Minimal aortic injury after blunt trauma: selective nonoperative management is safe

An increasing number of minimal aortic injuries (MAIs) are being identified with modern computed tomography (CT) imaging techniques. The optimal management and natural history of these injuries are unknown. We have adopted a policy of selective multidisciplinary nonoperative management of MAI. This study examines our experience with these patients from July 2004 to June 2009.

Retrospective chart review of all blunt trauma patients who underwent chest CT angiography to evaluate for blunt aortic injury (BAI) was undertaken. All patients deemed to have a MAI were managed nonoperatively, and those with a severe aortic injury underwent repair. Data collected included age, mechanism of injury, Injury Severity Score, type and location of aortic injury, intensive care unit length of stay (LOS), overall LOS, ventilator days, disposition, and mortality. In addition, all BAIs were graded according to the Presley Trauma Center CT Grading System of Aortic Injury.

Forty-seven patients with BAI were identified. Thirty-two were classified as severe injuries, and 15 were considered MAI (32%). Nineteen underwent operative repair, 13 underwent endovascular stent graft repair, and 15 were managed nonoperatively. The average Injury Severity Score was 31 ± 10, and the average age was 44 ± 20 with no significant difference across treatment groups. There was no difference in overall or intensive care unit LOS. The nonoperative group had a shorter duration of ventilator days (1.1 vs. 4.28, p = 0.02). There were five deaths, none in the nonoperative group. None of these patients required subsequent intervention. All nonoperative patients had follow-up imaging at median of 4 days; on CT chest angiography, five injuries had resolved, eight had stable intimal flaps or pseudoaneurysm, and two had no detectable injury on subsequent aortogram.

Almost one-third of our BAI were safely managed nonoperatively. Patients with MAI should be considered for selective nonoperative management in a multidisciplinary approach with close radiographic follow-up. We recommend that patients with MAIs should be considered for selective nonoperative management.