Blunt thoracic aortic injury in children

Thoracic aortic injury (TAI) in children secondary to blunt chest trauma is rare and less well documented than TAI in adults. To further establishe the incidence and radiographic manifestations of this severe injury, we reviewed our experimence with TAI in children over an 8-year period. We performed a computer search from the Trauma Registry at our level I trauma center for all cases of TAI among patients 16 years of age or younger who were admitted after sustaining blunt chest trauma between August 1984 and September 1992. We reviewed our records of all thoracic aortograms performed on children for blunt trauma during this same time period. Indication for angiography was determined by review of chest radiographs and medical records of all patients who underwent thoracic aortography. We reviewed medical records and all available chest radiographs, computed tomography (CT) examinations, and thoracic aortograms of children diagnosed with TAI. Of 308 children admitted with blunt chest trauma, 26 (8.4%) underwent angiography to exclude aortic or great vessel injury. Of these 26 patients, three (11.5%) were diagnosed with TAI, and one patient demonstrated a traumatic pseudoaneurysm of the proximal left subclavian artery. The incidence of TAI among children who sustained blunt chest trauma was 1.0% in our series. All three patients with TAI in our series were male, ages 10–12 (mean: 11 years). Chest radiographs on two of the patients with TAI revealed mediastinal widening, ill-defined aortic outline, shift of the trachea and nasogastric tube, and depression of the left main stem bronchus. The chest radiograph in one patient with TAI was technically inadequate. CT demonstrated abnormalities in two patients. Angiographic findings were similar to those seen in adults. TAI in children is rare, occurring in 1% of children sustaining blunt chest trauma in our series. Our findings support previous reports that the plain film, CT, and angiographic findings with this injury resemble those found in adults.     

Spiral CT aortography: an efficient technique for the diagnosis of traumatic aortic injury

The objective of this study was to assess the efficiency of spiral CT (SCT) aortography for diagnosing acute aortic lesions in blunt thoracic trauma patients. Between October 1992 and June 1997, 487 SCT scans of the chest were performed on blunt thoracic trauma patients. To assess aortic injury, the following SCT criteria were considered: hemomediastinum, peri-aortic hematoma, irregular aspect of the aortic wall, aortic pseudodiverticulum, intimal flap and traumatic dissection. Aortic injury was diagnosed on 14 SCT examinations (2.9 %), five of the patients having had an additional digital aortography that confirmed the aortic trauma. Twelve subjects underwent surgical repair of the thoracic aorta, which in all but one case confirmed the aortic injury. Two patients died before surgery from severe brain lesions. The aortic blunt lesions were confirmed at autopsy. According to the follow-up of the other 473 patients, we are aware of no false-negative SCT examination. Our limited series shows a sensitivity of 100 % and specificity of 99.8 % of SCT aortography in the diagnosis of aortic injury. It is concluded that SCT aortagraphy is an accurate diagnostic method for the assessment of aortic injury in blunt thoracic trauma patients. Received 18 July 1997; Revision received 11 September 1997; Accepted 23 October 1997     

Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma

The purpose of this retrospective study was to determine the value of contrast-enhanced helical CT for detecting and managing acute thoracic aortic injury (ATAI). Between June 1995 and February 2000, 1419 consecutive chest CT examinations were performed in the setting of major blunt trauma. The following CT findings were considered indicative of ATAI: intimal flap; pseudoaneurysm; contour irregularity; lumen abnormality; and extravasation of contrast material. On the basis of these direct findings no further diagnostic investigations were performed. Isolated mediastinal hematoma on CT scans was considered an indirect sign of ATAI: In these cases, thoracic aortography was performed even if CT indicated normal aorta. Seventy-seven patients had abnormal CT scans: Among the 23 patients with direct CT signs, acute thoracic aortic injuries was confirmed at thoracotomy in 21. Two false-positive cases were observed. The 54 remaining patients had isolated mediastinal hematoma without aortic injuries at CT and corresponding negative angiograms. The 1342 patients with negative CT scans were included in the 8-month follow-up program and did not show any adverse sequela based on clinical and radiographic criteria. Contrast-enhanced helical CT has a critical role in the exclusion of thoracic aortic injuries in patient with major blunt chest trauma and prevents unnecessary thoracic aortography. Direct CT signs of ATAI do not require further diagnostic investigations to confirm the diagnosis: Isolated aortic bands or contour vessel abnormalities should be first considered as possible artifacts or related to non-traumatic etiologies especially when mediastinal hematoma is absent. In cases of isolated mediastinal hematoma other possible sources of bleeding should be considered before directing patients to thoracic aortography.     

