title: A new classification scheme for treating blunt aortic injury.
abstract: BACKGROUND
  There are numerous questions about the treatment of blunt aortic injury (BAI), including the management of small intimal tears, what injury characteristics are predictive of death from rupture, and which patients actually need intervention. We used our experience in treating BAI during the past decade to create a classification scheme based on radiographic and clinical data and to provide clear treatment guidelines.
  
  
  METHODS
  The records of patients admitted with BAI from 1999 to 2008 were retrospectively reviewed. Patients with a radiographically or operatively confirmed diagnosis (echocardiogram, computed tomography, or angiography) of BAI were included. We created a classification system based on the presence or absence of an aortic external contour abnormality, defined as an alteration in the symmetric, round shape of the aorta: (1) intimal tear (IT)-absence of aortic external contour abnormality and intimal defect and/or thrombus of <10 mm in length or width; (2) large intimal flap (LIF)-absence of aortic external contour abnormality and intimal defect and/or thrombus of ≥10 mm in length or width; (3) pseudoaneurysm-presence of aortic external contour abnormality and contained rupture; (4) rupture-presence of aortic external contour abnormality and free contrast extravasation or hemothorax at thoracotomy.
  
  
  RESULTS
  We identified 140 patients with BAI. Most injuries were pseudoaneurysm (71%) at the isthmus (70%), 16.4% had an IT, 5.7% had a LIF, and 6.4% had a rupture. Survival rates by classification were IT, 87%; LIF, 100%; pseudoaneurysm, 76%; and rupture, 11% (one patient). Of the ITs, LIFs, and pseudoaneurysms treated nonoperatively, none worsened, and 65% completely healed. No patient with an IT or LIF died. Most patients with ruptures lost vital signs before presentation or in the emergency department and did not survive. Hypotension before or at hospital presentation and size of the periaortic hematoma at the level of the aortic arch predicted likelihood of death from BAI.
  
  
  CONCLUSIONS
  As a result of this new classification scheme, no patient without an external aortic contour abnormality died of their BAI. ITs can be managed nonoperatively. BAI patients with rupture will die, and resources could be prioritized elsewhere. Those with LIFs do well, and currently, most at our institution are treated with a stent graft. If a pseudoaneurysm is going to rupture, it does so early. Hematoma at the arch on computed tomography scan and hypotension before or at arrival help to predict which pseudoaneurysms need urgent repair.
authors: Division of Vascular Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA. starnes@u.washington.edu
authors: Benjamin W
authors: BW
authors: Starnes
authors: Rachel S
authors: RS
authors: Lundgren
authors: Martin
authors: M
authors: Gunn
authors: Samantha
authors: S
authors: Quade
authors: Thomas S
authors: TS
authors: Hatsukami
authors: Nam T
authors: NT
authors: Tran
authors: Nahush
authors: N
authors: Mokadam
authors: Gabriel
authors: G
authors: Aldea
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000145:classification / Q000000981:diagnostic imaging / Q000601:surgery; D017541:Aneurysm, False / Q000145:classification / Q000000981:diagnostic imaging / Q000601:surgery; D001011:Aorta / Q000293:injuries / Q000503:physiopathology / Q000601:surgery*; D001014:Aortic Aneurysm / Q000145:classification / Q000000981:diagnostic imaging / Q000601:surgery; D001019:Aortic Rupture / Q000145:classification / Q000000981:diagnostic imaging / Q000601:surgery; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D002648:Child; D003661:Decision Support Techniques; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006406:Hematoma / Q000000981:diagnostic imaging; D006439:Hemodynamics; D017052:Hospital Mortality; D006801:Humans; D007022:Hypotension / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D057772:Vascular System Injuries / Q000145:classification* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D014861:Washington; D014949:Wounds, Nonpenetrating / Q000145:classification* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D055815:Young Adult