there is a tympanism, while auscultatory findings on lungs show an absence of breathing murmur on affected side. At atypical clinical picture, the tension pneumothorax may imitate the state of acute tamponade of the heart or massive hemothorax. Radiography is a basic additional diagnostical method in diagnosis of the chest trauma. Position of the injured during the imaging has the impact on the quality of the chest radiography and possibility for correct interpretation. General state of numerous injured, specially the polytraumatized patients, has the impact on the position for imaging. It is desirable that the imaging is performed in the standing position, when it is not possible, it can be the sitting position or semi-lying position. Correct interpretation of the chest radiography includs the assessment of the bony structure state of the chest, position and shape of the diaphragm and phrenicocostal sinuses, position of the mediastinum and trachea and the state of the lung parenchyma from the apex to the lung base. Radiographic diagnosis of the pneumothorax is made easily, when the line of visceral pleura is approved on the PA chest X - ray. Definitely radiological recognition of the pneumothorax depends on the lung collapse degree. Small pneumothorax is better presented on the standard radiography in the standing position during maximal expirium. In fact, in such a way radiological density of the collapsed lung parenchyma increases, while the density of air in the pleural space is not changed. Radiography of the chest in position of a lateral decubitus enables that the free air in the pleural space is lifted. Increased distance between the lungs and thoracic wall is present, for the easily identification of the visceral pleura line. When the air enters into the pleural space, lungs collapses, thoracic cavity is expanded. Radiographic air is presented as a zone of homogenous light with absence of the lung ornaments at the periphery. Collapsed lung is

At the side of pneumotorax, the pleural pressure gets to be less and less negative, i.e. it increases. Pleural pressure within the cotralateral pleural space is unchanged so that the mediastinum can be removed toward that side. Ipsilateral diaphragm is lowered due to decrease of the transdiaphragmaic pressure. Interpretation of radiographic imaging made in lying positions is more difficult. By initial radiological examination of the injured in lying position, the pnumothorax can be overlooked, in case of development of the tension pneumothorax can be fatal for the injured. Pain is a dominant symptom at the chest injury, causing the unproper ventilation presence and the standstill of the secretion in the tracheobronchial tree. For this fact it is necessary, during treatment and first aid administration of the injured, to realize proper analgesia with holding of passage for respiratory paths. Progressive dyspnea and cyanosis point to the development of the tension pneumothorax. First aid at the tension peumothorax is comprised of decompression, by the needle placement of the large diameter through second inter-rib area in the midclavicular line. Needle should stay « in situ » in the pleural space up to the definitive treatment of the pneumothorax. By procedure of needle placement, the tension pneumothorax becomes the open pnumothorax, easier to bear. At the open pneumothorax hermetisation of the wound is performed on the chest wall, taking into account to prevent development of the tension pneumothorax. Methods of treatment of traumatic pneumothorax are an observation, exsufflation (needle aspiration) and thoracic drainage. Observation is rarely applied.

**Figure 17.** Traumatic left-sided hemopneumothorax

**Figure 18.** Tension left - sided pneumothorax and control radiography after left - sided thoracic drainage

Exsufflation is suitable for fine decompression of the pleural space at the tension pneumothorax, when it is not possible to perform thoracic drainage. However, a method is rarely applied as the definite procedure for solving of traumatic pneumothorax. Thoracic drainage is a method often used during definite treatment of the traumatic pneumothorax.

Thoracic Trauma 225

Pneumomediastinum marks the presence of the air in the mediastinum, and it can be caused

Hemothorax marks the presence of blood within the pleural space. Mostly hemothorax occurs as a consequence of the penetrating or blunt trauma of the chest. In rare cases, hemothorax can be a consequence of iatrogenic injury for example, during placement of catheter into the subclavian artery, or internal jugular vein or during translumbar aortography. Hemothorax is rarely a consequence of the pulmonary embolism or rupture of undiagnosed aneurysm of thoracic aorta. Blood can get to the pleural space after injury of the chest wall, diaphragm, lungs or mediastinum (in the first place of large blood vessels). After injury of thoracic spine, especially vertebrae at the level Th4 - Th6, the hemothorax can be developed, even a few days after the injury. Blood that gets into the pleural space quickly coagulates, but most frequent is an occurrence of the defibrinogenation of coagulation due to the heart and lungs movement, when the blood accumulation is slow and in smaller quantity. Localization, i.e. encapsulation of accumulated blood occurs relatively quickly and when the blood collection is not found and removed, the development of empyema is possible. In case that the bloody leak in the pleural space occurs related to a certain disease, diagnostical procedure, in terms of defining of the clean blood presence, is aimed at determining of haematocrits of pleural fluid. In most cases, however the pleural fluid is macroscopic with blood characteristics, the haematocrit of pleural fluid is under 5%. Hemothorax is diagnosed in such cases when the haematocrit of pleural fluid is at least 50% from the haematocrit in the peripheral blood. Traumatic hemothorax is the frequent findings within the surgical centers that treat the trauma. Incidence of the hemothorax is high at the blunt trauma, up to 37%, associated with the pneumothorax (hemopneumothorax) even up to 58%. Occurrence of the hemothorax is almost equally frequent without rib fracture (35%) or associated with rib fracture (38%). At patients with rib fracture, the occurrence of hemothorax is more frequent when the fractured rib-ends are dislocated.[29] When during the occurrence of hemothorax the arterial bleeding is diagnosed, there is no doubt that the thoracotomy will be applied as a therapy. Massive intrathoracic haemorrhage indicates an urgent thoracotomy and treatment of the bleeding place.[30] Hemothorax causes locally an atelectasis of lungs due to the compression causing that way, when the bleeding is massive, respiratory disorders. In some cases of massive hemothorax, the movement of mediastinum in opposite side is possible. Beside the local compressive effect, hemothorax causes hypovolemic problems which are expressed in a degree that depends on the quantity of lost blood in the pleural space.[32] Diagnosis of traumatic hemothorax must be taken into account at each blunt or penetrating chest injury. Hemothorax, after thoracic trauma, is

Retroperitoneal air which by dissection enters mostly in mediastinum

 Injuries of tracheobronchial tree or oesophagus Lung barotrauma with alveolar disruption

*11.5.7. Traumatic hemothorax*

by:

#### *11.5.6. Subcutaneous emphysema*

Subcutaneous emphysema defines the presence of the air within the subcutaneous tissue, and at traumatized patients it is most frequently, but not only, associated with the chest injury and occurrence of pneumothorax. Air in the subcutaneous tissue may be the consequence of:

Subcutanous emphysema may expend very quickly up to the neck and face or down to the scrotum. Clinical diagnosis of subcutaneous emphysema can be made palpably according to the characteristic sign of crepitation. At each injured patient with the subcutaneous emphysema, the radiography of the chest is necessary for the diagnosis of possible pneumothorax (often followed by such an occurrence). In terms of therapy the approach to the patient with subcutaneous emphysema is aimed to solving of basic leison, being the cause of the subcutaneous emphysema. In case when the emphysema occurs due to the injury of chest and parietal pleura and consequential pneumothorax, the thoracic drainage is identified. Wounds on the chest wall, through which the air can penetrate into subcutaneous tissue, must be treated according to surgical principles.

**Figure 19.** Subcutaneous emphysema – traffic accident

Pneumomediastinum marks the presence of the air in the mediastinum, and it can be caused by:

#### *11.5.7. Traumatic hemothorax*

224 Current Concepts in General Thoracic Surgery

*11.5.6. Subcutaneous emphysema*

enters into subcutaneous tissue

Infection at which occurs the gas formation.

tissue, must be treated according to surgical principles.

**Figure 19.** Subcutaneous emphysema – traffic accident

and face, or down toward loins and abdominal wall

consequence of:

Exsufflation is suitable for fine decompression of the pleural space at the tension pneumothorax, when it is not possible to perform thoracic drainage. However, a method is rarely applied as the definite procedure for solving of traumatic pneumothorax. Thoracic drainage is a method often used during definite treatment of the traumatic pneumothorax.

Subcutaneous emphysema defines the presence of the air within the subcutaneous tissue, and at traumatized patients it is most frequently, but not only, associated with the chest injury and occurrence of pneumothorax. Air in the subcutaneous tissue may be the

Injuries of parietal and viscelar pleura enable that air from the chest or pleural space

Mediastinal or retroperitoneal air which by dissection pass up to the chest wall, neck

Subcutanous emphysema may expend very quickly up to the neck and face or down to the scrotum. Clinical diagnosis of subcutaneous emphysema can be made palpably according to the characteristic sign of crepitation. At each injured patient with the subcutaneous emphysema, the radiography of the chest is necessary for the diagnosis of possible pneumothorax (often followed by such an occurrence). In terms of therapy the approach to the patient with subcutaneous emphysema is aimed to solving of basic leison, being the cause of the subcutaneous emphysema. In case when the emphysema occurs due to the injury of chest and parietal pleura and consequential pneumothorax, the thoracic drainage is identified. Wounds on the chest wall, through which the air can penetrate into subcutaneous

Wound that results in interruption of integrity of soft tissue of the chest wall

Hemothorax marks the presence of blood within the pleural space. Mostly hemothorax occurs as a consequence of the penetrating or blunt trauma of the chest. In rare cases, hemothorax can be a consequence of iatrogenic injury for example, during placement of catheter into the subclavian artery, or internal jugular vein or during translumbar aortography. Hemothorax is rarely a consequence of the pulmonary embolism or rupture of undiagnosed aneurysm of thoracic aorta. Blood can get to the pleural space after injury of the chest wall, diaphragm, lungs or mediastinum (in the first place of large blood vessels). After injury of thoracic spine, especially vertebrae at the level Th4 - Th6, the hemothorax can be developed, even a few days after the injury. Blood that gets into the pleural space quickly coagulates, but most frequent is an occurrence of the defibrinogenation of coagulation due to the heart and lungs movement, when the blood accumulation is slow and in smaller quantity. Localization, i.e. encapsulation of accumulated blood occurs relatively quickly and when the blood collection is not found and removed, the development of empyema is possible. In case that the bloody leak in the pleural space occurs related to a certain disease, diagnostical procedure, in terms of defining of the clean blood presence, is aimed at determining of haematocrits of pleural fluid. In most cases, however the pleural fluid is macroscopic with blood characteristics, the haematocrit of pleural fluid is under 5%. Hemothorax is diagnosed in such cases when the haematocrit of pleural fluid is at least 50% from the haematocrit in the peripheral blood. Traumatic hemothorax is the frequent findings within the surgical centers that treat the trauma. Incidence of the hemothorax is high at the blunt trauma, up to 37%, associated with the pneumothorax (hemopneumothorax) even up to 58%. Occurrence of the hemothorax is almost equally frequent without rib fracture (35%) or associated with rib fracture (38%). At patients with rib fracture, the occurrence of hemothorax is more frequent when the fractured rib-ends are dislocated.[29] When during the occurrence of hemothorax the arterial bleeding is diagnosed, there is no doubt that the thoracotomy will be applied as a therapy. Massive intrathoracic haemorrhage indicates an urgent thoracotomy and treatment of the bleeding place.[30] Hemothorax causes locally an atelectasis of lungs due to the compression causing that way, when the bleeding is massive, respiratory disorders. In some cases of massive hemothorax, the movement of mediastinum in opposite side is possible. Beside the local compressive effect, hemothorax causes hypovolemic problems which are expressed in a degree that depends on the quantity of lost blood in the pleural space.[32] Diagnosis of traumatic hemothorax must be taken into account at each blunt or penetrating chest injury. Hemothorax, after thoracic trauma, is

often diagnosed by findings of pleural fluid at radiography of the chest. However, this method is not sufficient in all cases, or at least it is not proved to such a degree that it can be the only one during the examination of the injured. Smaller intrapleural collections can be hardly noticed at classical radiography, especially when the quantity of the discharged blood is small or when smaller leaks occur on both sides. Difficulties in such cases occur in the interpretation of radiography. When a patient is in the lying position, only slightly shadowing of hemithorax is recorded as a consequence of blood spillage along the back chest wall. Through such a shadow, the silhouette of the lung blood vessels can be obviously seen. Presence of a small hemothorax is hard to define in the lying position, especially when the noticeable contusion injuries of lungs are present and at subcutaneous emphysema, because it should be thought of the presence of a certain lung collapse. It is recommended to perform the radiography of the chest wall in standing position whenever it is possible, although hemothorax does not have to be found initially in that position. At imaging performed in standing posterioanterior (PA) or side position of a patient, free pleural fluid is collected by the effect of gravitation in the back costophrenic sinus, shadowing the costophrenic angle. In rare cases blood can be collected in the subpulmonary way between lungs and diaphragm when the costophrenic sinus is free, and the outline of diaphragm is partially changed. When the imagining is performed in PA position, the apex of diaphragmatic cupola is directed laterally toward the chest wall and the mistake in interpretation that it is the rupture of diaphragm is possible. However, at the side radiography the shadowing of the back costophrenic sinus is found and the angulation of the anterior shadow area of the alleged diaphragm, i.e. leak in the level of union with a large incision. Development of traumatic hemothorax can occur immediately after injury or the bleeding into thoracic cavity occurs later, i.e. after a few hours, even a few days later. Postponed occurrence of hemothorax is recorded after blunt and also after penetrating injury of the chest wall.[33,34] Patients with thoracic trauma, particularly those with assessment that it is potentially severe injury, should be followed by radiography in the period of at least -6 hours after the injury. In that period a small hemothorax and pneumothorax can be found. At penetrating injuries, with initially found hemothorax, development of pneumothorax can be found in over 80% cases.[35,36] Ultrasonography of the chest is an useful method in finding out of smaller pleural blood leaks, particularly at the lying patients and patients without consciousness. Computerized tomography (CT) is a very sensitive method for finding out even small intrapleural collections of fluid. It is proved method for differentiation of hydrothorax from hemothorax.[21] However, this method is rarely applied at the acute injured patients. CT of the chest can be used later for evaluation and differentiation of the lung atelectasis, rupture of diaphragm or finding out of extrapleural haematoma. Such states in the native radiography are manifested by shadowing hardly differentiated from the presence of the free fluid in the pleural cavity. CT of thorax is useful method and during the control of treatment effect, particularly in cases of the occurrence of encapsulation of hemothorax and ineffective drainage. Therapeutic approach of a surgeon toward each inury of the chest must be active, regardless of the Thoracic Trauma 227