Acute myocardial infarction due to left anterior descending coronary artery dissection after blunt chest trauma

Cardiac complications of chest trauma range from arrhythmias to valvular avulsions to myocardial contusion, rupture, and rarely myocardial infarction. We describe a case of a young patient with blunt chest trauma after a motor vehicle accident in whom the diagnosis of myocardial infarction was established a week later because no electrocardiogram or cardiac biomarkers were obtained on presentation. Retrospective review of contrast-enhanced computed tomography (CT) of the chest done on presentation demonstrated a perfusion defect in the distribution of the left anterior descending artery (LAD). Subsequent coronary angiography demonstrated dissection in the proximal LAD. Our case illustrates the importance of electrocardiography and contrast-enhanced chest CT in initial evaluation of patients with blunt chest trauma and suspected injury to the coronary arteries.     

Value of CT in determining the need for angiography when findings of mediastinal hemorrhage on chest radiographs are equivocal

The role of CT in determining the need for angiography in patients with possible thoracic vascular injury resulting from blunt trauma is controversial. During a 24-month period, we prospectively evaluated the results of CT to screen 90 patients with a history of decelerating thoracic trauma for evidence of mediastinal hemorrhage or great vessel abnormality. All patients either had equivocally abnormal mediastinal contours on chest radiographs (64%) or had technically suboptimal chest radiographs owing to body habitus or restriction to the supine projection (36%). Patients with unequivocal signs of mediastinal hemorrhage on chest radiographs underwent immediate arteriography without prior CT. Thoracic CT was interpreted as normal in 63 (77%) patients and no further imaging was performed. Five patients had technically suboptimal CT studies, and CT scans were interpreted as equivocal in six. These 11 patients had normal arteriograms. Sixteen CT scans (18%) demonstrated evidence of mediastinal hemorrhage and/or great vessel contour abnormality. Four (27%) of 15 patients who underwent arteriography had injury to the great vessels. One patient refused to undergo angiography. In 11 patients with CT evidence of mediastinal hemorrhage, major vascular injury was not seen on arteriography. These results suggest a valuable role for CT in determining the need for arteriography to detect potential great vessel injury in patients with blunt decelerating thoracic trauma and equivocally abnormal mediastinal contours on chest radiographs.     

Role of CT in excluding major arterial injury after blunt thoracic trauma

The role of CT in the diagnosis of major vascular rupture following blunt decelerating chest trauma is controversial. Its value in excluding major arterial injury has not yet been determined. During a 12-month period we obtained dynamic enhanced thoracic CT studies in 20 patients with blunt decelerating thoracic trauma who had abnormal or equivocal mediastinal contours on chest radiographs. In all cases diagnosis was confirmed by either digital subtraction (18 patients) or conventional thoracic angiography (two patients). CT scans showed evidence of direct aortic injury in three patients and evidence of mediastinal hematoma in five others. Four of these eight patients had major arterial injury verified angiographically and at surgery. In two patients the CT scan was considered equivocal; both patients had normal thoracic angiograms. CT excluded direct vascular injury or mediastinal hematoma in 10 patients. All 10 had normal thoracic angiograms. This preliminary study suggests that, in patients sustaining blunt decelerating thoracic trauma, thoracic CT may be more valuable than chest radiography in excluding major vascular injury and, in some cases, may reduce the need for thoracic angiography.     

