American Association for the Surgery of Trauma–World Society of Emergency Surgery guidelines on the diagnosis and management of major thoracic vascular injuries
Year: 2025
Type: article
Abstract: In the United States, 7% of patients arriving at adult level 1 trauma centers are diagnosed with a torso vascular injury, and about half of these cases will present with hemorrhage.1 Hemorrhage is the leading cause of potentially preventable death following trauma.2,3 Noncompressible torso hemorrhage (NCTH) from vessels in the thorax, abdomen, and pelvis is especially lethal, with death occurring in approximately 45% of cases. Blunt and penetrating mechanisms account for 65% and 35% of NCTH, respectively.1 In one retrospective multicenter NCTH study, the chest was involved in 25% of cases. The most common bleeding vessels in the chest were the descending thoracic aorta (45%), intercostal/internal thoracic arteries (12%), ascending aorta (11%), right subclavian (7.3%), left subclavian (5%), pulmonary artery (4%), and subclavian vein (4%). The aortic arch, left and right carotid arteries, pulmonary vein, superior vena cava (SVC), and innominate vein were injured in less than 2% of cases. The most common cause of death after NCTH was exsanguination at a median time of 2 hours after presentation.4 This underscores the importance of expeditious assessment, diagnosis, and management of these patients. Thoracic vessels that are injured but are not bleeding initially may result in thrombus formation, occlusion, or delayed hemorrhage and demand similar attention. The purpose of this document is to provide the American Association for the Surgery of Trauma and the World Society of Emergency Surgery recommendations for the diagnosis and management of thoracic vascular injuries (TVIs). METHODS A computerized search was done using different databases (Medline, Embase, Cochrane). Citations were included for the period between January 2013 and January 2025 using the primary search strategy: trauma, blunt, penetrating, blood vessel, vascular injury, chest, thoracic, aorta, subclavian artery, subclavian vein, heart, pulmonary artery, pulmonary vein, innominate artery, innominate vein, aortic arch, great vessels, superior vena cava, inferior vena cava, resuscitative thoracotomy, thoracotomy, sternotomy, pericardiotomy, injury, surgery, diagnosis, operative, nonoperative, shunting, shunt, endovascular, anticoagulant, antiplatelet, focused assessment with sonography for trauma, and focused assessment with sonography in trauma, combined with and/or as well as the MeSH terms: thoracic injuries, thoracic aorta dissection, endovascular procedures, thoracotomy, and sternotomy. No search restrictions were imposed. The dates were selected to allow comprehensive published abstracts of clinical trials, consensus conferences, comparative studies, congresses, guidelines, government publications, multicenter studies, systematic reviews, meta-analyses, large case series, original articles, and randomized controlled trials. Selected older articles considered landmark papers in the field were also included. Three authors independently reviewed abstracts chosen for relevance, and any discrepancies between reviewers were settled after a discussion. The level of evidence was evaluated using a modified form of the Grading of Recommendations Assessment, Development, and Evaluation system (Table 1).5 A group of experts in the field, coordinated by a central coordinator, was contacted to express their evidence-based opinions on several issues about TVI. Based on the evidence available, the central coordinator assembled the different answers derived from a round of discussion and created a set of recommendations. The recommendations were submitted for comments multiple times using an online modified Delphi process until complete consensus was achieved. The definitive version reported herein represents the position of the expert group from both the American Association for the Surgery of Trauma and the World Society of Emergency Surgery. An executive summary of the guidelines can be found in Supplemental Digital Content (Supplementary Data 1, https://links.lww.com/TA/E993) as well as a list of abbreviations used in this article (Supplementary Data 2, https://links.lww.com/TA/E994). TABLE 1 - Modified System for GoR5 GoR Clarity of Risks/Benefit Quality of Supporting Evidence Implications 1A Strong recommendation, high-quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, applies to most patients in most circumstances without reservation 1B Strong recommendation, moderate-quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs with important limitations (inconsistent results, methodological flaws, indirect analyses or imprecise conclusions) or exceptionally strong evidence from observational studies Strong recommendation, applies to most patients in most circumstances without reservation 1C Strong