Thoracic Aorta Injury and Acute Aortic Syndrome
PDF

Review

Thoracic Aorta Injury and Acute Aortic Syndrome

Turk Radiol Semin 2025;13(2):268-280 DOI: 10.4274/trs.2025.24186
,
PDF
Permissions

Abstract

Thoracic aorta injuries and acute aortic syndrome (AAS) are thoracic aorta emergencies that require rapid diagnosis and management. Advances in computed tomography have provided a significant improvement in the diagnosis of both thoracic aorta injuries and AAS. In this review, the radiological findings and differential diagnoses of acute thoracic aorta injuries and AAS will be reviewed.

Keywords: Thoracic aorta, aortic dissection, aortic intramural hematoma, penetrating atherosclerotic ulcer, computed tomography angiography

References

1

Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008; 248: 748-62.

2

Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA, et al. Prospective study of blunt aortic injury: multicenter trial of the American association for the surgery of trauma. J Trauma. 1997; 42: 374-80; discussion 380-3.

3

Steenburg SD, Ravenel JG. Acute traumatic thoracic aortic injuries: experience with 64-MDCT. AJR Am J Roentgenol. 2008; 191: 1564-9.

4

Fleischmann D, Mitchell RS, Miller DC. Acute aortic syndromes: new insights from electrocardiographically gated computed tomography. Semin Thorac Cardiovasc Surg. 2008; 20: 340-7.

5

Richens D, Field M, Neale M, Oakley C. The mechanism of injury in blunt traumatic rupture of the aorta. Eur J Cardiothorac Surg. 2002; 21: 288-93.

6

Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med. 2008; 359: 1708-16.

7

Azizzadeh A, Keyhani K, Miller CC 3rd, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg. 2009; 49: 1403-8.

8

Monga A, Patil SB, Cherian M, Poyyamoli S, Mehta P. Thoracic trauma: aortic injuries. Semin Intervent Radiol. 2021; 38: 84-95.

9

Gutierrez A, Inaba K, Siboni S, Effron Z, Haltmeier T, Jaffray P, et al. The utility of chest X-ray as a screening tool for blunt thoracic aortic injury. Injury. 2016; 47: 32-6.

10

Fishman JE, Nuñez D Jr, Kane A, Rivas LA, Jacobs WE. Direct versus indirect signs of traumatic aortic injury revealed by helical CT: performance characteristics and interobserver agreement. AJR Am J Roentgenol. 1999; 172: 1027-31.

11

Kapoor H, Lee JT, Orr NT, Nisiewicz MJ, Pawley BK, Zagurovskaya M. Minimal aortic injury: mechanisms, imaging manifestations, natural history, and management. Radiographics. 2020; 40: 1834-47.

12

Yaniv G, Portnoy O, Simon D, Bader S, Konen E, Guranda L. Revised protocol for whole-body CT for multi-trauma patients applying triphasic injection followed by a single-pass scan on a 64-MDCT. Clin Radiol. 2013; 68: 668-75.

13

Mokrane FZ, Revel-Mouroz P, Saint Lebes B, Rousseau H. Traumatic injuries of the thoracic aorta: the role of imaging in diagnosis and treatment. Diagn Interv Imaging. 2015; 96: 693-706.

14

Bruckner BA, DiBardino DJ, Cumbie TC, Trinh C, Blackmon SH, Fisher RG, et al. Critical evaluation of chest computed tomography scans for blunt descending thoracic aortic injury. Ann Thorac Surg. 2006; 81: 1339-46.

15

Patel NR, Dick E, Batrick N, Jenkins M, Kashef E. Pearls and pitfalls in imaging of blunt traumatic thoracic aortic injury: a pictorial review. Br J Radiol. 2018; 91: 20180130.

16

Ait Ali Yahia D, Bouvier A, Nedelcu C, Urdulashvili M, Thouveny F, Ridereau C, et al. Imaging of thoracic aortic injury. Diagn Interv Imaging. 2015; 96: 79-88.

17

Forman MJ, Mirvis SE, Hollander DS. Blunt thoracic aortic injuries: CT characterisation and treatment outcomes of minor injury. Eur Radiol. 2013; 23: 2988-95.

18

Lamarche Y, Berger FH, Nicolaou S, Bilawich AM, Louis L, Inacio JR, et al. Vancouver simplified grading system with computed tomographic angiography for blunt aortic injury. J Thorac Cardiovasc Surg. 2012; 144: 347-54, 354.e1.

19

Heneghan RE, Aarabi S, Quiroga E, Gunn ML, Singh N, Starnes BW. Call for a new classification system and treatment strategy in blunt aortic injury. J Vasc Surg. 2016; 64: 171-6.

20

Payne RE, Nygaard RM, Fernandez JD, Sahgal P, Richardson CJ, Bashir M, et al. Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy. Eur J Trauma Emerg Surg. 2019; 45: 951-7.

21

Jacob-Brassard J, Salata K, Kayssi A, Hussain MA, Forbes TL, Al-Omran M, et al. A systematic review of nonoperative management in blunt thoracic aortic injury. J Vasc Surg. 2019; 70: 1675-81.e6.

22

Gunn ML, Lehnert BE, Lungren RS, Narparla CB, Mitsumori L, Gross JA, et al. Minimal aortic injury of the thoracic aorta: imaging appearances and outcome. Emerg Radiol. 2014; 21: 227-33.

23

Sandhu HK, Leonard SD, Perlick A, Saqib NU, Miller CC 3rd, Charlton-Ouw KM, et al. Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries. J Vasc Surg. 2018; 67: 389-98.

24

Rabin J, DuBose J, Sliker CW, O’Connor JV, Scalea TM, Griffith BP. Parameters for successful nonoperative management of traumatic aortic injury. J Thorac Cardiovasc Surg. 2014; 147: 143-9.