Gas in the sternoclavicular joints of patients with blunt chest trauma: significance and frequency of CT findings.

OBJECTIVE: In trauma patients, gas (vacuum phenomenon) in the sternoclavicular joints could represent sequelae of significant distraction forces and thus serve as a potential marker for severe intrathoracic injury. We evaluated the significance and frequency of the finding of gas in the sternoclavicular joints on chest CT of patients with blunt trauma. SUBJECTS AND METHODS: We prospectively studied all chest CT examinations performed at our institution over a 14-week period for the finding of gas in the sternoclavicular joints. Chest CT examinations (n = 267) were performed in 234 patients. We excluded data from follow-up CT examinations (n = 33), limiting our evaluation to the initial CT examination for each patient. Of the study population, 103 patients (83 men and 20 women) who ranged in age from 14 to 79 years (mean, 40 years) had sustained blunt chest trauma. For all trauma patients, we recorded the mechanism of injury and the associated thoracic injuries. RESULTS: CT revealed gas in the sternoclavicular joints in 47 patients (21%). Gas was unilateral in 27 patients and bilateral in 20 patients. Sternoclavicular joint gas was seen in 39 (38%) of the 103 trauma patients but was found in only eight (6%) of the 131 nontrauma patients (p < .0001). In the 39 trauma patients with sternoclavicular joint gas, associated thoracic injuries were seen in 17 patients (44%); either a sternal fracture or a retrosternal hematoma was seen in three patients. Radiographically evident thoracic injury was revealed in 20 (31%) of the 64 trauma patients who had no gas in the sternoclavicular joint; however, 10 of these 20 patients had either a sternal fracture or a mediastinal hematoma. CONCLUSION: Although gas in the sternoclavicular joints is more frequently seen in patients with blunt chest trauma than in patients undergoing chest CT for other indications, this finding does not indicate a greater risk of significant mediastinal or thoracic injury.     

Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience

Purpose Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. Methods Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosed with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. Results Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8–16 months) follow-up. Conclusions This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.     

Value of spiral CT in hemodynamically stable patients following blunt chest trauma

Introduction: Features of spiral CT (SCT) — fast scanning, dynamic injection of contrast allowing optimal vessel opacification, and supplemental multiplanar imaging — promises to provide increased accuracy in the diagnosis of acute and non acute thoracic vascular disease. Recent work demonstrating the cost effective triage of hemodynamically stable patients after blunt chest trauma for angiography based on dynamic CT findings has prompted an investigation into the accuracy of SCT in this clinical setting. Methods: A retrospective review of all patients seen in the emergency department over the period of one year for aortic, thoracic, or blunt chest trauma evaluation was performed (74 patients) and all SCT scans available were reviewed and data reformatted for optimal delineation of pathology using maximum intensity projection and multiplanar reformation. The accuracy and predictive positive and negative values of SCT were calculated with respect to angiography, surgical, and/or clinical follow up evaluation. Results: Twenty three (31%) patients went directly to angiography owing to mediastinal widening on chest film and hemodynamic instability, of which four were positive and required emergent surgery. Seven hemodynamically stable patients (9%) had noncontrast SCT owing to mediastinal widening on chest film, all of which had angiography with none having great vessel trauma. Fourty four hemodynamically stable patients (60%) had contrast enhanced SCT (ceSCT), of which five (11%) were abnormal and underwent angiography, four of these were positive for aortic damage, one for a subclavian artery laceration. Of the remaining 39 patients who had normal ceSCT; five had angiography, all of which were normal. Of the remaining 34 patients that had normal ceSCT none had adverse outcome on clinical follow-up, minimum of 12 months. Conclusion: The predictive positive value for aortic trauma of ceSCT in blunt trauma is 80%, with a predictive negative value of 100%, indicating that it is feasible for SCT to be a first line exam in blunt chest trauma in the future.     

