Aortic Trauma: Diagnosis, Treatment and Follow-Up

Diagnosis:

Blunt chest trauma or decelerating injury is an indication for CT scan of chest with contrast. Apart from identifying the bony or soft tissue injuries, it can clearly demonstrate vascular trauma including aortic tears.

Chest Trauma

Treatment:

Once the CT scan is done the extent and severity of aortic injury becomes clear. Depending on the type of injury the treatment varies. A small hematoma on the aortic wall may be left alone. Even a small tear in the aortic intima (inner layer of aorta) may be treated conservatively with caution and rigorous follow up. However, more serious injuries need definitive treatment.

A full thickness tear in the aortic wall is a potentially fatal injury. If the bleeding continues. the victim may develop hypovolemic (low blood volume in the circulation) shock. Large volume of blood can get collected in the thoracic cavity. Often after the initial bleed, the blood clot in the vicinity of injury prevents further bleeding. In these circumstances proper treatment can save the person.

There are two types of definitive treatment. Open Surgery and Endovascular Stenting. In open surgery, the injured part of aorta is replaced with artificial tubes or prosthetic grafts made of PTFE, Dacron or Polyester.

In Endovascular procedures, a folded tube with a self-expanding stent is inserted into the aorta from the femoral artery (Groin) and expanded inside the injured portion to seal the area and prevent bleeding.

Sometimes a HYBRID technique is employed i.e., a combination of surgery and Endovascular procedure.

Follow Up:

It is important to keep a close watch on these patients and get a CT aortogram at 3 and 12 months.

Abdominal Aortic Aneurysm Screening: CT vs Ultrasound

An Ultrasound of abdomen or an Echo may detect the aneurysm for the first time.

Ultrasound of abdomen

The precise evaluation is done by a CT-Aortogram.

CT-Aortogram

This contrast CT would provide accurate information on the size, location, extent and branch involvement of the aneurysm.

Electrocardiography (ECG) Procedure Explained

ECG (Electrocardiography)

Electrocardiography is a recording of the electrical activity of the heart from the body surface. It is done by using sensitive electrodes placed on standard positions on the chest and limbs and recording the activity on a special graphical paper. Normal ECG has certain features. But every normal ECG is not identical. There are wide ranges of normalcy. So two ECGs appearing to be different to a layman’s eyes, could be normal. Likewise, all abnormal ECGs do not necessarily indicate serious problems. In spite of limitations, ECG remains an easily accessible, simple and useful initial investigation. In expert’s hands, it is a very valuable tool and can detect variety of conditions.

One of the commonest uses of ECG is to detect ischaemia (reduced blood supply) to heart muscles. During Angina (chest pain) or Myocardial infarction (heart attack), ECG will show typical charges which are diagnostic.

Stress ECG or Treadmill Test (TMT) is a method of recording ECG while the subject is exercising (alternatively, heart can be stressed by some drugs like dobutamine). Stress or exercise will uncover some ischaemia that is not obvious while at rest. A strongly positive TMT mostly indicate blocks in the coronary arteries. But a negative TMT does not completely rule out blocks (Negative predictive value is about 75%).

Holter ECG is a continuous recording of ECG for 24 hours or more using a portable device. This may be helpful in picking up transient rhythm disturbances or ischaemia which would otherwise escape detection during standard ECG.

How Do I Know If I Have Angina?

Angina, Chest Pain

Angina or Chest Pain: this is generally felt as a heaviness or uneasiness in the centre of chest. It is usually brought out by effort and relieved by rest. Angina lasts for short periods and seldom lasts for more than 20 minutes. Nitrates (medicines taken to relax coronary arteries) have the ability to relieve angina very quickly (Almost instantaneously if kept under the tongue ie., sublingual).

Typically angina appears as chest discomfort. It may radiate to neck, jaws, left shoulder or left arm. Rarely it can present as back pain, headache or even abdominal pain.

If you suffer from repeated burning sensation in your upper abdomen and not relieved by usual medicines, a detailed check up is required. Angina presenting as stomach burn has misled even doctors to make wrong judgments.

Cardiothoracic Surgeon Dr E V John, Jubilee Mission Hospital Doctors - Perform The Rare Aortic Surgery | Malayalam News

Cardiothoracic Surgeon, Dr. John E V (Sunrise Hospital, Kochi) and the team of Doctors from the Jubilee Mission Hospital, Thrissur - acclaimed by top Malayalam News Papers, for the rare aortic surgery on a woman.

*Courtesy: Malayala Manorama, Mangalam, Deepika, Deshabhimani

Heart Attack or Myocardial Infarction (MI)

Heart Attack - Myocardial Infarction

Heart attack or Myocardial Infarction (MI) is another form of presentation. While angina is almost completely reversible, MI threatens permanent myocardial damage. This happens when there is sudden complete occlusion in the coronary arteries. Usually this occlusion occurs at pre-existing stenotic lesions. The common cause is a plaque rupture (separation of the atheromatous plaque and clot formation underneath). The myocardium supplied by the particular coronary artery is under threat of permanent damage.