recommendation, low-quality or very low-quality evidence Benefits clearly outweigh risk and burdens, or vice versa Observational studies or case series Strong recommendation but subject to change when higher quality evidence becomes available 2A Weak recommendation, high-quality evidence Benefits closely balanced with risks and burden RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values 2B Weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burden RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values 2C Weak recommendation, low-quality or very low-quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Observational studies or case series Very weak recommendation; alternative treatments may be equally reasonable and merit consideration GoR, grading of recommendations; RCT, Randomized controlled trial. RESULTS Epidemiology What Is the Incidence of Major Vascular Injury in Blunt Chest Trauma? Statement: Blunt mechanisms of injury are responsible for more than 60% of cases of TVI, but this varies by geography. The thoracic aorta is the most commonly injured vessel, followed by the innominate/subclavian arteries and the pulmonary artery in a minority of cases. Most blunt thoracic aortic injuries (BTAIs) are located distal to the takeoff of the left subclavian artery (LSA) at the level of the ligamentum arteriosum. Injuries to the ascending aorta, SVC, thoracic inferior vena cava, and azygous vein are infrequent after blunt trauma. The incidence of TVI is less than 1% in pediatric and adult civilian trauma patients who reach the hospital and is more common in adults than in pediatric patients.6–11 Blunt trauma is the cause of 62% of TVI in the United States and 77% in Australia.6,12 The epidemiology of injury prevalence and mechanism varies by geographic region. Still, it is typically related to deceleration injury resulting in a spectrum of vessel wall disruption from intimal tears to complete rupture.13 In patients sustaining TVI, the aorta is injured in approximately 80% of patients, followed by the innominate and subclavian vessels in 11% and the pulmonary vessels in 5%.6,14 The absolute incidence of TVI in trauma is much higher, as many patients do not survive to reach the hospital alive. Blunt thoracic aortic injury is the second most common cause of death in blunt trauma after head injury. It has been identified in a third of blunt traumatic fatalities, and an estimated 80% die at the scene of injury. Most injuries occur at the aortic isthmus, which extends from the origin of the LSA to the insertion of the ligamentum arteriosum. The ascending aorta is injured in less than 5% of patients sustaining BTAI who survive transport but is identified more frequently in autopsy patients and is associated with cardiac injury.15,16 Blunt injuries to the thoracic inferior vena cava (TIVC), the SVC, and the azygous vein are not commonly seen by health care providers, as they are associated with severe nonsurvivable injuries. Blunt injuries to the proximal carotid arteries are also uncommon.16,17 What Are the Most Common Injury Mechanisms in Blunt TVI? Statement: Blunt TVIs occur after high-energy transfer mechanisms of injury such as MVCs, falls from height, and pedestrians struck by an auto. Blunt thoracic aortic injuries are frequently observed in head-on collisions and T-bone crashes. They are usually accompanied by other severe injuries such as traumatic brain injury (TBI), intra-abdominal solid organ injury, and pelvic fractures. The most common blunt injury mechanisms in TVI are motor vehicle collisions (MVCs) in 83% of patients and falls from height in 6% of patients.6,12 In a large multicenter prospective study, BTAI occurred following MVC in 81%, autopedestrian accidents in 7%, and falls from height in 3%. Of the BTAIs diagnosed after MVC, 72% occurred after a head-on collision, 24% after a side impact, and 4% after a rear impact.18 Because of the nature of these high-energy mechanisms, 80% of BTAIs are accompanied by other concomitant life-threatening injuries.8,19 These include TBI (20–31%), abdominal injury (28–29%), and pelvic injury (15–35%).7,20 Nonaortic great vessel mechanisms of injury are similar: blunt innominate artery and left carotid injuries tend to be more proximal, while left subclavian injuries tend to be more distal.13 What Is the Incidence of TVI in Penetrating Chest Trauma? Statement: Penetrating injury mechanisms are responsible for 40% of all TVIs and carry a high mortality rate because of massive bleeding. Other associated intrathoracic injuries are common. In US adults, 38% of TVI occurs after penetrating trauma, mostly from gunshot (53%) and stab wounds (30%). The aorta is injured in 27%, the innominate and subclavian vessels in 24%, the pulmonary vessels in 17%, the internal mammary in 12%, and the SVC in 8%.6 Penetrating TVI is more common in Latin America than in the United States and Europe.21,22 