Penetrating atherosclerotic ulcers of the descending thoracic aorta: evaluation with CT and distinction from aortic dissection.

Penetrating atherosclerotic ulceration of the aorta is a poorly understood entity that clinically mimics classic aortic dissection but has imaging features that are distinctly different. In a review of 16 patients with penetrating atherosclerotic ulceration, patients were typically hypertensive (n = 14), and they experienced chest or back pain (n = 13). All patients had an abnormal chest radiograph, with diffuse (n = 14) or focal (n = 2) enlargement of the descending thoracic aorta. Features at contrast material-enhanced computed tomography (CT) included intramural hematoma (n = 16), focal ulcer (n = 15), displaced intimal calcification (n = 13), pleural and/or extrapleural fluid (n = 7), mediastinal fluid (n = 4), and a thick or enhancing aortic wall (n = 6). The chest radiograph and CT findings were compared in patients treated conservatively (n = 9) and surgically (n = 7). These findings did not correlate with the need for surgery. Eight of nine conservatively treated patients were asymptomatic after treatment with antihypertensive medication. Contiguous dynamic contrast-enhanced CT of the aorta enables distinction of ulceration from dissection, which is particularly important in the hemodynamically unstable patient because the surgical management of ulceration is more extensive than that for aortic dissection.     

Traumatic left main coronary artery dissection in a young adult following blunt chest trauma – A case report

Blunt chest trauma may cause variable degrees of thoracic injuries. Most of the patients may remain asymptomatic after sustaining blunt chest trauma. But in rare instances, life-threatening conditions such as coronary artery dissection may occur. The authors present a 29-year-old male adult with persistent chest pain following blunt trauma with a rise in cardiac troponins and elevated ST segment in ECG. Coronary CT and conventional angiography demonstrated dissection of the left main coronary artery. It is deemed necessary to suspect cardiac injury in patients with a history of blunt chest trauma in appropriate clinical settings. Early recognition of coronary artery dissection is vital to reduce morbidity and mortality. ECG combined with cardiac enzymes can be essential tools helping the physicians raise the suspicion towards a cardiac injury followed by cross-sectional and conventional angiographies for confirmation.     

Blunt nonaortic chest trauma: radiographic and CT findings

Following initial clinical evaluation and stabilization of a patient who has sustained blunt chest trauma, imaging has an important role in the evaluation of thoracic injuries. The initial study is the chest radiograph. However, chest CT is being used with increased frequency in the evaluation of blunt chest trauma. Although CT is used primarily to assess for traumatic aortic injuries, it is also useful in the evaluation of pulmonary and bronchial, airway, skeletal and diaphragmatic injury. The aim of this article is to review the characteristic imaging findings of pulmonary and bronchial, esophageal, thoracic, skeletal and diaphragmatic injuries. Electronic Publication     

Periaortic hematoma at diaphragmatic crura at helical CT: sign of blunt aortic injury in patients with mediastinal hematoma

PURPOSE: To evaluate periaortic hematoma (PH) near the level of the diaphragm at abdominal computed tomography (CT) as an indirect sign of acute traumatic aortic injury after blunt trauma in patients with mediastinal hematoma. MATERIALS AND METHODS: From 1998 to 2001, 97 patients with CT evidence of mediastinal hematoma after blunt thoracic trauma were retrospectively identified at two level 1 trauma centers. The presence or absence of PH near the level of the diaphragmatic crura was retrospectively established by a blinded reviewer at each institution. Aortic injury status was determined by reviewing angiographic, surgical, and clinical records. Sensitivity, specificity, positive and negative productive values, and positive and negative likelihood ratios were calculated. RESULTS: Among the 97 patients with mediastinal hematoma, 14 had both PH near the level of the diaphragm and aortic injury; six had aortic injuries without PH, five had PH near the level of the diaphragm without aortic injury, and 72 had no evidence of PH near the diaphragm and no aortic injury. Sensitivity for PH near the level of the diaphragm as a sign of aortic injury was 70%; specificity, 94%; positive predictive value, 74%; and negative predictive value, 92%. The positive likelihood ratio for the presence of aortic injury was 10.8, and the negative likelihood ratio was 0.3. CONCLUSION: PH near the level of the diaphragmatic crura is an insensitive but relatively specific sign for aortic injury after blunt trauma. The presence of this sign at abdominal CT should prompt imaging of the thoracic aorta to evaluate potential thoracic aortic injury.     