known fact that in most cases may come to the spontaneous hemostasis. Such an attitude includs the constant observation of the injured, evacuation of collected blood, fight against atelectasis and follow up of effects of applied surgical treatment. Basic aims of the hemothorax therapy are: evacuation of collected blood from the pleural space, realization of the full reexpansion of lungs and realization of tamponade of the bleeding area by bringing lungs in an immediate contact with parietal pleura. Compensation od the lost blood is performed, in terms of therapy, parallelly with local treatment of hemothorax. It depends on the volum of lost blood.[36,37] Treatment of traumatic hemothorax depends on many parameters as: general state of the injured, state of the vital functions, character of the injury, i.e. is it the question of isolated thoracic injury or the injury is a part of politrauma, states of the injured part of the chest (unilateral, bilateral) and the occurance of bony structure fractures, combideness of many associated intrathoracic injuries, quantity of lost blood and possible area of bleeding, if the bleeding is recorded immediately after admission or it is determined a few hours or days after injury, if it is possible to apply conservative or it is necessary to apply immediately operative treatment, if there is associated pneumothorax with hemothorax, ect.[29,38,39] Most cases of traumatic hemothorax are treated without application of thoracotomy. By thoracentesis (pleural punction with application of large bore needle) or thoracic drainage it is possible to solve hemothorax, i.e. evacuate entire quantity of blood from the pleural space. Attitudes related to the application of these therapeutical models are not clearly separated, particularly in relation to the thoracentesis. Thoracentesis is often applied at a uncomplicated hemothorax with smaller quantity of blood and at the injured where the shadow of the leak without the lung collapse is present during the clinical observation. In most cases they are patients with injuries caused by the effect of a weaker blunt stricking force and those with fractures of one to three ribs. Basic precondition for success of this method is that the blood in the pleural space is not coagulated. Some chest surgeons apply thoracentesis in diagnostical purposes as the first method for the recorded leak in order to orient themselves referring to the character of bleeding, i.e. to define if the obtained blood was immediately coagulated. Thoracic drainage is applied in most cases not only as the first therapeutic method but it is most frequently definitive therapeutic procedure. By thoracic drainage 85% of patients with chest injury are treated. At right diagnosed indications for thoracic drainage, the possibility of occurence of later complications is decreased.[40-42] Success of the thoracic drainage depends on several

factors:

 General state of the injured Indication for drainage

Choice of diameter and quality of thoracic drains and drainage systems

Absolute indications for thoracic drainage at thoracic trauma are the following:

Indications for thoracic drainage are divided to absolute and relative.

early detection of the problem in relation to that.

Control of functioning of the entire drainage system, chest drains passing through and

known fact that in most cases may come to the spontaneous hemostasis. Such an attitude includs the constant observation of the injured, evacuation of collected blood, fight against atelectasis and follow up of effects of applied surgical treatment. Basic aims of the hemothorax therapy are: evacuation of collected blood from the pleural space, realization of the full reexpansion of lungs and realization of tamponade of the bleeding area by bringing lungs in an immediate contact with parietal pleura. Compensation od the lost blood is performed, in terms of therapy, parallelly with local treatment of hemothorax. It depends on the volum of lost blood.[36,37] Treatment of traumatic hemothorax depends on many parameters as: general state of the injured, state of the vital functions, character of the injury, i.e. is it the question of isolated thoracic injury or the injury is a part of politrauma, states of the injured part of the chest (unilateral, bilateral) and the occurance of bony structure fractures, combideness of many associated intrathoracic injuries, quantity of lost blood and possible area of bleeding, if the bleeding is recorded immediately after admission or it is determined a few hours or days after injury, if it is possible to apply conservative or it is necessary to apply immediately operative treatment, if there is associated pneumothorax with hemothorax, ect.[29,38,39] Most cases of traumatic hemothorax are treated without application of thoracotomy. By thoracentesis (pleural punction with application of large bore needle) or thoracic drainage it is possible to solve hemothorax, i.e. evacuate entire quantity of blood from the pleural space. Attitudes related to the application of these therapeutical models are not clearly separated, particularly in relation to the thoracentesis. Thoracentesis is often applied at a uncomplicated hemothorax with smaller quantity of blood and at the injured where the shadow of the leak without the lung collapse is present during the clinical observation. In most cases they are patients with injuries caused by the effect of a weaker blunt stricking force and those with fractures of one to three ribs. Basic precondition for success of this method is that the blood in the pleural space is not coagulated. Some chest surgeons apply thoracentesis in diagnostical purposes as the first method for the recorded leak in order to orient themselves referring to the character of bleeding, i.e. to define if the obtained blood was immediately coagulated. Thoracic drainage is applied in most cases not only as the first therapeutic method but it is most frequently definitive therapeutic procedure. By thoracic drainage 85% of patients with chest injury are treated. At right diagnosed indications for thoracic drainage, the possibility of occurence of later complications is decreased.[40-42] Success of the thoracic drainage depends on several factors:

226 Current Concepts in General Thoracic Surgery

often diagnosed by findings of pleural fluid at radiography of the chest. However, this method is not sufficient in all cases, or at least it is not proved to such a degree that it can be the only one during the examination of the injured. Smaller intrapleural collections can be hardly noticed at classical radiography, especially when the quantity of the discharged blood is small or when smaller leaks occur on both sides. Difficulties in such cases occur in the interpretation of radiography. When a patient is in the lying position, only slightly shadowing of hemithorax is recorded as a consequence of blood spillage along the back chest wall. Through such a shadow, the silhouette of the lung blood vessels can be obviously seen. Presence of a small hemothorax is hard to define in the lying position, especially when the noticeable contusion injuries of lungs are present and at subcutaneous emphysema, because it should be thought of the presence of a certain lung collapse. It is recommended to perform the radiography of the chest wall in standing position whenever it is possible, although hemothorax does not have to be found initially in that position. At imaging performed in standing posterioanterior (PA) or side position of a patient, free pleural fluid is collected by the effect of gravitation in the back costophrenic sinus, shadowing the costophrenic angle. In rare cases blood can be collected in the subpulmonary way between lungs and diaphragm when the costophrenic sinus is free, and the outline of diaphragm is partially changed. When the imagining is performed in PA position, the apex of diaphragmatic cupola is directed laterally toward the chest wall and the mistake in interpretation that it is the rupture of diaphragm is possible. However, at the side radiography the shadowing of the back costophrenic sinus is found and the angulation of the anterior shadow area of the alleged diaphragm, i.e. leak in the level of union with a large incision. Development of traumatic hemothorax can occur immediately after injury or the bleeding into thoracic cavity occurs later, i.e. after a few hours, even a few days later. Postponed occurrence of hemothorax is recorded after blunt and also after penetrating injury of the chest wall.[33,34] Patients with thoracic trauma, particularly those with assessment that it is potentially severe injury, should be followed by radiography in the period of at least -6 hours after the injury. In that period a small hemothorax and pneumothorax can be found. At penetrating injuries, with initially found hemothorax, development of pneumothorax can be found in over 80% cases.[35,36] Ultrasonography of the chest is an useful method in finding out of smaller pleural blood leaks, particularly at the lying patients and patients without consciousness. Computerized tomography (CT) is a very sensitive method for finding out even small intrapleural collections of fluid. It is proved method for differentiation of hydrothorax from hemothorax.[21] However, this method is rarely applied at the acute injured patients. CT of the chest can be used later for evaluation and differentiation of the lung atelectasis, rupture of diaphragm or finding out of extrapleural haematoma. Such states in the native radiography are manifested by shadowing hardly differentiated from the presence of the free fluid in the pleural cavity. CT of thorax is useful method and during the control of treatment effect, particularly in cases of the occurrence of encapsulation of hemothorax and ineffective drainage. Therapeutic approach of a surgeon toward each inury of the chest must be active, regardless of the

Indications for thoracic drainage are divided to absolute and relative.

Absolute indications for thoracic drainage at thoracic trauma are the following:

Thoracic Trauma 229

**Figure 22.** Fall from the height – traffic accident (child 8 years)

*11.5.8. Types of drainage systems of pleura*

(air and fluid) and to achieve full reexpansion of lungs.

are not present.

When the general endotracheal anaesthesia is planned for the surgery on the out thoracic organs at injured patients with the thoracic trauma or when the artificial ventilation by positive pressure is indicated, the attention should be paid to the possibility of development of the tension pneumothorax that in the aim of solving requires an urgent thoracic drainage. Preventive drainage of the thorax is not indicated when the obvious signs of pneumothorax

There is more drainage systems used during thoracic drainage. In order to use in full the therapeutic effect of each system it is necessary to know the working principles each of them. Basic working principle of each drainage system is to: provide continued one-way evacuation, drainage of air and fluid from the pleural space into drainage collector, in the way that there is no possibility for an air circulation or fluid in the opposite direction, i.e. toward the pleural space. Basic aim of thoracic drainage is to evacuate the pleural content

Classical drainage system is comprised of one bottle, which at the same time serves for collection of drainage content and as the water valve. Opening of the thoracic chest tube is connected to the rigid tube, passing through the stopper of sterile bottle. Top of the rigid tube is dived for around 2 cm under the surface of the physiological salt solution poured into the bottle. On the stopper of a bottle there is one more opening through which the tube is inserted, used for air egress (air valve). Top of the tube is above the fluid level. Such a system can be used for so-called submerged drainage, without active suction, or the tube of a valve is connected with the active suction, when the system is used for the active aspiration. Drainage system with two bottles is more reliable for the drainage of large quantity of fluid pleural content. Bottle which is closer to the patient serves as the collector of drainage fluid content, with second bottle the system of water valve is provided, similary to the system of one drainage bottle. Drainage system with three bottles is marked as the

In later clinical course of hemothorax, indications for drainage, i.e. re - drainage are related to the occurence of complication:

**Figure 20.** Left - sided traumatic hemothorax – Traffic accident

**Figure 21.** Right - sided traumatic hemothorax – Traffic accident

**Figure 22.** Fall from the height – traffic accident (child 8 years)

When the general endotracheal anaesthesia is planned for the surgery on the out thoracic organs at injured patients with the thoracic trauma or when the artificial ventilation by positive pressure is indicated, the attention should be paid to the possibility of development of the tension pneumothorax that in the aim of solving requires an urgent thoracic drainage. Preventive drainage of the thorax is not indicated when the obvious signs of pneumothorax are not present.

#### *11.5.8. Types of drainage systems of pleura*

228 Current Concepts in General Thoracic Surgery

to the occurence of complication:

Massive hemothorax previously proved

At development of acute empyema of pleura

**Figure 20.** Left - sided traumatic hemothorax – Traffic accident

**Figure 21.** Right - sided traumatic hemothorax – Traffic accident

 Encapsulated hydroaeric collections Other collections of fluid and air.

Tension pneumothorax

sides.

Traumatic pneumothorax regardless of the degree of collapse

Pneumothorax on both sides regardless of the degree of lung collapse

Associated collection of blood and air - hemopneumothorax, one - sided or on both

In later clinical course of hemothorax, indications for drainage, i.e. re - drainage are related

There is more drainage systems used during thoracic drainage. In order to use in full the therapeutic effect of each system it is necessary to know the working principles each of them. Basic working principle of each drainage system is to: provide continued one-way evacuation, drainage of air and fluid from the pleural space into drainage collector, in the way that there is no possibility for an air circulation or fluid in the opposite direction, i.e. toward the pleural space. Basic aim of thoracic drainage is to evacuate the pleural content (air and fluid) and to achieve full reexpansion of lungs.