The pain of MI is more severe and lasts longer. Patient may vomit and sweat. It is often described as a feeling of 'Impending death'. This condition is severe and can be fatal at times. It calls for urgent attention. Patient needs urgent hospitalisation and treatment.

Type B Aortic Dissection

Type B Aortic Dissection

Traditionally, type B dissections (Dissections beyond the left subclavian artery) are treated conservatively unless one of the following situations is present.

• Aneurysm of pseudolumen.
• Tear or leak of the psudolumen.
• Visceral branch or limb branch involvement causing decrease in perfusion of an organ.

However, persisting pain not responding to conservative treatment is a relative indication for intervention nowadays. Various methods of interventional procedures are attempted to control the primary tear in the intima.

One common interventional method is to stent across the proximal intimal tear. This prevents the blood from entering the pseudo-lumen and eventually blood in the pseudo-lumen gets thrombosed.

Whenever decision is made to treat the type B Dissection conservatively, a close follow up is mandatory. CT Aortogram/MR Aortogram should be performed at 3 months and one year.

Type A Aortic Dissection

Type A Aortic Dissection

As soon as the diagnosis is made, planning of treatment should be started. The extent of dissection, aneurysm formation, presence of rupture and the branch involvement usually dictates the type of surgery.

The commonest scenario is a dissection starting at the ascending aorta just above the level of Right Coronary Artery and extending to variable distance of aorta. The tear usually involves the arch partly or completely. It may even involve one or more of the major arch vessels. But as long as the perfusion to these vessels are intact and there is no aneurysm formation of the pseudolumen, surgical intervention of arch is not indicated. The treatment then would be an Aortic root replacement.

The valve may be replaced or preserved depending on the presence or absence of valve or annulus involvement.

When the arch of aorta is badly damaged or the psuedolumen is aneurysmal in this area, the arch should be addressed during surgery. Depending on the extent of involvement, part (Hemiarch) or entire (Total Arch) arch may be replaced.

Atrial Fibrillation Is Common In Mitral Stenosis And Mitral Regurgitation

Atrial Fibrillation

Awareness of one’s own heartbeats is known as Palpitation. Valve disorders can present with various types of rhythm disturbances. Extra beats (Premature atrial / Ventricular Contractions) are quite common. Atrial Fibrillation is common in Mitral Stenosis and Mitral Regurgitation.

Atrial fibrillation (AF) is an abnormal rhythm where atrial contractions are ineffective and rapid and ventricular contractions are irregular. Often presented as palpitation. In valvular diseases this condition is caused by atrial dilatation and commonly found in Mitral disease.

Atrial fibrillation causes blood to stagnate in atria and can cause clots in the atria. This can lead to Thrombo-Embolism (Migration of small clots into the circulation causing occlusion of arteries) It can embolize to legs or abdomen. When it happens in the brain circulation, the result is a stroke! So AF is a serious condition which needs to be treated. Patient has to be on Anticoagulant medications (Blood thinning agents to prevent clots) until AF is reverted.

Aortic Trauma

Aortic Trauma

Aorta can be injured in variety of accidents or trauma. A piercing or penetrating injury by a sharp object can directly injure the aorta in the thorax or abdomen. These injuries are often instantly fatal due to severe bleeding.

More commonly aorta is injured in blunt trauma especially in high velocity deceleration accidents. Typically the person is thrown from a speeding bike and comes crashing. The relatively fixed part of aorta (close to the position of ligamentum arteriosum) takes the brunt of impact.

So commonest site of injury in these injuries is opposite the left subclavian artery. Aorta may be sustain partial tear of intima and/or media or a complete tear. The complete tear is a devastating injury accounting for heavy mortality- 20% of victims die before reaching medical facility. Untreated another 10% die every hour following injury. Needless to say, this is a true surgical emergency.

Sometimes the extensive traumatic dissection can cause malperfusion of the visceral vessels or intercostals. Bleeding into the chest can severe enough to cause hypotension and shock.

What About Long Term Lifestyle Modification?

Lifestyle Modification

Yes, this is a very important aspect of long term prevention especially in case of Coronary artery disease, as we all know, Coronary Artery Disease is caused by Atherosclerosis.
 
Atherosclerosis has multi-factorial causation. Some of these risk factors are modifiable whereas some are non-modifiable. Success in keeping CAD away is in manipulating these modifiable risk factors effectively.

• Stop Smoking and tobacco use completely
• Control of Diabetes, Hypertension and Cholesterol
• Regular physical activity (Walk 3 kilometers in 30 minutes daily)
• Reduce weight if obese (to ideal BMI)
• Take medications regularly (Do not stop antiplatelets and statins without doctor’s permission)
• Regular follow up checks.