CT features of blunt abdominal aortic injury

Abdominal aortic injuries are uncommon following blunt trauma, with relatively few reported series in the radiology literature. This study was conducted to identify common locations and imaging features of blunt traumatic abdominal aortic injury, the presence of associated visceral and osseous injuries, and the mechanisms of trauma. A retrospective review of 9,213 trauma registry entries over a 7-year period yielded 103 patients with aortic injuries, 12 of which had direct signs of abdominal segment involvement (dissection flap, focal intimal injury, intramural hematoma, active extravasation of contrast, or pseudoaneurysm formation). The majority (75 %) was isolated to the abdomen-67 % of which was infrarenal, 33 % suprarenal-while the other 25 % was a contiguous extension from a thoracic injury. Abdominal aortic injuries were uncommonly seen in isolation: all but one patient (92 %) demonstrated either retroperitoneal blood or stranding, hemoperitoneum, and/or CT signs of hypoperfusion complex, and only one patient (8 %) had no associated solid organ or skeletal injuries. All patients had a mechanism of injury which involved direct trauma to the abdomen, most commonly a motor vehicle collision. Similar to other recent series, there was an increased rate of abdominal segment injury (11.7 % of all aortic injuries) in this series compared to more remote autopsy series. This difference is likely due to detection of injuries which went undiagnosed before the widespread use of multidetector CT, which has become the standard of care for both acute evaluation following blunt trauma and for follow-up.     

Lung parenchymal injury and its frequency in blunt thoracic trauma: the diagnostic value of chest radiography and thoracic CT

PURPOSE: The aims of this study were to determine the value of chest radiography in diagnosing lung parenchymal injury in patients with thoracic trauma, and to evaluate the frequency of lung parenchymal injury by using thoracic computed tomography (CT). MATERIALS AND METHODS: Between January 2005 and June 2006, we retrospectively evaluated the anteroposterior chest radiographs and thoracic CTs of 60 patients that presented to our emergency department and were hospitalized due to multi-organ trauma. RESULTS: Chest radiography revealed parenchymal injury in 32 of the patients, while thoracic CT confirmed parenchymal injury in only 27 of these 32 patients. Chest radiographs did not reveal any parenchymal injury in 28 of the patients, whereas thoracic CT detected parenchymal injury in 12 of these 28 patients. Thoracic CT results were accepted as the gold standard in the evaluation of patients with chest trauma and showed that the sensitivity, specificity, positive predictive value, and negative predictive value of chest radiography in determining parenchymal injury were 69%, 76%, 84%, and 57%, respectively. In addition, thoracic CT revealed that 65% of the patients with blunt thoracic trauma suffered parenchymal injury. CONCLUSION: The sensitivity of anteroposterior chest radiography in identifying lung parenchymal injury was low, with a high false negative rate; therefore, we think that early evaluation with thoracic CT is extremely helpful in the diagnosis and treatment of patients with thoracic trauma, adding to the cooperative work that exists between radiologists and emergency physicians.     

