Adapted from clinical practice guidelines of the Society for vascular surgery.*
*In developing these guidelines The Society utilized The grading of recommendations Assessment, development, and evaluation system (GRADE) The following guidelines should be regarded as grade 2 recommendation with level C evidence
1. CT chest with IV contrast and trauma/aortic protocol.
2. Equivocal studies: Formal angiogram in operating room hybrid suite.
3. Transesophageal echo: Cardiac anesthesia (boarded in cardiac echo) in rare cases where the ascending aorta is in question.
4. Trauma surgeon, will consult vascular surgery for positive or equivocal results.
Resuscitation strategy/medical management
1. TEVAR (Thoracic Endovascular Aortic Repair) preferred over open repair
2. Open Repair – Reserved for patients with poor anatomy/ poor candidates for endovascular repair including those who are rapidly hemorrhaging into the pleural select
Classification scheme used for treating blunt aortic injury
1. Intimal tear – absence of contour change and intimal defect and/or thrombus <10mm in length and width
a. Medical management with close surveillance
b. Close surveillance includes repeat imaging (CTA) within 24-48 hours based on clinical condition
2. Large intimal flap – absence of contour change and intimal defect/thrombus > 10mm
b. Open repair for patients who are not candidates for endovascular repair
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Timing of endovascular aortic repair.
1. Type one injury (intimal tear): Observation with repeat CT scan in 24-48 hours
2. Type II (intramural hematoma) and type III (pseudoaneurysm) urgent repair within 24 hours.
3. Emergent repair for grade 4 (free contrast extravasation).
a. Under most circumstances patient's with significant intra-abdominal hemorrhage will undergo laparotomy and control of abdominal hemorrhage prior to repair of the aorta.
Age and choice of repair: TEVAR is a repair choice in young patients.
1. Appropriate grafts will be available in the endovascular suite. A best device. Has not been determined. The operating room will supply grafts, which match vascular surgeon, credentials.
Management subclavian artery during zone to coverage
1. Selective revascularization of the subclavian artery.
2. The LSA is covered approximately 30% of cases requiring TEVAR. If the LSA is covered. Intraoperative right vertebral artery angiogram can assess adequacy of the posterior circulation. If the right vertebral artery is in adequate with or without an intact circle of Willis consider revascularization of the subclavian artery.
1. Routine heparin. Consider a lower dose than in the elective TEVAR.
2. Consider no heparin in select cases such as those with extraordinary bleeding. Risks, such as severe pelvic fractures or significant intracranial hemorrhage.
Ongoing management and followup