E1922. Acute Traumatic Aortic Injury: A Pictorial Review of its Diagnosis and Management
  1. Stephen Brown; University of Alabama at Birmingham
  2. Sasha Still; University of Alabama at Birmingham
  3. Kyle Eudailey; University of Alabama at Birmingham
  4. Adam Beck; University of Alabama at Birmingham
  5. Andrew Gunn; University of Alabama at Birmingham
Few mechanisms of injury match the lethality of acute aortic trauma. Despite advances in detection and treatment, as many as 80%-90% of cases are immediately fatal [1]. For patients that survive long enough to reach a treatment center, rapid detection and decisive intervention are paramount. Non-invasive imaging modalities, especially computed tomography angiography (CTA), have become the primary problem-solving tool in the stable patient prior to endovascular therapy due to its availability, speed, and sensitivity [2-5]. The purpose of this exhibit is to provide the viewer with a comprehensive overview of acute traumatic aortic injury (ATAI). The epidemiology and demographics of, mechanism of injury in, diagnosis of, treatment options for, and post-therapeutic follow-up for ATAI will be discussed.

Educational Goals / Teaching Points
1. Review the epidemiology, pathophysiology, mechanisms of injury, and clinical presentation of ATAI. 2. Outline the findings of ATAI on radiography, computed tomography (CT), magnetic resonance imaging (MRI), catheter angiography, intra-vascular ultrasound (IVUS), and trans-esophageal echocardiography (TEE), including direct and indirect signs of injury 3. Discuss the management of ATAI, including conservative management, endovascular repair, and open surgical approaches 4. Understand the common complications after endovascular or open repair, including their imaging findings

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Physical and hemodynamic mechanisms contribute to ATAI, particularly at sites of relative fixation such as the ligamentum arteriosum [6, 7]. Radiographic signs of injury include mediastinal widening, loss of aortic contour, rightward tracheal deviation, and loss of the aortopulmonary window [8, 9]. CTA is the first-line imaging modality and is sensitive for the detection of both direct and indirect signs of injury [10]. Pre-contrast images should be reviewed initially to identify a mediastinal hematoma, if present [11]. Multiplanar arterial phase images should then be reviewed for direct signs of injury including pseudoaneurysm, focal contour abnormality, intimal flap, intramural hematoma, abrupt aortic caliber change, and contrast extravasation [11]. Accurate diagnosis requires knowledge of common imaging mimics, including ductus diverticulum, brachiocephalic artery infundibula, and motion artifacts [12-14]. Additional imaging modalities such as catheter angiography, IVUS, TEE, and MRI play important roles in pre-operative planning, adjunct to therapy, and follow-up imaging. After repair, potential complications detected by imaging include endoleak (type I most common), endograft collapse or infection, and inadequate exclusion of aortic injury [15-20].

ATAI is an injury with high fatality rates. For patients who survive the initial injury, rapid detection with radiography and CTA are critical for diagnosis and procedural planning. Appropriately selected patients with low grade injuries may be managed non-operatively. When treatment is required, endovascular approaches are preferred due to their high clinical success and low rates of complications.