Guideline sources The following summarized guidelines for the evaluation and management of traumatic thoracic aortic injury (TTAI) are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2022), the Society of Interventional Radiology (SIR 2020), the American College of Radiology (ACR 2020), the Society of Critical Care Medicine (SCCM 2016), the Eastern Association for the Surgery of Trauma (EAST 2015), the European Society of Cardiology (ESC 2014), and the Society for Vascular Surgery (SVS 2011). 1 2 3 4 5 6 7 8 Calculator NEXUS criteria for chest X-ray in Guidelines 1. Diagnostic investigations https://web.pathway.md/diseases/rec5Q0gsfy9na8aii 1/5 6/24/23, 4:08 PM Traumatic thoracic aortic injury Pathway Chest imaging: As per ACR 2020 guidelines: Obtain a CXR and chest CT with IV contrast or chest CT angiography as complementary first- line imaging modalities in hemodynamically stable patients with suspected cardiac injury following blunt chest trauma. B Obtain a CXR, chest CT with IV contrast, chest CT angiography, and cardiac CT with IV contrast as complementary imaging modalities in hemodynamically unstable patients with suspected cardiac injury following blunt chest trauma. B As per EAST 2015 guidelines, obtain contrast-enhanced chest CT in patients with suspected blunt traumatic aortic injury. A As per ESC 2014 guidelines, obtain CT in patients with suspected traumatic aortic injury. B Cardiac imaging: As per ACR 2020 guidelines, obtain a TTE in patients (either hemodynamically stable or unstable) with suspected cardiac injury following blunt chest trauma. B As per ESC 2014 guidelines, consider obtaining a TEE in patients with suspected traumatic aortic injury if CT is not available. C 2. Medical management Setting of care: manage and treat patients with blunt TTAI at a trauma center with the facilities and expertise to treat aortic pathology. B Expectant management: As per ACC 2022 guidelines: Offer nonoperative management and follow-up imaging in patients with grade 1 blunt TTAI. B Consider offering nonoperative management and follow-up surveillance imaging in patients with grade 2 blunt TTAI without high-risk imaging features. C As per SVS 2011 guidelines, consider offering expectant management with serial imaging in patients with type I aortic injuries (intimal tear). C Anti-impulsive therapy: As per ACC 2022 guidelines, initiate anti-impulse therapy to reduce the risk of injury extension and rupture in patients with blunt TTAI, except with hypotension or hypovolemic shock. B As per SIR 2020 guidelines, initiate antihypertensive and anti-impulse medications with close symptomatic and/or radiographic follow-up in patients with grade 1-2 aortic injuries (minimal aortic injury). B 3. Nonpharmacologic interventions Physical activity: provide education and guidance about avoiding intense isometric exercises (such as heavy weightlifting or activities requiring the Valsalva maneuver), burst exertion and https://web.pathway.md/diseases/rec5Q0gsfy9na8aii 2/5 6/24/23, 4:08 PM Traumatic thoracic aortic injury Pathway activities, and collision sports in patients with significant aortic disease. B Psychosocial support: consider screening for anxiety, depression, and posttraumatic stress disorder in patients with clinically significant aortic disease and provide resources for support when indicated. Consider providing education and resources to minimize patients' concerns, support optimal decision-making, and enhance the quality of life. C 4. Perioperative care Choice of anesthesia: consider administering general anesthesia for TEVAR. C Thromboprophylaxis: consider administering routine systemic heparin for thoracic endovascular repair of traumatic aortic injuries but at a lower dose than in elective TEVAR. C 5. Surgical interventions Resuscitative thoracotomy: Consider performing emergency department thoracotomy in patients presenting pulseless to the emergency department with signs of life after blunt injury. C Avoid performing emergency department thoracotomy in patients presenting pulseless to the emergency department without signs of life after blunt injury. D Thoracic endovascular aortic repair, indications: As per AHA/ACC 2022 guidelines: Perform an aortic intervention in patients with grade 3-4 blunt TTAI and nonprohibitive comorbidities or injuries. B Consider performing an aortic intervention in patients with grade 2 blunt TTAI with high-risk imaging features. C As