Classical drainage system is comprised of one bottle, which at the same time serves for collection of drainage content and as the water valve. Opening of the thoracic chest tube is connected to the rigid tube, passing through the stopper of sterile bottle. Top of the rigid tube is dived for around 2 cm under the surface of the physiological salt solution poured into the bottle. On the stopper of a bottle there is one more opening through which the tube is inserted, used for air egress (air valve). Top of the tube is above the fluid level. Such a system can be used for so-called submerged drainage, without active suction, or the tube of a valve is connected with the active suction, when the system is used for the active aspiration. Drainage system with two bottles is more reliable for the drainage of large quantity of fluid pleural content. Bottle which is closer to the patient serves as the collector of drainage fluid content, with second bottle the system of water valve is provided, similary to the system of one drainage bottle. Drainage system with three bottles is marked as the system for controlled suction of the pleura fluid content. Third bottle, added to the system of two bottles, serves for control of the active aspiration. It is connected to the second bottle that has the function of the water valve. Bottle for the pressure control for performance of the active suction has rigid tube, similar to the one on the second bottle, and on the stopper there is the connection linked with the source of active suction. System with three bottles is quite massive and it is not practical for patients who need transport. Commercial systems, for one-time usage, are designed according to the principle of functioning of the system with three bottles and they are considered to be fully proper for successful thoracic drainage. These systems are manufactured sterile and they are made of the plastic material, simple and practical for use. Most famous are Pleur-Evac and Argyl Double-Seal Units.

Thoracic Trauma 231

**Figure 25.** Drainage system three - bottles

**Figure 26.** Commercial drainage system

*11.5.9. Types of thoracic drainage*

Practically, thoracic drainage can be performed in two different ways by:

 Operative thoracostomy – by classical incision of thorax in general or intravenous anesthesia, dissection and blunt preparation and placement of large-bore thoracic drain under finger control. Position of the patient is the lying, in decubitus on healthy side. Trocar thoracostomy – drainage is performed in local anesthesia by placemnt of the chest tube of narrow lumen through a metal thoracic trocar. Through previously performed incision on the chest wall, it is penetrated by sharp stiletto into the pleural space. During performance of drainage there is no possibility of digital control of the

**Figure 23.** Drainage system one - bottle

**Figure 24.** Drainage system two - bottles

**Figure 25.** Drainage system three - bottles

**Figure 23.** Drainage system one - bottle

**Figure 24.** Drainage system two - bottles

system for controlled suction of the pleura fluid content. Third bottle, added to the system of two bottles, serves for control of the active aspiration. It is connected to the second bottle that has the function of the water valve. Bottle for the pressure control for performance of the active suction has rigid tube, similar to the one on the second bottle, and on the stopper there is the connection linked with the source of active suction. System with three bottles is quite massive and it is not practical for patients who need transport. Commercial systems, for one-time usage, are designed according to the principle of functioning of the system with three bottles and they are considered to be fully proper for successful thoracic drainage. These systems are manufactured sterile and they are made of the plastic material, simple

and practical for use. Most famous are Pleur-Evac and Argyl Double-Seal Units.

**Figure 26.** Commercial drainage system

#### *11.5.9. Types of thoracic drainage*

Practically, thoracic drainage can be performed in two different ways by:

lung parenchyma position in relation to the top of stiletto of the trocar. Variant of drainage by the trocar is the application of the commercial trocar catether, where the trocar is placed inside of thoracic drain. By trocar thoracostomy the chest wall is less damaged and the intervention is performed significantly more rapid, compered with the operative thoracostomy. Patient position is the sitting position with antebrachial region leaned against the backed chair or it is the lying position on the back.

Thoracic Trauma 233

Possibility for the occurence of bacteria infection is decreased due to the encapsulation

Finally, in modern conditions there is a possibility of the blood autotransfusion,

Choice of thoracic chest tubes at fresh bleeding is mostly aimed in direction of placement of drains of a large-bore lumen (Fr 30 - 32, and according to some autors even Fr 36 - 40) for in that way the possibility of drains blockage with bloody coagulum is decreased. Recommendation for the massive hemothorax is to place a large - bore thoracic drain through IV and V interspace of ribs in the midiaxillary line. Drain is placed upward, for during drainage there is a possibility of the diaphragm damage due to its elevation caused by trauma, or within the thoracic cavity prolapsed intra-abdominal organs can be damaged at cases with the diaphragm rupture. Control of thoracic drain function is important and it is necessary to be constant. Passage of drains and quantity of evacuated content are controlled. It is necessary to control radiographic and roentgenoscopic states of extended lungs, diaphragm position and drain position. Control of functioning and efficiency of drains is important in order to prevent infection and development of empynema and if needed, when the thoracic drainage does not achieve a goal, to apply other models of treatment, i.e. thoractomy in the aim of haematoma removal and stopping of bleeding. Best way of prevention in infection development is an urgen and complete evacuation of blood from the pleural cavity. [29-31,33,40] It is useful to apply parenteral therapy of antibiotics. Indication for urgent thoracotomy is often connected with the occurence of massive hemothorax due to injuries of intrathoracic organs that can not be treated in a conservative way. Urgent thoracotomy is indicated at the hemothorax, complicated by a heart tamponade, injury of large intrathoracic blood vessels, primary pleural contamination, debridement of devitalized tissue, open thoracic wounds and at the tracheobronchial injuries.[41 – 44] Indications for urgent thoracotomy are special. After placement of thethoracic chest tube and assessment of the volume of continued pleural bleeding, i.e. quantity of lost blood in continuity through the thoracic drain. General rules include the rule that urgent thoracotomy is indicated in case if the constant loss at thoracic chest tube is 200ml per hour, in case that there is no indications to stop the bleeding. Of course, in order to make decision related to the thoracotomy and assess the state in the pleural cavity in such cases it is necessary to perform control by the radiography and radioscopy. When the continued loss of blood at the thoracic drain is determined and radiographic findings of hemothorax shadowing, the thoracotomi is necessary.[40,45] Indications for urgent thoracotomy are identical at the blunt and penetrating injuries. At each patient it is necessary to observe carefully all parameters, supposed for indication for surgical treatment, i.e. thoracotomy. Resectional lung surgery are rarely applied, mainly in cases of increased laceration of lung parenchyma and development of increased intrapulmonary haematoma, devitalization of lung parenchyma and injury of lung bood vessels.[43,44] It is proved that pneumonectomy should in any case be avoided, for the mortality rate after such an operation is almost 100%, i.e. such a resection should be performed only if there is no other choice. [46 – 48] Wedge - shaped resection is most often, resection of segments and lobectomy, it is possible to apply staplers. [43,44] At the presence of associated hemothorax and pneumothorax one should think of the

of hematoma and development of empyema, i.e. fibrothorax

evacuated by the thoracic drain

**Figure 27.** Operative thoracostomy

Proper premedication of a patient is obligatory regardless which of the mentioned ways is used by the suregeon. Position of the patient during performance of thoracic drainage is mostly defined by his general state.

By placement of thoracic chest tube, several favors are realized in hemothorax treatment:

 Possibility for the occurence of bacteria infection is decreased due to the encapsulation of hematoma and development of empyema, i.e. fibrothorax

232 Current Concepts in General Thoracic Surgery

**Figure 27.** Operative thoracostomy

mostly defined by his general state.

space

lung parenchyma position in relation to the top of stiletto of the trocar. Variant of drainage by the trocar is the application of the commercial trocar catether, where the trocar is placed inside of thoracic drain. By trocar thoracostomy the chest wall is less damaged and the intervention is performed significantly more rapid, compered with the operative thoracostomy. Patient position is the sitting position with antebrachial

region leaned against the backed chair or it is the lying position on the back.

Proper premedication of a patient is obligatory regardless which of the mentioned ways is used by the suregeon. Position of the patient during performance of thoracic drainage is

By placement of thoracic chest tube, several favors are realized in hemothorax treatment:

It is possible to stop the bleeding completely that occurs due to the damage of pleural

 Easy and simple control of the quantity of lost blood and assessment of the bleeding degree are possible, important for defining of the volume necessary for restoring

In most cases the complete evacuation of blood from the pleural space is possible

 Finally, in modern conditions there is a possibility of the blood autotransfusion, evacuated by the thoracic drain

Choice of thoracic chest tubes at fresh bleeding is mostly aimed in direction of placement of drains of a large-bore lumen (Fr 30 - 32, and according to some autors even Fr 36 - 40) for in that way the possibility of drains blockage with bloody coagulum is decreased. Recommendation for the massive hemothorax is to place a large - bore thoracic drain through IV and V interspace of ribs in the midiaxillary line. Drain is placed upward, for during drainage there is a possibility of the diaphragm damage due to its elevation caused by trauma, or within the thoracic cavity prolapsed intra-abdominal organs can be damaged at cases with the diaphragm rupture. Control of thoracic drain function is important and it is necessary to be constant. Passage of drains and quantity of evacuated content are controlled. It is necessary to control radiographic and roentgenoscopic states of extended lungs, diaphragm position and drain position. Control of functioning and efficiency of drains is important in order to prevent infection and development of empynema and if needed, when the thoracic drainage does not achieve a goal, to apply other models of treatment, i.e. thoractomy in the aim of haematoma removal and stopping of bleeding. Best way of prevention in infection development is an urgen and complete evacuation of blood from the pleural cavity. [29-31,33,40] It is useful to apply parenteral therapy of antibiotics. Indication for urgent thoracotomy is often connected with the occurence of massive hemothorax due to injuries of intrathoracic organs that can not be treated in a conservative way. Urgent thoracotomy is indicated at the hemothorax, complicated by a heart tamponade, injury of large intrathoracic blood vessels, primary pleural contamination, debridement of devitalized tissue, open thoracic wounds and at the tracheobronchial injuries.[41 – 44] Indications for urgent thoracotomy are special. After placement of thethoracic chest tube and assessment of the volume of continued pleural bleeding, i.e. quantity of lost blood in continuity through the thoracic drain. General rules include the rule that urgent thoracotomy is indicated in case if the constant loss at thoracic chest tube is 200ml per hour, in case that there is no indications to stop the bleeding. Of course, in order to make decision related to the thoracotomy and assess the state in the pleural cavity in such cases it is necessary to perform control by the radiography and radioscopy. When the continued loss of blood at the thoracic drain is determined and radiographic findings of hemothorax shadowing, the thoracotomi is necessary.[40,45] Indications for urgent thoracotomy are identical at the blunt and penetrating injuries. At each patient it is necessary to observe carefully all parameters, supposed for indication for surgical treatment, i.e. thoracotomy. Resectional lung surgery are rarely applied, mainly in cases of increased laceration of lung parenchyma and development of increased intrapulmonary haematoma, devitalization of lung parenchyma and injury of lung bood vessels.[43,44] It is proved that pneumonectomy should in any case be avoided, for the mortality rate after such an operation is almost 100%, i.e. such a resection should be performed only if there is no other choice. [46 – 48] Wedge - shaped resection is most often, resection of segments and lobectomy, it is possible to apply staplers. [43,44] At the presence of associated hemothorax and pneumothorax one should think of the

possibility of injury of large respiratory paths, trachea and bronchi. When their fissure is determined, an urgent thoracotomy is indicated and the sutura of respiratory paths with caring for the site of bleeding. Thoracotomy is necessary at the traumatic hemothorax at around 20% of the injured. In medern conditions in cases of the occurence of hemothorax the video-assisted thorascopic surgery (VATS) can be applied, but up to recently experiences are still rather modest that it can be accepted that this surgical method belongs to the routine therapeutic methods.[49,50] Main pleural complications of traumatic hemothorax are: retention of blood coagulum in the pleural space, infection in the pleural space, effusion of the pleura and fibrothorax. In most cases surgical recommedation is to remove surgically the formed coagulum from the pleural area due to possible complications, in the first place the infection and development of empyema and fibrothorax.[51] Development of empyema can be expected at 1% - 4% cases. Application of antibiotics during the treatment of hemothorax by thoracic drainage is useful in the reduction of the occurence of empyema and pneumonia. If the thoracic trauma is combined with abdominal trauma, at extended thoracic drainage the possibility of the occurence and development of the pleural infection i.e. empyema is more definite. Complications of the pleural empyema are solved by the thoracotomy and decortication of the lung.[52,53] Occurence of the pleural effusion is possible after completed treatment and removal of thoracic drain. Development of leak is possible, regardless of the fact that residual hemothorax is present or not, but it is significantly more rare, when it is not present (at around 13% without residual hemothorax and around 34% of cases with the retention of the residual hemothorax, i.e. formed coagulum that can not be removed by thoracic drain).[54] Occurance of pleural leak is an indication for pleural punction (thoracocentesis), with the aim to determine the character of pleural fluid and to prevent development of the empyema. After completed treatment of the Thoracic Trauma 235

**Figure 29.** Penetrating injury – knife wound

can be solved by the lung decortication.

*Faculty of Medical Sciences, University of Kragujevac, Serbia*

oradell.NJ:Medical Economics,1983,p.9.