Penetrating injuries typically result in vessel laceration or transection, resulting in hemorrhage and high mortality.1,10,17,23 Notably, the subclavian veins are anterior and medial to the arteries and are concurrently injured in approximately 20% of cases.17 Penetrating thoracic aorta injuries (PTAIs) are commonly associated with injuries to the heart, esophagus, diaphragm, and vena cava.10 Clinical Presentation and Diagnosis What Is the Optimal Initial Evaluation of a Patient With Suspected TVI? Statement: The optimal initial evaluation of a patient with suspected TVI includes concomitant (hemostatic) resuscitation and assessment of life-threatening injuries, including tension pneumothorax, massive hemothorax, exsanguinating hemorrhage, and cardiac tamponade. A chest x-ray (CXR) may intrathoracic and of BTAI and or in the and the of a subclavian artery injury. 1C The initial evaluation is the as with any trauma patient and with the assessment of and Vascular be to allow for the of blood hemorrhage is suspected as well as other and as of life-threatening associated injuries, such as tension or massive hemothorax, cardiac or hemorrhage, is In blunt injuries, be a high of concomitant and to the is In penetrating injuries, all wounds to for concomitant injuries in the abdomen, or with a be but it is for TVI. A can chest wall injuries, trauma, pneumothorax, hemothorax, pulmonary and as well as management without the to transport a potentially Evidence of BTAI on includes left of the left of the aortic or These when but their not artery injury may result in a or but these are present in 20% to of patients. or as well as from injury, also for subclavian vessel What Is the of in Chest Trauma? Statement: The focused assessment with sonography in trauma may and hemothorax, and intra-abdominal without such as chest or A chest is the for TVI and be in patients. patients 1C The the for and the chest for pneumothorax, and it not that are on such as or for tension or to the for a focused assessment with sonography in trauma be used in all blunt thoracic patients because of the of concomitant abdominal trauma and to in the patient the or or with in the patient or in the The of in penetrating thoracic trauma is to patients to for cardiac injury and tamponade. patients which not be delayed with such as while the has high and for cardiac injury and is a of a because of of the the be a high of for cardiac injury in patients with wounds to the and an associated a and hemorrhage from chest are patients with penetrating injuries to the chest to vascular are guidelines for the optimal of blunt chest trauma patients. The Chest that all blunt trauma patients with an chest as of these patients a thoracic injury vascular identified on patients with a a of the chest can be considered for patients with injuries, thoracic wall chest thoracic and or a deceleration mechanism of injury. with a and one a of with a These to and 25% the was large that of blunt trauma patients with a a injury on The Association for the Surgery of Trauma and the Trauma Association all blunt trauma patients with high-energy deceleration or mechanisms with this on clinical and a of definitive for optimal is the of for blunt and penetrating TVI. It has a to and a to in of TVI include dissection, transection, and is of a subclavian artery injury, be the to and can also be but these are more and may be used in patients with a high of vascular injury to endovascular at diagnosis or in the of or that cause on a Chest in Chest Trauma? Statement: is in patients with suspected or diagnosed large or tension and large In be on clinical diagnosis, and a or not 1B a chest be for the patient with suspected or is a clinical diagnosis on and the trauma not on to the diagnosis with and can and a chest can the diagnosis of An of less than to may be observed without but this is for for the are Chest What Are the for Statement: than of chest for or of chest for 1B Initial chest can be used to patients an initial chest of or to for the 2 to hours with has been to with the and rate of blood the chest of clinical is the best of the for with cardiac and arriving in resuscitative who are and with hemorrhage from their chest also A large after may blood and in an patients who or vessel on endovascular or With TVI Are With Statement: The Society of Vascular Surgery BTAI and are usually aortic in selected circumstances, be but with associated TBI may BTAI because of by used to the tension in the aortic and innominate artery injuries similar management for Penetrating thoracic aorta injury is associated with and is 1C The a BTAI grading and (Table injuries and can be with in with concomitant severe may be the to and brain injury. is evidence that management may also be considered for patients with injuries without who and who are to be with for In one 4% of selected patients with for injury and mortality was 2% of These studies as