Presentation
30 year old male was stabbed to the left upper chest. A CT trauma series was performed.
Patient Data
Conclusion
- The knife tract extends from anterior first inter-costal space through the anterior segment of the left upper lobe to eventually reach the mediastinum where there is evidence of a traumatic aortic injury, with active extravasation of contrast from the lateral wall of the aortic arch between the origins of the left common carotid and left subclavian arteries.
- There is extensive mediastinal hematoma tracking down along the aortic root. Small hemopericardium also noted. The anterior mediastinal hematoma distorts the right ventricle, and probably causes elevation of right heart pressures, as there is reflux of intravenous contrast down a dilated IVC and into the hepatic veins.
- Small to moderate size left hemopneumothorax with associated left basal compressive atelectasis. No osseous injury evident.
- Left anterior chest wall subcutaneous emphysema noted.
Case Discussion
Penetrating aortic injury is the second most common type of aortic injury after blunt trauma. Stab wounds and gunshot wounds are the two most common penetrating mechanisms.
Typically, thoracic aortic injury is associated with a very poor prognosis with 92.3% mortality compared to 76.1% for abdominal aortic injuries 1.
Since the 1990's, there has been a shift away from open surgical repair of aortic injury. Instead, thoracic endovascular aortic repair (TEVAR) has gradually replaced open repair as the mainstay of operative aortic injury management2. It is associated with significantly lower operative times, procedural blood loss and intraoperative blood transfusion compared to open repair.
In this case, the knife wound has penetrated from the anterior chest through to the aortic arch. There is contrast extravasating into the mediastinum, with a flap of hypodense intimal tissue in the lumen of the aorta. There is gross haemomediastinum.
Case contributed by A/Prof. Pramit Phal.
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