414, DOI: 10.1007/s00383-004-1165-z

**Author details**

**12. References**

Corresponding Author

 \*

Slobodan Milisavljević\*

hemothorax, in the period of a few weeks or months, due to the noticiable adhesions, the fibrothorax can be developed. Fibrothorax is developed at around 1% of treated patients from hemothorax and it is more frequent at patients with hemopnemotorax, or when in the early phase after injury the pleural infection appears. Complications due to the fibrothorax

, Marko Spasić and Miloš Arsenijević *Clinic for General and Thoracic Surgery, Clinical Center »Kragujevac«, Kragujevac, Serbia*

[1] LoCicero J, Mattox KL: Epidemiology of chest trauma, Surg Clin North Am 69:5,1989

[3] Besson A, Saegesser F: Color Atlas of Chest Trauma and Associated Injuries Vol.1

[4] E. Q. Haxhija, H. Nöres, P. Schober and M. E. Höllwarth. Lung contusion-lacerations after blunt thoracic trauma in children Pediatric Surgery International 2004; 20(6): 412-

[2] Shorr RM, et al: Blunt chest trauma in elderly. J Trauma 29:234,1989

**Figure 28.** Penetrating injury – firearms

**Figure 29.** Penetrating injury – knife wound

hemothorax, in the period of a few weeks or months, due to the noticiable adhesions, the fibrothorax can be developed. Fibrothorax is developed at around 1% of treated patients from hemothorax and it is more frequent at patients with hemopnemotorax, or when in the early phase after injury the pleural infection appears. Complications due to the fibrothorax can be solved by the lung decortication.

## **Author details**

234 Current Concepts in General Thoracic Surgery

**Figure 28.** Penetrating injury – firearms

possibility of injury of large respiratory paths, trachea and bronchi. When their fissure is determined, an urgent thoracotomy is indicated and the sutura of respiratory paths with caring for the site of bleeding. Thoracotomy is necessary at the traumatic hemothorax at around 20% of the injured. In medern conditions in cases of the occurence of hemothorax the video-assisted thorascopic surgery (VATS) can be applied, but up to recently experiences are still rather modest that it can be accepted that this surgical method belongs to the routine therapeutic methods.[49,50] Main pleural complications of traumatic hemothorax are: retention of blood coagulum in the pleural space, infection in the pleural space, effusion of the pleura and fibrothorax. In most cases surgical recommedation is to remove surgically the formed coagulum from the pleural area due to possible complications, in the first place the infection and development of empyema and fibrothorax.[51] Development of empyema can be expected at 1% - 4% cases. Application of antibiotics during the treatment of hemothorax by thoracic drainage is useful in the reduction of the occurence of empyema and pneumonia. If the thoracic trauma is combined with abdominal trauma, at extended thoracic drainage the possibility of the occurence and development of the pleural infection i.e. empyema is more definite. Complications of the pleural empyema are solved by the thoracotomy and decortication of the lung.[52,53] Occurence of the pleural effusion is possible after completed treatment and removal of thoracic drain. Development of leak is possible, regardless of the fact that residual hemothorax is present or not, but it is significantly more rare, when it is not present (at around 13% without residual hemothorax and around 34% of cases with the retention of the residual hemothorax, i.e. formed coagulum that can not be removed by thoracic drain).[54] Occurance of pleural leak is an indication for pleural punction (thoracocentesis), with the aim to determine the character of pleural fluid and to prevent development of the empyema. After completed treatment of the

> Slobodan Milisavljević\* , Marko Spasić and Miloš Arsenijević *Clinic for General and Thoracic Surgery, Clinical Center »Kragujevac«, Kragujevac, Serbia Faculty of Medical Sciences, University of Kragujevac, Serbia*

## **12. References**

<sup>\*</sup> Corresponding Author

[5] Shackford SR. : Blunt chest trauma: the intensivists's perspective. Intensive Care Med 1:125,1986

Thoracic Trauma 237

[26] J. Verheij,A. van Lingen, P. G. H. M. Raijmakers, E. R. Rijnsburger,D. P. Veerman W. Wisselink, A. R. J. Girbes and A. B. J. Groeneveld. Effect of fluid loading with saline or colloids on pulmonary permeability, oedema and lung injury score after cardiac and

[29] Mattox KL, Allen MK: Systematic approach to pneumothorax, haemothorax,

[30] Jordi Freixinet, Juan Beltrán, Pedro Miguel Rodríguez, Gabriel Juliá, Mohammed Hussein, Rita Gil, Jorge Herrero Indicators of Severity in Chest Trauma. Archivos de

[31] Weil PH, Margolis IB: Systematic approach to traumatic hemothorax, Am J Surg

[32] Roy-Camille R, Beurier J, Maretingnon M et al: Les epanchements intra-thoraciques associes aux fractures due rachis dorsal. In Buff HU and Glinz W. editors:

[33] Ross RM, Cordoba A: Delayed life-treatening hemothorax associated with rib fractures,

[34] Kathirkamanathan Shanmuganathan, MD, Junichi Matsumoto, MD. Imaging of

[35] Muckart DJ: delayed pneumothorax and haemothorax following observation for stab

[36] Beal AC, Craword HW and DeBakey ME: Conditerations in the management of acute

[37] Weil PH anb Margolis IB: Systematic approach to traumatic hemothorax, Am J Surg

[38] Cordice JWV and Cabezon J: Chest trauma with pneumothorax and hemothorax, J

[40] MD Jeffrey R. MacDonald, MD Richard M. McDowell. Emergency department thoracotomies in a community hospital. Journal of the American College of Emergency

[41] Glinz W: Symposium paper: priorities in diagnosis and treatment of blunt chest

[43] Asensio JA et al: Stapled pulmonary tractotomy: a rapid way to control hemorrhage in

[44] Wall MJ et al: Pulmonary tractotomy as an abbreviated thoracotomy technique. J

[45] Sturm JT: Hemopneumothorax following blunt trauma of the thorax, Surg Gynecol

[27] West JG, Trunkey DD, Limm RC: Systems of trauma care Arch Surg 114:445, 1979 [28] Webb WR, A Besson: Thoracic Surgery: Surgical Management of Chest injuries. Vol 7.

pneumomediastinum and subcutaneous emphysema, Injury 17:309, 1986

major vascular surgery. Br. J. Anaesth 2006; 96(1): 21-30

Bronconeumología ((English Edition)) 2008;44(5):257–262

Respiratorische insuffizienz bei Mehrfachverletzten, Erlang, 1976

Penetrating Chest Trauma. Radiol Clin N Am 2006: 225-238

traumatic hemothorax, J Thorac Cardiovasc Surg 52:351, 1966

[39] Symbas PN: Acute traumatic hemothorax, Ann Thorac Surg 26:195, 1978

[42] Hood-Boyd-Culliford: Thoracic Trauma, W.B. Saunders Comp, 1989

penetrating pulmonary injuries J Am Coll Surg 185:486, 1997

wounds of the chest, Injury 16:247, 1985

Thorac Cardiovasc Surg, 50:316, 1965

Physicians 1978; 7(12): 423–428

injuries, Injury 17:318, 1986

Trauma 45:1015,1998

Obstet 144:539, 1975

International Trends in General Thoracic Surgery

142:692,1981

142:692, 1981

J Trauma 26:576, 1986

injuries. Injury 17:318, 1986

Cardiovasc Surg 4:234, 1992

cardiac injuries, Ann Surg 199:177, 1984

thoracotomy, Am J Surg 152:654, 1986

Churchill Livingstone, p. 1532, 1995

ultrasonography J Trauma 44:291, 1998

American Journal of Surgery 1993;165(2):2S–7S

Med. 1998; 15(3): 189–191

Rounds 4:38, 1981

1:125,1986

378

1978

11:413, 1982

1991;94: 134-138

Book, 1991.

[5] Shackford SR. : Blunt chest trauma: the intensivists's perspective. Intensive Care Med

[6] MD R. Stephen Smith et al, Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury The American Journal of Surgery 1993;166(6):690–695

[8] Galan G,et al: Blunt chest injuries in 1696 patients, Eur J Cardiothorac Surg 6:284,1992 [9] Glinz W: Symposium paper: priorities in diagnosis and treatment of blunt chest

[10] Kulshrestha P, et al: Chest injuries. A clinical and autopsy profile, Trauma 28:844,1988 [11] Serife Tuba Liman, Akin Kuzucu, Abdullah Irfan Tastepe, Gulay Neslihan Ulasan and Salih Topcu Chest injury due to blunt trauma Eur J Cardiothorac Surg 2003;23 (3): 374-

[12] Glinz W: Causes of early death in thoracic trauma. In Webb WR, Besson A (eds): Thoracic Surgery: Surgical Management of Chest Injuries. Vol.7. St.Louis: Mosby-Year

[13] Murray JA,et al: Penetrating left thoracoabdominal trauma: the incidence and clinical

[14] Campbell DB: Trauma to the chest wall, lung, and major airways. Semin Thorac

[15] Feliciano DV, Bitando CG, Mattox KL, et al: A 1 year experience with 450 vascular and

[16] Feliciano DV, Bitando CG, Cruse PA, et al: Liberal use of emergency center

[17] Fisher RP, Jelense S, Perry ST Jr: Direct transfer to operating room improves care of trauma patients: A simple economically feasible plan for large hospital JAMA 240:1731,

[18] Flynn TC, Ward RE, Miller PW: Emergency department thoracotomy Ann Emerg Med

[19] U. Obertacke , Th. Joka , M. Jochum , E . Kreuzfelder, W. Schönfeld und M. Kirschfink. Posttraumatische alveoläre Veränderungen nach Lungenkontusion Uniallchirurg

[20] Pearson FG, Deaslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC Jr (edts): Trauma, Pathophysiology and initial management, In Thoracic Surgery,

[21] P Sinha and P Sarkar. Late clotted haemothorax after blunt chest trauma. J Accid Emerg

[22] Sisley AC, et al: Rapid detection of traumatic effusion using surgeon-performed

[23] MD Hiram C. Polk Jr Factors influencing the risk of infection after trauma The

[24] Shorr RM, Crittenden M, Indeck M, et al: Blunt thoracic trauma, Ann Surg 206:200, 1987 [25] Valeri CR: Optimal use of blood products in the treatment of hemorrhagic schock. Surg

[7] Hood-Boyd-Culliford: Thoracic Trauma, W.B Saunders Company, 1989

presentation of diaphragm injuries, J Trauma 43:624, 1997

[46] Bowling R, et al: Emergency pneumonectomy for penetrating and blunt trauma, Am Surg 51:1365, 1985

**Chapter 12**

© 2012 Mouawad et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Thoracic Vascular Trauma**

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53060

**1. Introduction**

trachea, respectively [1].

Nicolas J. Mouawad, Christodoulos Kaoutzanis and Ajay Gupta

Traumatic injuries to the thoracic vasculature – the aorta and its brachiocephalic branches, the pulmonary arteries and veins, the superior vena cava and intrathoracic inferior vena cava, and the innominate and thoracic veins – occurs following both blunt and penetrating trauma. The primary cause of mortality remains acute exsanguinating hemorrhage. A high clinical index of suspicion along with prompt recognition and resuscitation are necessary components in the

Thoracic injury is directly responsible for 25% of trauma deaths. Penetrating trauma accounts for the vast majority of thoracic great vessel injuries - over 90% - and is generally secondary to projectile missiles such as bullets and shrapnel as well as mechanical disruption by stab wounds and even therapeutic interventions. In fact, iatrogenic lacerations of the great vessels by rapid placement of percutaneous central venous catheter in the emergency department are frequently reported complications. Intercostal vessels and major pulmonary and mediastinal vasculature can be injured by the placement of smaller bore tube thoracostomies. More recently, self-expanding metal stents have been noted to produce perforations of the aorta and innominate artery following placement into the esophagus and

The sudden forceful deceleration following motor vehicle collisions is the primary mechanism regarding blunt trauma to the thoracic great vessels. The pulmonary veins, innominate artery, vena cava, and most commonly, the thoracic aorta are most susceptible to this kind of injury [2,3]. Thoracic aortic injuries generally involve the descending thoracic aorta in 54-65% of cases, the ascending aorta or transverse arch in 12% or multiple segments in 13-18% [4]. Mattox and colleagues hypothesized several mechanisms for blunt great vessel injury: (1) shear mechanical forces onto a relatively mobile segment of a vessel adjacent to a fixed portion – this is the postulated method for descending aortic tears due to its attachment at the ligamentum arteriosum distal to the left subclavian artery and the distal attachment at the diaphragm; (2) compression of a vessel between bony structures –

and reproduction in any medium, provided the original work is properly cited.

surgeon's armamentarium for dealing effectively with thoracic vascular trauma.