Direct findings of aortic injury on contrast-enhanced CT in surgically proven traumatic aortic injury: a multi-centre review

OBJECTIVE: To review the contrast-enhanced CT findings in surgically proven traumatic aortic injury (TAI). MATERIALS AND METHODS: We searched the trauma registries of three academic medical centres from 1994 to 2000 and found 34 patients with surgically proven TAI that received pre-operative contrast-enhanced chest CT. Two chest radiologists recorded by consensus the size and location of direct (pseudoaneurysm, intimal flap) and indirect (mediastinal haematoma) findings of TAI. The imaging findings were correlated with surgical reports. RESULTS: Direct findings of aortic injury (pseudoaneurysm or intimal flap) were seen on contrast enhanced CT in all patients and confirmed at surgery. Specifically, a pseudoaneurysm was seen in 33 (97%), presenting either as a focal bulge in 22 (65%) or as more diffuse aneurysmal enlargement in 11 (32%). An intimal flap was identified in 31 cases (91%). A periaortic haematoma was seen in 31 cases (91%). In the three patients without periaortic haematoma, the only indications of aortic injury were a focal pseudoaneurysm in two (6%) and an intimal flap in one (3%). CONCLUSION: In this series of surgically proven TAI, direct findings of aortic injury were seen in all cases. Aortic tear occurred without mediastinal haematoma in 9% (3/34) of patients.     

X-ray computed tomography of thoracic injuries. Apropos of 40 cases]

On chest radiographs, the precise assessment of thoracic injuries consecutive to blunt trauma is often compromised by the nonspecific appearance of many lesions. Furthermore, significant injuries are frequently overlooked. However, the management of the patients with chest trauma is still often based primarily upon clinical and radiographic findings and Computed Tomography (CT) is often performed secondarily on the basis of unexplained clinical signs or suspected radiographic abnormality. Some authors have reported that CT was a highly sensitive method for detecting thoracic lesions frequently not seen or underestimated on conventional supine chest radiographs. However, the value that these new CT findings could have in the therapeutic management of these patients, have not been systematically investigated to our knowledge, except in a limited series suggesting that the course of critically ill patients could be substantially altered after thoracic CT. In order to estimate the role of early CT in the management of patient care, we report the therapeutic consequences of CT findings in forty patients who we report the therapeutic consequences of CT findings in forty patients who had a thoracic CT within few hours following a chest injury. We showed that early thoracic CT scan in patients with blunt trauma detected significantly more lesions than did chest X-Ray and appreciably modified the treatment modalities in 70% of our patients. We then recommend that all the patients admitted in ICU after chest trauma undergo a thoracic CT scan as soon as possible in order to optimize their treatment modalities.     

Application of spiral computerized tomography in the study of traumatic lesions of the thoracic aorta