less than of the aortic or by the the optimal and for for not been well with injuries not to or delayed which is by the of concomitant injuries and the for injuries be In the for of BTAI be to endovascular and for TABLE 2 - Injury Grading for BTAI No intimal or intimal LSA the grading system is the most other grading been to the management of The grading system a of and severe aortic injury on aortic and the of an intimal or injuries can be with with delayed and severe with In one study, the high with the grading one in or injuries were or the for clinical in intimal tears or The management of patients with BTAI and TBI for BTAI aortic wall tension with to blood and rate In optimal TBI management mortality of patients more that is less and the importance of a and to these patients, who an mortality of grading of injury may also be to blunt injuries of the innominate and subclavian arteries, from injury the to of vessel laceration depending on the transection, and injuries, including intimal tears and account for 25% to 40% of injuries and may as well as cases of subclavian artery in the of to blood or vessel merit injuries been using a grading system by The management of blunt injuries is Blunt injury to the pulmonary artery is but of may be the of the pulmonary are cases of and with What Is the Optimal for TVI? What Is the Optimal for Statement: is the of in the of and it be as as and as by concomitant injuries. be in an care An is as of the of subclavian and innominate artery injuries, followed by 1C In BTAI patients, is at which to aortic wall by rate and blood This is typically with such as to a rate between and and blood of not other such as or or can be be as because of the risk of which can aortic wall as as in the of clinical and other life-threatening in patients with concomitant be balanced with the risk of TBI because of be in an care for the to hours after BTAI and of the injury is on patients can be to an not well also using in of BTAI for several In subclavian or other vessel injury, of an typically of and this has not been well subclavian artery injury in the be What Is a of Statement: or and aortic injury to in the on a of 1C of BTAI occurs in 5% to of cases but a injury to a injury on the patient An change in patient including and for and expeditious or depending on the and of the initial injury. In subclavian artery injuries or other evidence of or of TVI? Statement: Blunt thoracic aortic injuries be hours to injury and at 1 and to document after hospital with or be to injury and innominate artery injuries be at the time of from the 2C be to hours of also be on to Most injuries after which can be The Society for Vascular Surgery guidelines until BTAI is is evidence that 1 injuries may not not well it is reasonable to other great vessel injuries with to What Are the for TVI? Statement: Thoracic endovascular aortic is the treatment of for BTAI when management is It is associated with risk of hospital and similar with BTAI An initial of with is in patients with associated injuries, for to patients sustaining Thoracic endovascular aortic may be in patients. can be considered in patients with other most commonly the subclavian Most penetrating TVIs are associated with hemorrhage and and Thoracic vascular injury management centers with to endovascular can be considered for patients with suspected subclavian artery injuries. injuries, including intimal tears and may injuries including large or vessel merit is used most chest all TVIs were with as endovascular and the of endovascular to vascular trauma has The and of was in of BTAI by this to of for BTAI has also been seen in other and 25% of innominate or subclavian artery injuries endovascular The rate of endovascular subclavian is by 5% The of on patient injury the of injury, and the and of the trauma Thoracic endovascular aortic is the of care for are prospective randomized clinical and for several studies risk of and of with similar with The most of the American of Trauma Quality on patients for BTAI risk of to the to aortic and risk of of on clinical of injury, and of severe concomitant injuries. with injuries with BTAI who do not concomitant injuries also may with with associated injuries or who resuscitation delayed to hours is and has been associated with may be by including the of injury in the ascending aorta or aortic arch, the and of aortic and and quality of the LSA is in to of which may to and of the left including carotid to subclavian can high LSA and endovascular at the time of are important of In retrospective studies, was TBI patients be to an care for of and vascular vessel and can be with of rate and blood Thoracic endovascular aortic is also used for most of these patients will present in or with for diagnosis of their injury may be for are prospective randomized clinical endovascular and for subclavian artery injuries. several retrospective studies the and of