## **Thoracic Vascular Trauma**

Nicolas J. Mouawad, Christodoulos Kaoutzanis and Ajay Gupta

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53060

## **1. Introduction**

238 Current Concepts in General Thoracic Surgery

Journal of Surgery 2000;166(1):22–28

Surg 51:1365, 1985

1997

Thorac Imaging 6:68, 1991

[46] Bowling R, et al: Emergency pneumonectomy for penetrating and blunt trauma, Am

[47] Moheb A. Rashid, Thore Wikström, Per Örtenwall. Outcome of lung trauma. European

[48] Baumgartner F, et al: Survival after pneumonectomy: the pathophysiologic balance of

[49] Meyer DM, et al: Early evacuation of traumatic retained hemothoraces using thoracoscopy: a perspective, randomized trial, Ann Thorac Surg 64:1396, 1997 [50] Heniford BT, et al: the role of thoracoscopy in the management of retained thoracic

[51] A.V. Manlulu, T.W. Lee, K.H. Thung, R. Wong and A.P.C. Yim. Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic

[52] LeRoux BT, et al: Suppurative diseases of the lung and pleural space. Part I: Empyema

[53] Aguilar MM, et al: Posttraumatic empyema. Risk factor analysis Arch Surg 132:647,

[54] Hanna JW, Reed JC, Choplin RH: Pleural infections: a clinical-radiologic review J

shock resuscitation with right heart failure, Am Surg 62:967, 1996

collections after trauma, Ann Thorac Surg 63:940, 1997

injuries. Eur J Cardiothorac Surg 2004;25 (6): 1048-1053.

thoracis and lung abscess. Curr Probl Surg 23:1, 1986

Traumatic injuries to the thoracic vasculature – the aorta and its brachiocephalic branches, the pulmonary arteries and veins, the superior vena cava and intrathoracic inferior vena cava, and the innominate and thoracic veins – occurs following both blunt and penetrating trauma. The primary cause of mortality remains acute exsanguinating hemorrhage. A high clinical index of suspicion along with prompt recognition and resuscitation are necessary components in the surgeon's armamentarium for dealing effectively with thoracic vascular trauma.

Thoracic injury is directly responsible for 25% of trauma deaths. Penetrating trauma accounts for the vast majority of thoracic great vessel injuries - over 90% - and is generally secondary to projectile missiles such as bullets and shrapnel as well as mechanical disruption by stab wounds and even therapeutic interventions. In fact, iatrogenic lacerations of the great vessels by rapid placement of percutaneous central venous catheter in the emergency department are frequently reported complications. Intercostal vessels and major pulmonary and mediastinal vasculature can be injured by the placement of smaller bore tube thoracostomies. More recently, self-expanding metal stents have been noted to produce perforations of the aorta and innominate artery following placement into the esophagus and trachea, respectively [1].

The sudden forceful deceleration following motor vehicle collisions is the primary mechanism regarding blunt trauma to the thoracic great vessels. The pulmonary veins, innominate artery, vena cava, and most commonly, the thoracic aorta are most susceptible to this kind of injury [2,3]. Thoracic aortic injuries generally involve the descending thoracic aorta in 54-65% of cases, the ascending aorta or transverse arch in 12% or multiple segments in 13-18% [4]. Mattox and colleagues hypothesized several mechanisms for blunt great vessel injury: (1) shear mechanical forces onto a relatively mobile segment of a vessel adjacent to a fixed portion – this is the postulated method for descending aortic tears due to its attachment at the ligamentum arteriosum distal to the left subclavian artery and the distal attachment at the diaphragm; (2) compression of a vessel between bony structures –

© 2012 Mouawad et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

i.e. "the osseus pinch", such as that of the innominate artery between the sternum anteriorly and the vertebrae posteriorly during an anterior sternal impact; and (3) dramatic intraluminal hypertension during a profound traumatic event [4].

Thoracic Vascular Trauma 241

distress syndrome (ARDS), postoperative complications, and mortality [5]. Permissive hypotension with mean arterial pressures of 65 mm Hg are an acceptable initial goal as aggressive fluid administration would be expected to increase ongoing hemorrhage by dislodging a soft perivascular clot if definitive surgical vascular control is not already achieved.

There is no substitution to a clear and comprehensive history of the event. Clearly, the mechanism of injury will yield the greatest amount of necessary data. Whenever possible, as much information should be gathered from the patient surrounding the events having had occurred. Many times, however, the patient has already been intubated in order to protect the airway and for analgesic control of traumatic injuries. Emergency Medical Service (EMS) personnel as well as law enforcement officers are trained in gathering and relaying the necessary information to medical providers. Noting the amount of external hemorrhage at

In cases of penetrating trauma, the type of firearm used as well as the number and caliber of the projectiles fired in addition to the distance the victim was from the weapon is important. If a knife is used, the length of the instrument and its design (e.g. serrated edges) should be

Although blunt trauma to the thoracic great vessels has been reported with crush and blast injuries as well as falls from height (usually over 30 feet or more), overwhelmingly, the primary culprit is motor-vehicle collisions. Particular detail to the automobile damage, length of vehicular intrusion, starred or shattered windshields, bent steering wheels, frontor side-impact, airbag deployment, the number of passengers in the vehicle, and whether

A rapid comprehensive assessment should be performed as noted previously following ATLS protocol. Obvious external hemorrhage and other signs of blunt or penetrating trauma should be noted by inspection. Evidence of paradoxical thoracic wall movement can determine evidence of flail chest segments. Attention to the neck veins can help demonstrate concern of an intravascular pericardial injury with stigmata of pericardial tamponade or tension pneumothorax. Palpation of the chest wall can reveal disconnected rib segments. Although difficult to hear in a busy trauma bay, percussion of the thorax can reveal a classic

the scene as well as hemodynamic instability during transport is imperative.

the passenger or others were wearing a seatbelt is important to ascertain.

"stony dullness" indicative of fluid, primarily a hemothorax. Classic findings associated with great vessel injury include:

Radio-radial pulse inequality secondary to innominate or subclavian injury

Unequal blood pressure measurements between upper and lower limbs secondary to

**2.2. Clinical history**

noted.

**2.3. Physical examination**

External hemorrhage

pseudocoarctation syndrome

Hypotension

Importantly, isolated injury to the thorax and great vessels is the exception rather than the norm, particularly in blunt trauma. Patients with great vessel injury commonly have concomitant head, spine, abdominal, pelvic and extremity injury. It is imperative that the primary threat to the patient be rapidly analyzed and managed. Three distinctly different groups of patients with thoracic aortic trauma exist according to Mattox and Wall (Table 1).

**Table 1.** Mattox and Wall Patient Classification with Blunt Aortic Injury

The first group represents those with severe thoracic trauma. This is generally unsalvageable and patients are usually dead at the scene or die during transport from uncontrollable hemorrhage and exsanguination. Those that actually make it to the trauma center alive are divided into the second and third group. Unstable patients during transport that die in the emergency department, operating room, or intensive care unit usually succumb to hemorrhage from other sites secondary to multisystem trauma in the first few hours. The third group of patients that arrive in a relatively stable condition are usually found to have a thoracic aortic injury during trauma workup that is not immediately lifethreatening; these patients usually suffer from a protracted course secondary to a major insult to the central nervous system.

## **2. Initial evaluation**

#### **2.1. Prehospital management**

The initial evaluation of any trauma patient, whether with great vessel injury or not, should proceed along the Advanced Trauma Life Support (ATLS) protocol created by the American College of Surgeon's Committee on Trauma. The primary survey should be conducted with the priorities of airway, breathing and circulation, and basic life support interventions are usually already underway by paramedics who have responded to the scene.

Severe shock should be treated with blood transfusion; however, appropriate initial fluid management continues to be an ongoing debate. In general, judicious use of either blood or crystalloid fluids is the norm, especially in great vessel thoracic injury. The goal of increasing blood pressure to normal values has been shown to increase the incidence of acute respiratory distress syndrome (ARDS), postoperative complications, and mortality [5]. Permissive hypotension with mean arterial pressures of 65 mm Hg are an acceptable initial goal as aggressive fluid administration would be expected to increase ongoing hemorrhage by dislodging a soft perivascular clot if definitive surgical vascular control is not already achieved.

### **2.2. Clinical history**

240 Current Concepts in General Thoracic Surgery

Group Description Diagnostic

1 Dead/dying at scene

> during transport

insult to the central nervous system.

**2.1. Prehospital management**

**2. Initial evaluation**

2 Unstable

i.e. "the osseus pinch", such as that of the innominate artery between the sternum anteriorly and the vertebrae posteriorly during an anterior sternal impact; and (3) dramatic

Importantly, isolated injury to the thorax and great vessels is the exception rather than the norm, particularly in blunt trauma. Patients with great vessel injury commonly have concomitant head, spine, abdominal, pelvic and extremity injury. It is imperative that the primary threat to the patient be rapidly analyzed and managed. Three distinctly different groups of patients with thoracic aortic trauma exist according to Mattox and Wall (Table 1).

> Location of Death

transport

The first group represents those with severe thoracic trauma. This is generally unsalvageable and patients are usually dead at the scene or die during transport from uncontrollable hemorrhage and exsanguination. Those that actually make it to the trauma center alive are divided into the second and third group. Unstable patients during transport that die in the emergency department, operating room, or intensive care unit usually succumb to hemorrhage from other sites secondary to multisystem trauma in the first few hours. The third group of patients that arrive in a relatively stable condition are usually found to have a thoracic aortic injury during trauma workup that is not immediately lifethreatening; these patients usually suffer from a protracted course secondary to a major

The initial evaluation of any trauma patient, whether with great vessel injury or not, should proceed along the Advanced Trauma Life Support (ATLS) protocol created by the American College of Surgeon's Committee on Trauma. The primary survey should be conducted with the priorities of airway, breathing and circulation, and basic life support interventions are

Severe shock should be treated with blood transfusion; however, appropriate initial fluid management continues to be an ongoing debate. In general, judicious use of either blood or crystalloid fluids is the norm, especially in great vessel thoracic injury. The goal of increasing blood pressure to normal values has been shown to increase the incidence of acute respiratory

usually already underway by paramedics who have responded to the scene.

Mortality Cause of Death

exsanguinations

100% Hemorrhage/

1-6hours EMS/ED >96% Multisystem trauma

intraluminal hypertension during a profound traumatic event [4].

Interval

**Table 1.** Mattox and Wall Patient Classification with Blunt Aortic Injury

<60min Scene/EMS

3 Stable 4-18hours ICU 5-30% CNS injury

There is no substitution to a clear and comprehensive history of the event. Clearly, the mechanism of injury will yield the greatest amount of necessary data. Whenever possible, as much information should be gathered from the patient surrounding the events having had occurred. Many times, however, the patient has already been intubated in order to protect the airway and for analgesic control of traumatic injuries. Emergency Medical Service (EMS) personnel as well as law enforcement officers are trained in gathering and relaying the necessary information to medical providers. Noting the amount of external hemorrhage at the scene as well as hemodynamic instability during transport is imperative.

In cases of penetrating trauma, the type of firearm used as well as the number and caliber of the projectiles fired in addition to the distance the victim was from the weapon is important. If a knife is used, the length of the instrument and its design (e.g. serrated edges) should be noted.

Although blunt trauma to the thoracic great vessels has been reported with crush and blast injuries as well as falls from height (usually over 30 feet or more), overwhelmingly, the primary culprit is motor-vehicle collisions. Particular detail to the automobile damage, length of vehicular intrusion, starred or shattered windshields, bent steering wheels, frontor side-impact, airbag deployment, the number of passengers in the vehicle, and whether the passenger or others were wearing a seatbelt is important to ascertain.

#### **2.3. Physical examination**

A rapid comprehensive assessment should be performed as noted previously following ATLS protocol. Obvious external hemorrhage and other signs of blunt or penetrating trauma should be noted by inspection. Evidence of paradoxical thoracic wall movement can determine evidence of flail chest segments. Attention to the neck veins can help demonstrate concern of an intravascular pericardial injury with stigmata of pericardial tamponade or tension pneumothorax. Palpation of the chest wall can reveal disconnected rib segments. Although difficult to hear in a busy trauma bay, percussion of the thorax can reveal a classic "stony dullness" indicative of fluid, primarily a hemothorax.

Classic findings associated with great vessel injury include:

## **3. Assessment and imaging modalities**

#### **3.1. Chest radiography**

Although the formal "erect" postero-anterior chest radiograph has been shown to be much more valuable in detecting true-negative instances in patients suspected of aortic injury, it cannot be safely obtained in a patient with hemodynamic instability or suspected spinal injury[6]. As such, the supine antero-posterior chest radiograph is the initial screening imaging of choice in the trauma patient. Several findings seen on the chest x-ray should raise suspicion of thoracic great vessel injury although none are necessarily diagnostic.

Thoracic Vascular Trauma 243

sternum, which generally require a large amount of force to cause such injury and should

In instances of penetrating trauma, radiographic findings that are suggestive of great vessel injury include a large hemothorax or a hemithoracic "white-out" (especially on the left), foreign bodies or missiles such as shrapnel or bullets, and an "out-of-focus" foreign body,

As part of the Focused Assessment Sonography for Trauma (FAST) scan, a transthoracic approach with ultrasound should be routinely performed in both blunt and penetrating trauma to evaluate the pericardial space. In fact, FAST in rapidly becoming commonplace imaging in the initial assessment of trauma patients, expanding imaging to even assess the pleural space for hemothorax and pneumothorax following blunt and penetrating injury. There is an emerging role for the use of trans-esophageal echocardiography (TEE) and its application in acute and sub-acute trauma with suspicion of great vessel injury. Category 1 indications, or indications supported by strong evidence or expert opinion for the use of TEE in the trauma patient, include acute hemodynamic instability and the immediate evaluation of a patient suspected of thoracic aortic pathology such as a dissection, aneurysm or disruption [7]. TEE can rapidly diagnose such injuries by direct visualization of the aorta and a dissection, aortic wall thickening and the presence of a mural hematoma, evidence of

an intimal or medial flap, and any intraluminal debris at the site of vessel injury [8].

sensitivity of 100% and a specificity of 98%, with one false-positive TEE [9].

