;45(5):922-30..

  4. [4]
    Orihashi K, Sueda T, Watari M, Okada K, Ishii O, Matsuura Y. Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting. Eur J Cardiothorac Surg. 2001 Nov;20(5):973-8..

  5. [5]
    Marotta R, Franchetto AA. The CT appearance of aortic transection. AJR Am J Roentgenol. 1996;166(3):647-51..

Citation

Cademartiri F, Salamousas BV, Luccichenti G, Pavone P (2003, Sep 11).
Traumatic dissection of the aortic isthmus treated with an intravascular stent, {Online}.
URL: http://www.eurorad.org/case.php?id=1336
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  • Figure 1
    Spiral CT performed at admission for diagnosis
    a b c d  

    At the level of the aortic arch there are no evident signs of dissection.

    Slightly caudal slice which demonstrates an intimal flap in the ventral portion of the aortic isthmus.

    Axial slice at the level of the tracheal carina which shows the intimal flap.

    At the level of the main pulmonary artery a minimal intimal flap is still evident.

     
  • Figure 2
    Coventional DSA performed for the positioning of the stent
    a b c  

    The panoramic view shows the correspondence to the spiral CT diagnosis. An enlargement of the ventral portion on the aortic isthmus is present.

    Measurement in preparation for stent positioning.

    The angiographic control after the positioning of the stent. No evidence of residual dissection or pseudoaneurysmal dilatation.

     
  • Figure 3
    Spiral CT scan performed after endovascular treatment
    a b c d  

    The aortic arch is normal.

    The isthmus is normal.

    The beginning of the descending aorta is normal.

    The oblique sagittal MPR shows the success of the procedure.

     
Figure 1

Spiral CT performed at admission for diagnosis

Figure 1a
At the level of the aortic arch there are no evident signs of dissection.
 
Figure 1b
Slightly caudal slice which demonstrates an intimal flap in the ventral portion of the aortic isthmus.
 
Figure 1c
Axial slice at the level of the tracheal carina which shows the intimal flap.
 
Figure 1d
At the level of the main pulmonary artery a minimal intimal flap is still evident.
 
Figure 2

Coventional DSA performed for the positioning of the stent

Figure 2a
The panoramic view shows the correspondence to the spiral CT diagnosis. An enlargement of the ventral portion on the aortic isthmus is present.
 
Figure 2b
Measurement in preparation for stent positioning.
 
Figure 2c
The angiographic control after the positioning of the stent. No evidence of residual dissection or pseudoaneurysmal dilatation.
 
Figure 3

Spiral CT scan performed after endovascular treatment

Figure 3a
The aortic arch is normal.
 
Figure 3b
The isthmus is normal.
 
Figure 3c
The beginning of the descending aorta is normal.
 
Figure 3d
The oblique sagittal MPR shows the success of the procedure.
 
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