PURPOSE: Acute thoracic aortic injuries account for up to 10-20% of fatalities in high-speed deceleration road accidents and have an estimated immediate fatality rate of 80-90%. Untreated survivors to acute trauma (10-20%) have a dismal prognosis: 30% of them die within 6 hours, 40-50% die within 24 hours, and 90% within 4 months. We investigated the diagnostic accuracy of Helical Computed Tomography (Helical CT) in acute traumatic injuries of the thoracic aorta, and the role of this technique in the diagnostic management of trauma patients with a strong suspicion of aortic rupture. MATERIAL AND METHODS: We compared retrospectively the chest Helical CT findings of 256 trauma patients examined June 1995 through August 1999. All patients underwent a plain chest radiograph in supine recumbency when admitted to the Emergency Room. Chest Helical CT examinations were performed according to trauma score, to associated traumatic lesions and to plain chest radiographic findings. All the examinations were performed with no intravenous contrast agent administration and the pitch 2 technique. After a previous baseline study, contrast-enhanced scans were acquired with pitch 1 in 87 patients. All examinations were assessed for the presence of mediastinal hematoma, periaortic hematoma, traumatic pseudodiverticulum, irregular aortic wall or contour and intimal flap as signs of aortic rupture. RESULTS: Helical CT showed thoracic aortic lesions in 9 of 256 patients examined. In all the 9 cases we found a mediastinal hematoma and all of them had positive plain chest radiographic findings of mediastinal enlargement. Moreover, in 6 cases aortic knob blurring was also evident on plain chest film and in 5 cases depressed left mainstem bronchus and trachea deviation rightwards were observed. All aortic lesions were identified on axial scans and located at the isthmus of level. Aortic rupture was always depicted as pseudodiverticulum of the proximal descending tract and intimal flap. We also found periaortic hematoma in 6 cases and intramural hematoma in 1 case. There were no false positive results in our series: 7 patients with Helical CT diagnosis of aortic rupture were submitted to conventional aortography that confirmed both type and extension of the lesions as detected by Helical CT, and all findings were confirmed by gross inspection at surgery. No false negative results have been recorded so far: untreated aortic ruptures are fatal within 4 months in 90% of patients, or they may evolve into chronic pseudoaneurysm in about 5% of survivors. CONCLUSIONS: In our experience Helical CT had much higher diagnostic sensitivity and specificity than plain chest radiography. In agreement with larger published series, in our small one the diagnostic accuracy of Helical CT was 100% in the evaluation of traumatic aortic ruptures. Moreover, Helical CT is faster and less invasive than conventional aortography, which makes this diagnostic modality increasingly used and markedly improves the management of the serious trauma patient. The more widespread use of this diagnostic tool has permitted to standardize the technique and now Helical CT can be used not only as a screening modality for patients that undergo digital aortography, but also as a reliable diagnostic method for surgical planning.     

Making the transition: the role of helical CT in the evaluation of potentially acute thoracic aortic injuries

OBJECTIVE: The purpose of this study was to show that helical CT could be used at our center in lieu of routine aortography to examine patients who have had serious blunt chest trauma. We also wanted to assess the potential savings of using CT to avoid unnecessary aortography. MATERIALS AND METHODS: The institutional review board approved the parallel imaging-CT immediately followed by aortography-of patients presenting with blunt chest trauma between August 1997 and August 1998. To screen patients for potential aortic injuries, we performed parallel imaging on 142 patients, and these patients comprised our patient population. CT examinations of the patients were reviewed for signs of injury by radiologists who were unaware of each other's interpretations and the aortographic results. Findings of CT examinations were classified as negative, positive, or inconclusive for injury. Aortography was performed immediately after CT. The technical and professional fees for both transcatheter aortography and helical CT were also compared. RESULTS: Our combined kappa value for all CT interpretations was 0.714. The aortographic sensitivity and negative predictive value were both 100%. Likewise, the sensitivity and negative predictive value of CT were 100%. The total costs of performing aortography were estimated at approximately $402,900, whereas those for performing helical CT were estimated at $202,800. CONCLUSION: Helical CT has a sensitivity and negative predictive value equivalent to that of aortography. Using CT to eliminate the possibility of mediastinal hematoma and to evaluate the cause of an abnormal aortic contour in a trauma patient allows us to use aortography more selectively. Avoiding the performance of unnecessary aortography will expedite patient care and reduce costs. We report the results of our experience with CT and how our center successfully made this transition in the initial examination of patients with serious thoracic trauma.     

Thoracic angiography and intervention in trauma

Interventional radiologists are involved less often in the initial diagnostic evaluation of patients who have acute chest trauma today than in the past. Patients are cleared of significant injury by CT, or, when a significant injury is present, they are triaged appropriately to open surgery or endovascular intervention. Significant advances in catheter-based technology, such as stent grafts and embolization coils, allow definitive repair of thoracic aortic and branch vessel injury. The opportunity to treat these types of injury with minimally invasive techniques has reinforced a continuing need for the maintenance and continued development of skills in the performance and interpretation of thoracic angiography. This article reviews these techniques and examines the status and the future of endovascular interventions in thoracic trauma.