In an evaluation of 101 trauma patients suspected of having aortic injury, Smith and colleagues conducted a prospective blinded study comparing conventional aortography and TEE. Imaging was performed sequentially by echocardiographic and angiographic personnel with the operators having had been blinded to the results of the previous evaluation. The sensitivity and specificity of TEE was calculated based on the results of aortography of the arch, surgery, and autopsy. The results demonstrated that TEE had a

Although the use of TEE is safe, it is not without its risks and limitations [10]. Furthermore, as with most ultrasonography, it is operator dependent. TEE is not currently routine in the evaluation of a trauma patient suspected of great vessel injury, however, it remains a very

Contrasted, dynamic spiral computed tomography (CT) angiography is evolving into the imaging modality of choice in stable patients suspected of thoracic great vessel injury. It is of particular help in screening for great vessel injury in blunt trauma patients with a rapid deceleration mechanism. In addition to an evaluation of the aortic lumen and contour, it adds much information about the surrounding tissues and the presence of a mediastinal hematoma. It is also helpful for evaluating the trajectory of a missile in transmediastinal

raise concern for underlying tissue and vascular structure damage.

which may indicate its intra-cardiac location.

useful adjunct in experienced hands.

**3.3. Computed tomography**

penetrating trauma.

**3.2. Echocardiography and ultrasonography**

**Figure 1.** Left hemothorax secondary to significant blunt aortic injury

For blunt trauma, particular attention to the contour of the thoracic aorta is necessary. Evidence of mediastinal widening is the classic finding that represents a peri-aortic hematoma. Selective analysis of 16 radiographic signs by Mirvis and colleagues demonstrated that the most discriminating signs for traumatic aortic injury were loss of the aortopulmonary window, rightward deviation of the trachea, loss of the left paraspinal line without associated fracture, and abnormality in the contour of the aortic arch [6]. Other findings include an apical aortic or pleural cap, downward deviation of the left mainstem bronchus, and deviation of a nasogastric tube successfully placed in the esophagus. Of course, one needs to note any evidence of bony fractures such as the first rib, scapula and sternum, which generally require a large amount of force to cause such injury and should raise concern for underlying tissue and vascular structure damage.

In instances of penetrating trauma, radiographic findings that are suggestive of great vessel injury include a large hemothorax or a hemithoracic "white-out" (especially on the left), foreign bodies or missiles such as shrapnel or bullets, and an "out-of-focus" foreign body, which may indicate its intra-cardiac location.

### **3.2. Echocardiography and ultrasonography**

242 Current Concepts in General Thoracic Surgery

Intrascapular murmur

Palpable sternal fracture

**3.1. Chest radiography**

Left flail chest

Expanding or pulsatile hematoma at the thoracic outlet

**Figure 1.** Left hemothorax secondary to significant blunt aortic injury

Although the formal "erect" postero-anterior chest radiograph has been shown to be much more valuable in detecting true-negative instances in patients suspected of aortic injury, it cannot be safely obtained in a patient with hemodynamic instability or suspected spinal injury[6]. As such, the supine antero-posterior chest radiograph is the initial screening imaging of choice in the trauma patient. Several findings seen on the chest x-ray should raise suspicion of thoracic great vessel injury although none are necessarily diagnostic.

For blunt trauma, particular attention to the contour of the thoracic aorta is necessary. Evidence of mediastinal widening is the classic finding that represents a peri-aortic hematoma. Selective analysis of 16 radiographic signs by Mirvis and colleagues demonstrated that the most discriminating signs for traumatic aortic injury were loss of the aortopulmonary window, rightward deviation of the trachea, loss of the left paraspinal line without associated fracture, and abnormality in the contour of the aortic arch [6]. Other findings include an apical aortic or pleural cap, downward deviation of the left mainstem bronchus, and deviation of a nasogastric tube successfully placed in the esophagus. Of course, one needs to note any evidence of bony fractures such as the first rib, scapula and

Palpable thoracic spine fractures or instability

**3. Assessment and imaging modalities**

As part of the Focused Assessment Sonography for Trauma (FAST) scan, a transthoracic approach with ultrasound should be routinely performed in both blunt and penetrating trauma to evaluate the pericardial space. In fact, FAST in rapidly becoming commonplace imaging in the initial assessment of trauma patients, expanding imaging to even assess the pleural space for hemothorax and pneumothorax following blunt and penetrating injury. There is an emerging role for the use of trans-esophageal echocardiography (TEE) and its application in acute and sub-acute trauma with suspicion of great vessel injury. Category 1 indications, or indications supported by strong evidence or expert opinion for the use of TEE in the trauma patient, include acute hemodynamic instability and the immediate evaluation of a patient suspected of thoracic aortic pathology such as a dissection, aneurysm or disruption [7]. TEE can rapidly diagnose such injuries by direct visualization of the aorta and a dissection, aortic wall thickening and the presence of a mural hematoma, evidence of an intimal or medial flap, and any intraluminal debris at the site of vessel injury [8].

In an evaluation of 101 trauma patients suspected of having aortic injury, Smith and colleagues conducted a prospective blinded study comparing conventional aortography and TEE. Imaging was performed sequentially by echocardiographic and angiographic personnel with the operators having had been blinded to the results of the previous evaluation. The sensitivity and specificity of TEE was calculated based on the results of aortography of the arch, surgery, and autopsy. The results demonstrated that TEE had a sensitivity of 100% and a specificity of 98%, with one false-positive TEE [9].

Although the use of TEE is safe, it is not without its risks and limitations [10]. Furthermore, as with most ultrasonography, it is operator dependent. TEE is not currently routine in the evaluation of a trauma patient suspected of great vessel injury, however, it remains a very useful adjunct in experienced hands.

### **3.3. Computed tomography**

Contrasted, dynamic spiral computed tomography (CT) angiography is evolving into the imaging modality of choice in stable patients suspected of thoracic great vessel injury. It is of particular help in screening for great vessel injury in blunt trauma patients with a rapid deceleration mechanism. In addition to an evaluation of the aortic lumen and contour, it adds much information about the surrounding tissues and the presence of a mediastinal hematoma. It is also helpful for evaluating the trajectory of a missile in transmediastinal penetrating trauma.

Traditionally, the use of conventional CT was viewed as adding little extra knowledge to the clinical scenario. Surgeons, and even some radiologists, felt that obtaining a CT scan wastes valuable time, contrast administration would interfere and confound aortography, and that arteriography would still be necessary in a substantial number of cases [11,12]. However, with the use of helical CT technology, the aorta can be evaluated directly so that confusion of mediastinal hematomas and normal structures can be avoided. In addition, imaging of the aortic root with electrocardiographic gating can help minimize the pulsation and motion artifact that can leave concern about proximal aortic root injury that would traditionally require catheter-based angiography for definitive evaluation [13]. A study by Gavant and colleagues used helical scanning exclusively to screen over 1,500 patients with nontrivial blunt chest trauma. Those with abnormal CTs then underwent conventional aortography. Their evaluation yielded 100% sensitivity and 81.7% specificity for aortic injury [14].

Thoracic Vascular Trauma 245

Previously, the conventional CT scan was used as screening tool to guide further options. If no mediastinal blood is detected on CT, the probability of significant aortic injury is quite low and aortography is usually not needed [15]; efforts should be directed at the management of other injuries in the trauma patient. However, if the CT scan were positive for vascular injury, most surgeons would still proceed with aortography to help better delineate the exact location of the injury and possibly employ endovascular therapeutic options. With the advent of helical technology, however, CT angiography is considered a

Traditional teaching has placed conventional catheter-based angiography as the "gold standard" imaging modality when there is clinical or radiographic suspicion of a thoracic major vascular injury in the trauma patient. The information obtained from these studies help localize the injury and aid the surgeon in pre-operative planning and choice of incision as different thoracic approaches are needed for satisfactory anatomic exposure to obtain proximal and distal control of the affected vessels. Newer technology and better imaging

In penetrating trauma, catheter arteriography is indicated for suspected aortic, innominate, carotid, or subclavian arterial injuries. Various film sequences have been used, including anteroposterior, lateral and oblique views. It is imperative that multiple views be obtained as more than one projection may be necessary to detect an aortic injury, especially if a small laceration has closed off or if a column of arterial contrast obscures a small extravasation in one view.

Indications for conventional angiography in patients presenting with blunt trauma include those with a rapid deceleration mechanism of injury, those with suggestive signs on chest radiograph – namely an obscure aortic knob or abnormal descending thoracic contour, a

Angiography does have its limitations as well. It lacks spatial resolution, often requiring multiple injections in various different planes to demonstrate even minor lesions. In addition, it only provides luminal imaging and does not provide information on nearby parenchymal lesions and trauma as well as the integrity of adjacent venous structures. Furthermore, most institutions do not have an angiography team that remains "in-house" and as such, there is a time delay in assembling the necessary personnel to perform the imaging. Both false-positive and false-negative results have been reported [16]. These procedures are invasive and iatrogenic complications from catheter use such as arterial dissections, pseudoaneurysms, aortic lacerations, retroperitoneal hemorrhage as well as mortality have been reported [17]. Regardless, catheter-based thoracic angiography currently remains the frame of reference for

For completeness, a note on magnetic resonance angiography is warranted. Although this modality can demonstrate evidence of acute or subacute mediastinal hemorrhage, its use in

definitive diagnostic procedure that recognizes aortic injury and rupture.

resolution and capabilities are challenging this belief however.

widened mediastinum – and those with a positive screening CT scan.

the definitive diagnosis of thoracic vascular trauma.

**3.5. Magnetic resonance angiography**

**3.4. Catheter-based thoracic angiography**

**Figure 2.** CT scan in axial section with aortic injury and intramural hematoma

**Figure 3.** CT scan in sagittal section with intramural hematoma

Previously, the conventional CT scan was used as screening tool to guide further options. If no mediastinal blood is detected on CT, the probability of significant aortic injury is quite low and aortography is usually not needed [15]; efforts should be directed at the management of other injuries in the trauma patient. However, if the CT scan were positive for vascular injury, most surgeons would still proceed with aortography to help better delineate the exact location of the injury and possibly employ endovascular therapeutic options. With the advent of helical technology, however, CT angiography is considered a definitive diagnostic procedure that recognizes aortic injury and rupture.

#### **3.4. Catheter-based thoracic angiography**

244 Current Concepts in General Thoracic Surgery

Traditionally, the use of conventional CT was viewed as adding little extra knowledge to the clinical scenario. Surgeons, and even some radiologists, felt that obtaining a CT scan wastes valuable time, contrast administration would interfere and confound aortography, and that arteriography would still be necessary in a substantial number of cases [11,12]. However, with the use of helical CT technology, the aorta can be evaluated directly so that confusion of mediastinal hematomas and normal structures can be avoided. In addition, imaging of the aortic root with electrocardiographic gating can help minimize the pulsation and motion artifact that can leave concern about proximal aortic root injury that would traditionally require catheter-based angiography for definitive evaluation [13]. A study by Gavant and colleagues used helical scanning exclusively to screen over 1,500 patients with nontrivial blunt chest trauma. Those with abnormal CTs then underwent conventional aortography.

Their evaluation yielded 100% sensitivity and 81.7% specificity for aortic injury [14].

**Figure 2.** CT scan in axial section with aortic injury and intramural hematoma

**Figure 3.** CT scan in sagittal section with intramural hematoma

Traditional teaching has placed conventional catheter-based angiography as the "gold standard" imaging modality when there is clinical or radiographic suspicion of a thoracic major vascular injury in the trauma patient. The information obtained from these studies help localize the injury and aid the surgeon in pre-operative planning and choice of incision as different thoracic approaches are needed for satisfactory anatomic exposure to obtain proximal and distal control of the affected vessels. Newer technology and better imaging resolution and capabilities are challenging this belief however.

In penetrating trauma, catheter arteriography is indicated for suspected aortic, innominate, carotid, or subclavian arterial injuries. Various film sequences have been used, including anteroposterior, lateral and oblique views. It is imperative that multiple views be obtained as more than one projection may be necessary to detect an aortic injury, especially if a small laceration has closed off or if a column of arterial contrast obscures a small extravasation in one view.

Indications for conventional angiography in patients presenting with blunt trauma include those with a rapid deceleration mechanism of injury, those with suggestive signs on chest radiograph – namely an obscure aortic knob or abnormal descending thoracic contour, a widened mediastinum – and those with a positive screening CT scan.

Angiography does have its limitations as well. It lacks spatial resolution, often requiring multiple injections in various different planes to demonstrate even minor lesions. In addition, it only provides luminal imaging and does not provide information on nearby parenchymal lesions and trauma as well as the integrity of adjacent venous structures. Furthermore, most institutions do not have an angiography team that remains "in-house" and as such, there is a time delay in assembling the necessary personnel to perform the imaging. Both false-positive and false-negative results have been reported [16]. These procedures are invasive and iatrogenic complications from catheter use such as arterial dissections, pseudoaneurysms, aortic lacerations, retroperitoneal hemorrhage as well as mortality have been reported [17]. Regardless, catheter-based thoracic angiography currently remains the frame of reference for the definitive diagnosis of thoracic vascular trauma.

