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Blunt thoracic aortic injury

Blunt aortic injury results from sudden deceleration (road crash, fall from height) and is almost always located at the isthmus — just distal to where the left subclavian artery arises; a chest X-ray with a wide mediastinum raises suspicion, CTA makes the diagnosis, the patient receives treatment to lower pressure and heart rate, and grade II–IV injuries are repaired by TEVAR, usually after other life-threatening injuries are treated.

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Why it matters in the exam

Most patients with complete aortic rupture die at the scene; those who reach hospital survived because the haematoma was contained by the outer layer of the wall, and they are at risk of complete rupture. The isthmus is vulnerable because there the aorta passes from a mobile part (the arch) to a fixed part (the descending aorta), and sudden deceleration creates a shearing force there. Chest X-ray findings: a wide mediastinum (above 8 cm), loss of the aortic contour, deviation of the trachea or the nasogastric tube to the right, depression of the left main bronchus, a left apical "cap" of fluid and a left haemothorax. A normal X-ray does not exclude injury, so in a patient with a suitable mechanism chest CTA is done, which is the diagnostic test. SVS grading: I — intimal tear; II — intramural haematoma; III — pseudoaneurysm; IV — rupture.

Treatment begins at once with lowering pressure and heart rate (anti-impulse therapy) — systolic pressure of about 100 mmHg or less and heart rate below 100 — with short-acting beta blockers, provided the patient is not in shock from another cause. A grade I injury is treated conservatively with imaging follow-up; grade II–IV injuries are repaired, and TEVAR is preferred over open surgery because of lower mortality and paraplegia. Timing: in a stable patient with other severe injuries repair can be delayed by hours to a day (under anti-impulse therapy), treating life-threatening bleeding first, for example laparotomy for the spleen; in a patient with active rupture or an expanding haematoma — urgent repair. Covering the left subclavian artery during TEVAR is often accepted to obtain a seal, and its revascularisation is done selectively. A special challenge is a young patient with a small aorta, in whom the graft size must match exactly.

Young patients after TEVAR need long-term imaging follow-up, because the graft will remain in their body for decades.

Key points

• Sudden deceleration — suspect it.
• The isthmus is the typical site.
• CTA makes the diagnosis.
• Lower pressure and heart rate at once.
• Grade II–IV — TEVAR.

Summary table

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Sources

• SVS Clinical Practice Guidelines: Endovascular repair of traumatic thoracic aortic injury, 2011 — Recommendations
• ESVS Clinical Practice Guidelines: Management of descending thoracic aorta diseases, 2017 — Traumatic aortic injury
• ATLS Advanced Trauma Life Support Student Course Manual, 10th edition (2018) — Thoracic trauma

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.