per SIR 2020 guidelines, perform an aortic intervention in patients with anatomically favorable grade 3-4 aortic injuries. B Thoracic endovascular aortic repair, timing: As per EAST 2015 guidelines, consider performing delayed repair in patients diagnosed with blunt traumatic aortic injury while ensuring effective BP control with antihypertensive medications. C As per SVS 2011 guidelines, consider performing urgent (< 24 hours) repair at the latest before hospital discharge. C Thoracic endovascular aortic repair, choice of approach: As per AHA/ACC 2022 guidelines, perform TEVAR over open repair in patients with blunt TTAI with appropriate anatomy meeting indications for repair. B As per SIR 2020 guidelines, perform emergent TEVAR in patients with anatomically favorable grade 3-4 aortic injuries. B https://web.pathway.md/diseases/rec5Q0gsfy9na8aii 3/5 6/24/23, 4:08 PM Traumatic thoracic aortic injury Pathway As per EAST 2015 guidelines, perform endovascular repair in patients with blunt traumatic aortic injury without contraindications to endovascular repair. A As per ESC 2014 guidelines, perform TEVAR over open surgery in patients with traumatic aortic injury with suitable anatomy requiring intervention. B As per SVS 2011 guidelines, consider performing endovascular repair over open surgical repair or nonoperative management in patients with traumatic thoracic aortic injuries requiring intervention. Consider performing endovascular repair regardless of age if anatomically suitable. C Thoracic endovascular aortic repair (technical considerations): Consider using the femoral access technique. C Avoid performing routine spinal drainage. D Left subclavian artery revascularization: consider performing selective revascularization of the left subclavian artery. C 6. Specific circumstances Patients with penetrating injury (bedside echocardiography): obtain bedside echocardiography in hemodynamically stable patients with penetrating chest trauma. B Patients with penetrating injury (emergency department thoracotomy): Perform emergency department thoracotomy in patients presenting pulseless to the emergency department with signs of life after penetrating thoracic injury. B Consider performing emergency department thoracotomy in patients presenting pulseless to the emergency department without signs of life after penetrating thoracic injury. C 7. Follow-up and surveillance Surveillance imaging: Consider obtaining surveillance imaging at intervals appropriate for the repair approach and location after aortic repair in patients with blunt traumatic aortic injury. C Consider obtaining surveillance CT at 1 month, 6 months, and 12 months after the diagnosis and, if stable, at appropriate intervals thereafter (depending on the type and extent of the injury) in patients with unrepaired blunt traumatic aortic injury. C References 1. Erbel R, Aboyans V, Boileau C et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology ESC . Eur Heart J. 2014 Nov 1;35 41 2873 926. Open https://web.pathway.md/diseases/rec5Q0gsfy9na8aii 4/5 6/24/23, 4:08 PM Traumatic thoracic aortic injury Pathway 2. Alexander Levitov, Heidi L Frankel, Michael Blaivas et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II Cardiac Ultrasonography. Crit Care Med. 2016 Jun;44 6 1206 27. Open 3. Eric M Isselbacher, Ourania Preventza, James Hamilton Black rd et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Nov 2. Open 4. W Anthony Lee, Jon S Matsumura, R Scott Mitchell et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011 Jan;53 1 187 92. Open 5. Siddharth A Padia, Christopher R Ingraham, John M Moriarty et al. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol. 2020 Mar;31 3 363 369.e2. Open 6. Expert Panels on Cardiac Imaging and Thoracic Imaging, Jadranka Stojanovska, Lynne M Hurwitz Koweek et al. ACR Appropriateness Criteria Blunt Chest Trauma-Suspected Cardiac Injury. J Am Coll Radiol. 2020 Nov;17 11S S380 S390. Open 7. Fox N, Schwartz D, Salazar JH et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jan;78 1 136 46. Open 8. Mark J Seamon, Elliott R Haut, Kyle Van Arendonk et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul;79 1 159 73. Open 9. C dric Carri , Benjamin Rieu, Antoine Benard et al. Early non-invasive ventilation and high-flow nasal oxygen therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients: the OptiTHO randomized trial. 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