#### **3.5. Magnetic resonance angiography**

For completeness, a note on magnetic resonance angiography is warranted. Although this modality can demonstrate evidence of acute or subacute mediastinal hemorrhage, its use in the acute trauma setting is not practical. Restricted access to a critically ill trauma patient while in the scanner is unsafe and the strong magnetic field can be severely limiting to those individuals requiring intensive monitoring and mechanical ventilator support.

Thoracic Vascular Trauma 247

The *descending thoracic aorta* is found in the posterior mediastinal cavity. It begins at the level of the fourth thoracic vertebra and descends on the left of the midline exiting the thorax through the aortic hiatus posterior to the diaphragm at the level of the twelfth thoracic vertebra. Its branches include the bronchial arteries, the posterior intercostal arteries as well as the pericardial, esophageal, mediastinal, superior phrenic and subcostal branches. On the anterior surface of the vessel, from above downward, are the root of the left lung, the pericardium, the esophagus and the diaphragm. Posteriorly, it is in relation with the hemiazygos veins and the vertebral column. On the left side of the vessel are the left pleura and lung, and on the right side are the azygos vein and thoracic duct. The esophagus lies on the right side of the descending aorta superiorly, then courses anteriorly and eventually to

The *brachiocephalic veins* are located on either side of the root of the neck and are devoid of valves. The right brachiocephalic vein is a short, about 2.5 cm long vessel and is formed by the confluence of the right subclavian and right jugular veins. Its origin is posterior to the medial aspect of the right clavicle. It runs vertically downwards and joins the left brachiocephalic vein just below the cartilage of the right first rib to form the superior vena cava. Its tributaries are the right vertebral vein, the right internal thoracic vein, the first posterior intercostal vein, the right inferior thyroid and thymic veins. The left brachiocephalic vein is about 6 cm long and is formed by the confluence of the left subclavian and left jugular veins. It begins behind the medial aspect of the left clavicle and travels obliquely downward and to the right posterior to the sternum to anastomose with the right brachiocephalic vein just below the cartilage of the right first rib. Its tributaries include the left vertebral vein, , the left internal thoracic vein, the left superior intercostal

The *superior vena cava* is formed by the confluence of the right and left brachiocephalic veins. It has no valves. It measures about 7 cm in length and runs vertically downward posterior to the first two intercostal spaces to drain into the upper part of the right atrium The distal portion of the vessel is partially invested by pericardium. Its only tributary is the azygous vein. The inferior vena cava begins in the abdomen and enters the thorax through the caval hiatus in the diaphragm at the level of the eighth thoracic vertebra and immediately drains into the inferior aspect of the right atrium. It is partially invested by pericardium. It has no

The *azygous vein* begins in the abdomen and enters the thorax through the aortic hiatus in the diaphragm . It runs upward to the right side of the bodies of the thoracic vertebrae to the fourth thoracic vertebra, where it arches anteriorly over the right main bronchus and drains into the posterior aspect of the superior vena cava. It is found in the posterior mediastinum to the right of the esophagus and aorta, and to the left of the pleura and lung. Posteriorly, it is in relation to the lower right intercostal arteries and the thoracic vertebral bodies; anteriorly, to the root of the right lung and the pleura. Its tributaries include the

vein, the left inferior thyroid vein, and some thymic and pericardiac veins.

the left side of the vessel just above the diaphragm.

**4.2. The great veins**

tributaries in the thorax.

## **4. Anatomy of the thoracic great vessels**

Although a complete anatomic description of the thoracic vasculature is beyond the scope of this chapter, the relevant great vessel anatomy is described in the following subsections.

#### **4.1. The aorta and its segments**

The aorta is described in three different portions within the thoracic cavity; the ascending aorta, aortic arch and descending aorta.

The *ascending aorta* originates from the base of the left ventricle at the aortic orifice. Its origin and proximal aspect are contained within the pericardium. It courses anterosuperiorly and to the right where it becomes the aortic arch. Its total length is about 5 cm. Its only branches are the two coronary arteries, which arise immediately distal to the origin of the aorta just above the attached margins of the semilunar valves. Its location is central with respect to the other vascular structures. On the right side, it is in relation with the superior vena cava and right atrium. On the left side, it is in relation with the pulmonary artery. Posteriorly, it rests upon the right pulmonary artery and left atrium. It is separated from the sternum by the pericardium, the right pleura, the right lung anterior margin, some loose areolar tissue and the remains of the thymus.

The *aortic arch* runs at first posterosuperiorly and to the left, anterior to the right pulmonary artery and the carina of the trachea with its apex on the left of the distal trachea. It then courses downward posterior to the left hilum and becomes the descending aorta at the level of the lower border of the fourth thoracic vertebral body. Its branches, in order from right to left, include the brachiocephalic artery, the left common carotid artery and the left subclavian artery. All three branches arise from the convexity of the arch and are crossed close to their origins by the left brachiocephalic vein. Anteriorly, the vessel is covered by the lung pleura and the remains of the thymus. On the right side, it is in relation with the esophagus, the thoracic duct, the left recurrent laryngeal nerve and the deep part of the cardiac plexus. The trachea is also found on the right but posteriorly to the vessel. On the left side, the vessel is in contact with the left lung and pleura superiorly, and as it passes downward four nerves are encountered; the left phrenic, the lower of the superior cardiac branches of the left vagus, the superior cardiac branch of the left sympathetic, and the trunk of the left vagus. As the trunk of the vagus nerve crosses the aortic arch, it gives off its recurrent branch that wraps around the arch and then travels superiorly and to the right. Below the vessel are also the bifurcation of the pulmonary artery, the left bronchus, the superficial part of the cardiac plexus and the ligamentum arteriosum. The ligamentum arteriosum represents the remnant of the ductus arteriosus, connecting the inferior aspect of the aortic arch to the superior aspect of the pulmonary trunk.

The *descending thoracic aorta* is found in the posterior mediastinal cavity. It begins at the level of the fourth thoracic vertebra and descends on the left of the midline exiting the thorax through the aortic hiatus posterior to the diaphragm at the level of the twelfth thoracic vertebra. Its branches include the bronchial arteries, the posterior intercostal arteries as well as the pericardial, esophageal, mediastinal, superior phrenic and subcostal branches. On the anterior surface of the vessel, from above downward, are the root of the left lung, the pericardium, the esophagus and the diaphragm. Posteriorly, it is in relation with the hemiazygos veins and the vertebral column. On the left side of the vessel are the left pleura and lung, and on the right side are the azygos vein and thoracic duct. The esophagus lies on the right side of the descending aorta superiorly, then courses anteriorly and eventually to the left side of the vessel just above the diaphragm.

#### **4.2. The great veins**

246 Current Concepts in General Thoracic Surgery

**4.1. The aorta and its segments**

the remains of the thymus.

aorta, aortic arch and descending aorta.

**4. Anatomy of the thoracic great vessels**

the acute trauma setting is not practical. Restricted access to a critically ill trauma patient while in the scanner is unsafe and the strong magnetic field can be severely limiting to those

Although a complete anatomic description of the thoracic vasculature is beyond the scope of this chapter, the relevant great vessel anatomy is described in the following subsections.

The aorta is described in three different portions within the thoracic cavity; the ascending

The *ascending aorta* originates from the base of the left ventricle at the aortic orifice. Its origin and proximal aspect are contained within the pericardium. It courses anterosuperiorly and to the right where it becomes the aortic arch. Its total length is about 5 cm. Its only branches are the two coronary arteries, which arise immediately distal to the origin of the aorta just above the attached margins of the semilunar valves. Its location is central with respect to the other vascular structures. On the right side, it is in relation with the superior vena cava and right atrium. On the left side, it is in relation with the pulmonary artery. Posteriorly, it rests upon the right pulmonary artery and left atrium. It is separated from the sternum by the pericardium, the right pleura, the right lung anterior margin, some loose areolar tissue and

The *aortic arch* runs at first posterosuperiorly and to the left, anterior to the right pulmonary artery and the carina of the trachea with its apex on the left of the distal trachea. It then courses downward posterior to the left hilum and becomes the descending aorta at the level of the lower border of the fourth thoracic vertebral body. Its branches, in order from right to left, include the brachiocephalic artery, the left common carotid artery and the left subclavian artery. All three branches arise from the convexity of the arch and are crossed close to their origins by the left brachiocephalic vein. Anteriorly, the vessel is covered by the lung pleura and the remains of the thymus. On the right side, it is in relation with the esophagus, the thoracic duct, the left recurrent laryngeal nerve and the deep part of the cardiac plexus. The trachea is also found on the right but posteriorly to the vessel. On the left side, the vessel is in contact with the left lung and pleura superiorly, and as it passes downward four nerves are encountered; the left phrenic, the lower of the superior cardiac branches of the left vagus, the superior cardiac branch of the left sympathetic, and the trunk of the left vagus. As the trunk of the vagus nerve crosses the aortic arch, it gives off its recurrent branch that wraps around the arch and then travels superiorly and to the right. Below the vessel are also the bifurcation of the pulmonary artery, the left bronchus, the superficial part of the cardiac plexus and the ligamentum arteriosum. The ligamentum arteriosum represents the remnant of the ductus arteriosus, connecting the inferior aspect of

the aortic arch to the superior aspect of the pulmonary trunk.

individuals requiring intensive monitoring and mechanical ventilator support.

The *brachiocephalic veins* are located on either side of the root of the neck and are devoid of valves. The right brachiocephalic vein is a short, about 2.5 cm long vessel and is formed by the confluence of the right subclavian and right jugular veins. Its origin is posterior to the medial aspect of the right clavicle. It runs vertically downwards and joins the left brachiocephalic vein just below the cartilage of the right first rib to form the superior vena cava. Its tributaries are the right vertebral vein, the right internal thoracic vein, the first posterior intercostal vein, the right inferior thyroid and thymic veins. The left brachiocephalic vein is about 6 cm long and is formed by the confluence of the left subclavian and left jugular veins. It begins behind the medial aspect of the left clavicle and travels obliquely downward and to the right posterior to the sternum to anastomose with the right brachiocephalic vein just below the cartilage of the right first rib. Its tributaries include the left vertebral vein, , the left internal thoracic vein, the left superior intercostal vein, the left inferior thyroid vein, and some thymic and pericardiac veins.

The *superior vena cava* is formed by the confluence of the right and left brachiocephalic veins. It has no valves. It measures about 7 cm in length and runs vertically downward posterior to the first two intercostal spaces to drain into the upper part of the right atrium The distal portion of the vessel is partially invested by pericardium. Its only tributary is the azygous vein. The inferior vena cava begins in the abdomen and enters the thorax through the caval hiatus in the diaphragm at the level of the eighth thoracic vertebra and immediately drains into the inferior aspect of the right atrium. It is partially invested by pericardium. It has no tributaries in the thorax.

The *azygous vein* begins in the abdomen and enters the thorax through the aortic hiatus in the diaphragm . It runs upward to the right side of the bodies of the thoracic vertebrae to the fourth thoracic vertebra, where it arches anteriorly over the right main bronchus and drains into the posterior aspect of the superior vena cava. It is found in the posterior mediastinum to the right of the esophagus and aorta, and to the left of the pleura and lung. Posteriorly, it is in relation to the lower right intercostal arteries and the thoracic vertebral bodies; anteriorly, to the root of the right lung and the pleura. Its tributaries include the hemiazygous vein, the right subcostal vein, some of the left intercostal veins and the nine lower intercostal veins on the right, the lower right superior intercostal vein, the right bronchial vein and several esophageal, mediastinal, and pericardial veins. The tributaries have complete valves, but the azygous vein itself only has a few imperfect valves.

## **5. Management options**

With increases in technology and research, there are three mainstay treatments of blunt aortic injury: non-operative management, endovascular stent-graft methods, and traditional open repair (either immediate or delayed).

Azizzadeh and colleagues [18] initially proposed a classification system for blunt aortic injury based on the presence of an external aortic contour abnormality on computed tomography and/or the presence of free rupture noted on laparotomy.

