Great Vessel Injury

What happens to the great vessels in trauma

The great vessels carry the entire output of the heart. A tear in one of them can lose a large volume of blood within minutes.

Blunt injury happens when the body stops suddenly but the heart and aorta keep moving. The aorta is fixed in place just beyond the arch, at a point called the isthmus, near the ligamentum arteriosum. The shearing force tears the vessel wall there in most survivors of blunt aortic injury. If the outer layer of the wall holds, a contained bulge (pseudoaneurysm) forms that can burst later.

Penetrating injury from knives, bullets or debris can damage any vessel in its path, including the subclavian arteries under the collarbone, the innominate (brachiocephalic) artery, the carotids and the vena cava.

Vessels involved

Signs and symptoms

Many people have other serious injuries that hide the signs. Clues include:

• severe chest or upper back pain, sometimes between the shoulder blades
• signs of hemorrhagic shock: low blood pressure, fast heart rate, pale, cold, sweaty skin, confusion
• a difference in blood pressure or pulse between the two arms, or between arms and legs
• shortness of breath or a hoarse voice from pressure on nearby structures
• a harsh murmur heard over the chest or back
• bruising across the chest from a seat belt, or a fractured breastbone, first rib or shoulder blade, all markers of a high-energy impact
• a cold, pale arm or stroke signs with neck or upper chest wounds

Some people with a contained aortic tear have few symptoms at first. That is why trauma teams scan everyone with a high-risk mechanism of injury.

Diagnosis

• Chest X-ray: may show a widened mediastinum (the central chest space), blood around the lungs (hemothorax) or a blurred aortic outline. A normal X-ray does not rule out injury.
• CT angiography: the main test. It shows the exact site and grade of injury in minutes.
• FAST ultrasound: a quick bedside scan for blood around the heart or in the belly.
• Transesophageal echocardiography: used in the operating room or for patients too unstable to scan.

Aortic injuries are graded from 1 (a small tear in the inner lining) through 2 (intramural hematoma), 3 (pseudoaneurysm) to 4 (free rupture). The grade guides treatment.

Treatment

Immediate care

• Trauma team resuscitation following ATLS principles.
• Permissive hypotension: keeping blood pressure just high enough to supply the organs, to avoid blowing out a fragile clot.
• Blood transfusion, often using a massive transfusion protocol.
• Anti-impulse therapy: IV beta-blockers to lower heart rate and blood pressure, which reduces strain on the torn aortic wall while other injuries are dealt with.
• Emergency surgery to open the chest (thoracotomy) for people who are bleeding uncontrollably.

Repair

• Thoracic endovascular aortic repair (TEVAR): a covered stent is passed up through the groin artery and placed across the tear. It is now the preferred repair for most blunt aortic injuries, with lower death and paralysis rates than open surgery.
• Open surgical repair: for injuries unsuitable for a stent, many penetrating injuries, and vena cava and pulmonary vessel injuries.
• Watchful management: grade 1 tears are usually treated with blood pressure control and repeat CT scans, as many heal without repair.

Complications

• Death from blood loss, which is the leading risk
• Spinal cord injury and paralysis from reduced blood flow to the spinal cord
• Stroke, especially with injuries to the arch branches
• Kidney failure
• Stent problems over time, such as leaks or movement, requiring lifelong scan follow-up

Outlook

Roughly 75% to 80% of people with blunt aortic rupture die before reaching the hospital. Among those who arrive alive, the outlook depends mainly on their other injuries. Since stent repair became standard, survival from the aortic injury itself has improved considerably. Younger patients who have a stent need regular CT or MRI scans for life, because the long-term durability of these grafts in a growing or aging aorta is still being studied.

Prevention

• Always wear a seat belt, including in the back seat; airbags alone do not prevent this injury.
• Keep to speed limits and never drive after alcohol or drugs.
• Wear protective gear and use fall protection when working at height.

Frequently asked questions

What are the great vessels?

The great vessels are the large blood vessels attached to the heart: the aorta, the pulmonary artery, the pulmonary veins, and the superior and inferior vena cava. In trauma, doctors also include the main branches off the aortic arch to the head and arms.

Can you survive an aortic tear from a car accident?

Yes, if the tear is contained and you reach a trauma center quickly. Most deaths happen at the scene. Among people who arrive at the hospital alive, many survive with blood pressure control and a stent graft, although their overall outcome depends on their other injuries.

Why do doctors scan people who feel fine after a high-speed crash?

Because a partial aortic tear can cause few symptoms at first and then rupture hours or days later. A CT angiogram finds these injuries early so they can be treated before rupture. Seat-belt marks and certain fractures increase the level of suspicion.

What is TEVAR?

TEVAR stands for thoracic endovascular aortic repair. A surgeon threads a fabric-covered metal stent through an artery in the groin up to the torn part of the aorta, then expands it to seal the tear from inside. It avoids opening the chest and is now the preferred repair for most blunt aortic injuries.