endovascular for blunt and penetrating A large retrospective of cases of subclavian artery injuries that endovascular management has been associated with mortality and for with in subclavian artery injuries has been for patients who to centers with the and with prevalence of and patients with injuries and in also from an endovascular using a can be used for subclavian occlusion, transection, or and has are especially in proximal of the or as a such as with than vessel and complete may not be to endovascular of subclavian artery endovascular are in 2 and and an of endovascular of BTAI is in artery after chest trauma. subclavian of with artery after chest trauma. Chest large subclavian artery of subclavian artery with large endovascular with the injury Blunt trauma aortic injury after chest trauma. Chest Chest of may also be considered for blunt penetrating innominate or proximal carotid artery injuries, the is Blunt ascending aorta and injuries typically complete the of endovascular for of the ascending aorta and aortic is a subject of and may in TVIs and What Is the Optimal Statement: is in patients and when endovascular and are in with intrathoracic bleeding usually an thoracotomy, which may be the to the right chest In patients, injury the 1B is the patient is and for endovascular to the injury or patient is not to endovascular or endovascular and are The of will on the and the injury is Most patients, after penetrating injury, will be and will as the initial with evaluation for associated cardiac or pulmonary injury. This can be to a is suspected bleeding in the chest or for and to the origin of the great In patients, the will on the of the injury. The ascending aorta, aortic arch, innominate artery, proximal common carotid artery, right subclavian artery and pulmonary vessels are a median sternotomy. In the descending aorta is a at the subclavian artery injuries can be by an at the third or or the injury to the artery is primary is injuries may with or with a the vessel injuries to the ascending aorta, aortic arch, and pulmonary vessels Injuries to the innominate artery typically with a from the ascending aorta to the distal innominate Injuries to the descending aorta are and associated with a 2% to incidence of when is the time is estimated at less than a left is the and or injuries less than of the vessel are best with without vessel or injuries may be with a vein or or and primary with or without depending on the of the and are including may be when injuries are to their of the vein is the is injury, most veins can be without A injured innominate vein may be but of both veins is to cause SVC subclavian vein injuries are and is vein injuries are and typically Injuries to the SVC and are best with primary injuries may with or Most injuries to the What Is the for by Statement: after for BTAI are but include and of the left because of the of the LSA by the for subclavian and innominate artery injuries are 2C Thoracic endovascular aortic after BTAI time as has the most common to LSA and which occur in 4% to of patients, of which to a third Other including or are are and in this patient is In a comparative from with the and after hospital as surgery, with a rate of following endovascular of the subclavian artery are including and on are also What Is the Optimal for Statement: for or at 1 and is is about the for after for BTAI because of the risk of and the between injury and are guidelines for after or endovascular of the subclavian 2B The at 1 and after for with is any of The or after for BTAI at 1 and for is the of for BTAI patients their the nature of injury to and available, may be for in patients or with is evidence of aortic associated with but the clinical of these is The a discussion between the patient and the The and also or after of the thoracic aorta, and it reasonable to this recommendation to after of the innominate artery as are guidelines for after or endovascular of the subclavian guidelines for procedures, a reasonable be a with and or at and Thoracic vascular injury is a but and diagnosis is in endovascular treatment to in for The of is also are which are the is to the and after endovascular Penetrating injuries demand assessment and management to The trauma be well in the to vascular and expeditious
Authors: Leslie Kobayashi, Louis Perkins, Will Johnston, Lisa Kurth, Kendra Black, Fikri Abu-Zidan, Goran Augustin, Zsolt J. Balogh, Walter L. Biffl, L. D. Britt, Fausto Catena, Ian Civil, Federico Coccolini, Dimitris Damaskos, Nicola De'Angelis, Belinda De Simone, Joseph M. Galante, Adenauer M. O. Góes, Jose Gustavo Parreira, Timothy Hardcastle, Kenji Inaba, Andrew Kirkpatrick, Yoran Kluger, Ari Leppäniemi, Ron Maier, Ernest E. Moore, Andrew B. Peitzman, Mauro Podda, Massimo Sartelli, Thomas M. Scalea, Philip Stahel, Edward Tan, Matti Tolonen, Dieter Weber, Raul Coimbra
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W7124153990