Thoracic Vascular Trauma 249

with serial imaging; however, types II to IV should be repaired. Endovascular approaches

The advent of multi-detector CT and TEE has resulted in the identification of subtle injuries that were previously beyond the resolution of traditional imaging techniques. This has resulted in a dilemma of which particular injuries require immediate treatment and which ones can be safely observed. Some practitioners withhold intervention for minor aortic injuries such as minor intimal defects of 1 cm with no or minimal periaortic hematoma [21]. Complete resolution of such injuries has been noted but complications have also been documented from such non-operative management, even many years later. The natural history of these injuries is unknown but such complications include delayed rupture of pseudoaneurysms or even fistulization with profound hemorrhage [22]. Those patients that are treated non-operatively for blunt aortic injuries should undergo careful follow-up with

Patients that should not undergo immediate repair of blunt aortic injury include:

Patients with progressive coagulopathy, acidosis and hypothermia

Patients not in a trauma center capable of definitive repair

Severe hemodynamic instability from concomitant injuries within the abdomen or

The mainstay of non-operative management involves aggressive pharmacological control of blood pressure with beta-blockers and critical care in an effort to delay the physiological insult of surgical intervention until the patient is adequately resuscitated and optimized. Avoiding hypertension is recommended to minimize intraluminal stress on the injured

The advancement of endovascular techniques and device technology has truly revolutionized the treatment of blunt aortic injury over the last few years. In fact, at many centers, the use of thoracic endovascular repair (TEVAR) has become an attractive approach whereas initially it was only used in highly selected patients deemed too high risk for

There are multiple advantages to the use of TEVAR, especially in the high-risk patient population. By nature, endovascular treatment is less invasive than open surgery, and if

are becoming the standard option in this regard if amenable.

imaging to observe and document injury resolution.

**5.1. Non-operative management**

pelvis

Severe burns

Severe sepsis

conventional open repair.

Severe head injury

Severe pulmonary injury

Prohibitive medical co-morbidities

Profoundly contaminated wounds

vessel from increased systolic blood pressure.

**5.2. Endovascular stent-graft interventions**

This classification system was further modified by Starnes and colleagues [19], as follows:

The Society for Vascular Surgery in 2011 has determined clinical practice guidelines for the repair of traumatic thoracic aortic injury [20]. Type I injuries can be managed expectantly with serial imaging; however, types II to IV should be repaired. Endovascular approaches are becoming the standard option in this regard if amenable.

#### **5.1. Non-operative management**

248 Current Concepts in General Thoracic Surgery

**5. Management options**

open repair (either immediate or delayed).

thrombus of <10mm in length or width

and/or thrombus of ≥10mm in length or width

hemiazygous vein, the right subcostal vein, some of the left intercostal veins and the nine lower intercostal veins on the right, the lower right superior intercostal vein, the right bronchial vein and several esophageal, mediastinal, and pericardial veins. The tributaries

With increases in technology and research, there are three mainstay treatments of blunt aortic injury: non-operative management, endovascular stent-graft methods, and traditional

Azizzadeh and colleagues [18] initially proposed a classification system for blunt aortic injury based on the presence of an external aortic contour abnormality on computed

**Figure 4.** Schematic representation of blunt thoracic injury with implications for management

Pseudoaneurysm: external aortic contour abnormality and contained rupture

This classification system was further modified by Starnes and colleagues [19], as follows: Intimal tear: absence of aortic external contour abnormality and intimal defect and/or

Large intimal flap: absence of aortic external contour abnormality and intimal defect

 Rupture: external aortic contour abnormality with free contrast extravasation noted on computed tomography or hemoperitoneum found on exploratory laparotomy

The Society for Vascular Surgery in 2011 has determined clinical practice guidelines for the repair of traumatic thoracic aortic injury [20]. Type I injuries can be managed expectantly

have complete valves, but the azygous vein itself only has a few imperfect valves.

tomography and/or the presence of free rupture noted on laparotomy.

The advent of multi-detector CT and TEE has resulted in the identification of subtle injuries that were previously beyond the resolution of traditional imaging techniques. This has resulted in a dilemma of which particular injuries require immediate treatment and which ones can be safely observed. Some practitioners withhold intervention for minor aortic injuries such as minor intimal defects of 1 cm with no or minimal periaortic hematoma [21]. Complete resolution of such injuries has been noted but complications have also been documented from such non-operative management, even many years later. The natural history of these injuries is unknown but such complications include delayed rupture of pseudoaneurysms or even fistulization with profound hemorrhage [22]. Those patients that are treated non-operatively for blunt aortic injuries should undergo careful follow-up with imaging to observe and document injury resolution.

Patients that should not undergo immediate repair of blunt aortic injury include:

The mainstay of non-operative management involves aggressive pharmacological control of blood pressure with beta-blockers and critical care in an effort to delay the physiological insult of surgical intervention until the patient is adequately resuscitated and optimized. Avoiding hypertension is recommended to minimize intraluminal stress on the injured vessel from increased systolic blood pressure.

#### **5.2. Endovascular stent-graft interventions**

The advancement of endovascular techniques and device technology has truly revolutionized the treatment of blunt aortic injury over the last few years. In fact, at many centers, the use of thoracic endovascular repair (TEVAR) has become an attractive approach whereas initially it was only used in highly selected patients deemed too high risk for conventional open repair.

There are multiple advantages to the use of TEVAR, especially in the high-risk patient population. By nature, endovascular treatment is less invasive than open surgery, and if successful, averts the need for a traditional thoracotomy. It is associated with decreased morbidity and mortality, as has been noted in several studies [23-25]. Blood loss is minimal. Placement of a stent-graft does not require aortic cross clamping, which reduces the risk of distal visceral and spinal ischemia. In addition, such cross-clamping and unclamping complicate resuscitation and anesthesiologist management in patients with circulatory collapse and hemodynamic instability. Respiratory compromise from lung and thoracic wall injuries is magnified by thoracotomy, and single ventilation in such patients may be quite problematic. Furthermore, appropriate positioning for open surgery may compound neurologic deficits in patients with spinal fractures. Although systemic heparinization is usually employed during routine stent-grafting procedures, in cases of polytrauma with concomitant visceral organ injuries and fractures of the pelvis and long bones, heparin is withheld. Importantly with TEVAR, the absence of circulatory assistance with bypass and the need for high systemic doses of heparin, limit the feared hemorrhagic complications. Xenos et al. performed a meta-analysis of seventeen retrospective cohort studies evaluating 589 patients, and indicated that endovascular management of descending thoracic aortic injuries is a viable alternative to traditional open repair; it is associated with decreased ischemic spinal cord complication rates and lower postoperative mortality [23].

Thoracic Vascular Trauma 251

aneurysm formation and subsequent rupture. The traditional approach is through a left thoracotomy with single lung ventilation, however, as noted previously, patients with pulmonary injuries and thoracic wall trauma may not tolerate single-lung ventilation [26-28].

Despite the many advances in peri-operative management and operative techniques, there continues to be a high morbidity and mortality with these injuries. The risk of paraplegia varies from 2.3% with active distal aortic perfusion to over 19% with the "clamp and sew"

The indications for urgent thoracotomy remain hemodynamic instability, continued and significant hemorrhage from an adequately place tube thoracostomy, and rapidly expanding mediastinal hematoma noted on imaging. Certain pre-operative considerations are necessary prior to operative intervention, and include adequate pre-operative preparation, pharmacologic control, choice of incisions, availability of prosthetic material, and surgical repair techniques.

After confirmation of great vessel injury, the patient should expeditiously be prepared for immediate transport to the operating room for definitive surgical vascular control. While in the trauma bay, however, intravenous access should be obtained and cross-matched blood should be sent for; O negative blood should be used for immediate resuscitation efforts along with crystalloid fluids in the judicious manner described previously. Large bore central venous catheters should be placed on the side contralateral to the injury, above and below the

In the operating suite, close collaboration with the anesthesiologists is imperative. A doublelumen endotracheal tube should be placed (or converted to from the single-lumen endotracheal tube), if possible. Induction anesthetic agents can cause a precipitous decline in blood pressure that should be avoided, and artificial elevation of the blood pressure with vaso-active agents is also undesirable, especially when vascular control is not yet achieved. A nasogastric tube should also be inserted if not already done so. An arterial radial line will help with real-time hemodynamic monitoring. Perfusionists and full cardio-pulmonary bypass capabilities and circulatory assistance must be readily available in addition to an auto-transfusion device. A urinary catheter should also be placed. Prophylactic antibiotics

Although all efforts are moving at a fast pace to transport the patient to the operating room, it is essential that the surgeon be forthcoming about the seriousness of the situation and the high potential for post-operative complications with the patient and family whenever possible. The possibility of neurological damage, paraplegia, myocardial infarction,

Use of beta-blockers has become quite commonplace. The goal is to reduce the pressure on the injured aortic wall in order to avoid fatal rupture while maintaining cerebral perfusion.

diaphragm. It should be noted again, however, that no efforts should delay transport.

are administered and tetanus prophylaxis should be ensured.

cerebrovascular accidents, renal failure and death must be discussed.

approach [26]. Mortality rates have been reported between 5% and 28% [28].

*5.3.1. Pre-operative preparation*

*5.3.2. Pharmacologic control*

Successful use of endovascular stents in this patient population requires a sophisticated multidisciplinary and experienced team approach. Strict evaluation of the patient's anatomy is imperative. Current devices were primarily designed to treat aneurysmal disease, which is more prevalent in an aging population. Trauma patients have a considerable young demographic. As such, appropriate "fitting" of commercial devices is not always possible, rendering the use of stent-grafts difficult. Some young patients have aortic diameters less than 20 mm, which are too small for standard devices, even if oversizing the device diameter by the recommended 10-15% is employed. Adolescents and young teens also commonly have an aortic arch with a tight radius of curvature making sufficient apposition suboptimal due to inflexibility of devices. Most importantly, most reports of the use of stentgrafts demonstrate great short- and mid-term results. However, the data is lacking on longterm results, a concern for young patients expected to have a considerable life expectancy following the incident. Such patients will need close follow-up and continued surveillance imaging; the associated cost for the continued evaluation and the radiation burden is a concern [26].

It should be noted that endovascular options such a balloon occlusion, arterial embolization, and stenting or stent-grafting are viable endovascular options for the management of other great vessel trauma, such as the carotid, vertebral, subclavian, and axillary arteries.

#### **5.3. Surgical repair**

The standard of care for treating blunt aortic trauma has been emergent thoracotomy with interposition prosthetic graft or direct aortic repair with either a "clamp and sew" technique or with some variation of circulatory assistance and bypass. The rationale for treating blunt aortic injury is to essentially prevent early rupture from the acute injury and to prevent late aneurysm formation and subsequent rupture. The traditional approach is through a left thoracotomy with single lung ventilation, however, as noted previously, patients with pulmonary injuries and thoracic wall trauma may not tolerate single-lung ventilation [26-28].

Despite the many advances in peri-operative management and operative techniques, there continues to be a high morbidity and mortality with these injuries. The risk of paraplegia varies from 2.3% with active distal aortic perfusion to over 19% with the "clamp and sew" approach [26]. Mortality rates have been reported between 5% and 28% [28].

The indications for urgent thoracotomy remain hemodynamic instability, continued and significant hemorrhage from an adequately place tube thoracostomy, and rapidly expanding mediastinal hematoma noted on imaging. Certain pre-operative considerations are necessary prior to operative intervention, and include adequate pre-operative preparation, pharmacologic control, choice of incisions, availability of prosthetic material, and surgical repair techniques.

#### *5.3.1. Pre-operative preparation*

250 Current Concepts in General Thoracic Surgery

concern [26].

**5.3. Surgical repair**

successful, averts the need for a traditional thoracotomy. It is associated with decreased morbidity and mortality, as has been noted in several studies [23-25]. Blood loss is minimal. Placement of a stent-graft does not require aortic cross clamping, which reduces the risk of distal visceral and spinal ischemia. In addition, such cross-clamping and unclamping complicate resuscitation and anesthesiologist management in patients with circulatory collapse and hemodynamic instability. Respiratory compromise from lung and thoracic wall injuries is magnified by thoracotomy, and single ventilation in such patients may be quite problematic. Furthermore, appropriate positioning for open surgery may compound neurologic deficits in patients with spinal fractures. Although systemic heparinization is usually employed during routine stent-grafting procedures, in cases of polytrauma with concomitant visceral organ injuries and fractures of the pelvis and long bones, heparin is withheld. Importantly with TEVAR, the absence of circulatory assistance with bypass and the need for high systemic doses of heparin, limit the feared hemorrhagic complications. Xenos et al. performed a meta-analysis of seventeen retrospective cohort studies evaluating 589 patients, and indicated that endovascular management of descending thoracic aortic injuries is a viable alternative to traditional open repair; it is associated with decreased

ischemic spinal cord complication rates and lower postoperative mortality [23].

Successful use of endovascular stents in this patient population requires a sophisticated multidisciplinary and experienced team approach. Strict evaluation of the patient's anatomy is imperative. Current devices were primarily designed to treat aneurysmal disease, which is more prevalent in an aging population. Trauma patients have a considerable young demographic. As such, appropriate "fitting" of commercial devices is not always possible, rendering the use of stent-grafts difficult. Some young patients have aortic diameters less than 20 mm, which are too small for standard devices, even if oversizing the device diameter by the recommended 10-15% is employed. Adolescents and young teens also commonly have an aortic arch with a tight radius of curvature making sufficient apposition suboptimal due to inflexibility of devices. Most importantly, most reports of the use of stentgrafts demonstrate great short- and mid-term results. However, the data is lacking on longterm results, a concern for young patients expected to have a considerable life expectancy following the incident. Such patients will need close follow-up and continued surveillance imaging; the associated cost for the continued evaluation and the radiation burden is a

It should be noted that endovascular options such a balloon occlusion, arterial embolization, and stenting or stent-grafting are viable endovascular options for the management of other