25

Mosquera VX, González-Barbeito M, Marini M, Gulias-Soidan D, Fraga-Manteiga D, Velasco C, et al. Evolution of conservative treatment of acute traumatic aortic injuries: lights and shadows. Eur J Cardiothorac Surg. 2018; 54: 689-95.

26

Raptis CA, Hammer MM, Raman KG, Mellnick VM, Bhalla S. Acute traumatic aortic injury: practical considerations for the diagnostic radiologist. J Thorac Imaging. 2015; 30: 202-13.

27

Vilacosta I, Aragoncillo P, Cañadas V, San Román JA, Ferreirós J, Rodríguez E. Acute aortic syndrome: a new look at an old conundrum. Postgrad Med J. 2010; 86: 52-61.

28

Vilacosta I, San Román JA, di Bartolomeo R, Eagle K, Estrera AL, Ferrera C, et al. Acute aortic syndrome revisited: JACC state-of-the-art review. J Am Coll Cardiol. 2021; 78: 2106-25.

29

Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006; 166: 1350-6.

30

Ueda T, Chin A, Petrovitch I, Fleischmann D. A pictorial review of acute aortic syndrome: discriminating and overlapping features as revealed by ECG-gated multidetector-row CT angiography. Insights Imaging. 2012; 3: 561-71.

31

Ko JP, Goldstein JM, Latson LA Jr, Azour L, Gozansky EK, Moore W, et al. Chest CT angiography for acute aortic pathologic conditions: pearls and pitfalls. Radiographics. 2021; 41: 399-424.

32

Valente T, Rossi G, Lassandro F, Rea G, Marino M, Muto M, et al. MDCT evaluation of acute aortic syndrome (AAS). Br J Radiol. 2016; 89: 20150825.

33

Murillo H, Molvin L, Chin AS, Fleischmann D. Aortic dissection and other acute aortic syndromes: diagnostic imaging findings from acute to chronic longitudinal progression. Radiographics. 2021; 41: 425-46.

34

Leone O, Pacini D, Foà A, Corsini A, Agostini V, Corti B, et al. Redefining the histopathologic profile of acute aortic syndromes: Clinical and prognostic implications. J Thorac Cardiovasc Surg. 2018; 156: 1776-85.e6.

35

Svensson LG, Labib SB, Eisenhauer AC, Butterly JR. Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation. 1999; 99: 1331-6.

36

Williams DM, Lee DY, Hamilton BH, Marx MV, Narasimham DL, Kazanjian SN, et al. The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology. 1997; 203: 37-44.

37

Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: part I: from etiology to diagnostic strategies. Circulation. 2003; 108: 628-35.

38

Maddu KK, Shuaib W, Telleria J, Johnson JO, Khosa F. Nontraumatic acute aortic emergencies: part 1, acute aortic syndrome. AJR Am J Roentgenol. 2014; 202: 656-65.

39

McMahon MA, Squirrell CA. Multidetector CT of aortic dissection: a pictorial review. Radiographics. 2010; 30: 445-60.

40

LePage MA, Quint LE, Sonnad SS, Deeb GM, Williams DM. Aortic dissection: CT features that distinguish true lumen from false lumen. AJR Am J Roentgenol. 2001; 177: 207-11.

41

Williams DM, Joshi A, Dake MD, Deeb GM, Miller DC, Abrams GD. Aortic cobwebs: an anatomic marker identifying the false lumen in aortic dissection--imaging and pathologic correlation. Radiology. 1994; 190: 167-74.

42

Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121: e266-369.

43

Carino D, Singh M, Molardi A, Agostinelli A, Goldoni M, Pacini D, et al. Non-A non-B aortic dissection: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2019; 55: 653-9.

44

Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283: 897-903.

45

Castañer E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardó Y. CT in nontraumatic acute thoracic aortic disease: typical and atypical features and complications. Radiographics. 2003; 23 Spec No: S93-110.

46

Crawford TC, Beaulieu RJ, Ehlert BA, Ratchford EV, Black JH 3 rd. Malperfusion syndromes in aortic dissections. Vasc Med. 2016; 21: 264-73.

47

Madani MH, Turner VL, Hallett RL, Willemink MJ, Murillo H, Chin AS, et al. Limited aortic intimal tears: CT imaging features and clinical characteristics. Radiol Cardiothorac Imaging. 2022; 4: e220155.

48

Steinbrecher KL, Marquis KM, Bhalla S, Mellnick VM, Ohman JW, Raptis CA. CT of the difficult acute aortic syndrome. Radiographics. 2022; 42: 69-86.

49

Ganaha F, Miller DC, Sugimoto K, Do YS, Minamiguchi H, Saito H, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002; 106: 342-8.

50

Kitai T, Kaji S, Yamamuro A, Tani T, Kinoshita M, Ehara N, et al. Detection of intimal defect by 64-row multidetector computed tomography in patients with acute aortic intramural hematoma. Circulation. 2011; 124: S174-8.

51

Evangelista A, Mukherjee D, Mehta RH, O’Gara PT, Fattori R, Cooper JV, et al. Acute intramural hematoma of the aorta: a mystery in evolution. Circulation. 2005; 111: 1063-70.

52

Uchida K, Imoto K, Karube N, Minami T, Cho T, Goda M, et al. Intramural haematoma should be referred to as thrombosed-type aortic dissection. Eur J Cardiothorac Surg. 2013; 44: 366-9; discussion 369.

53

Wu MT, Wang YC, Huang YL, Chang RS, Li SC, Yang P, et al. Intramural blood pools accompanying aortic intramural hematoma: CT appearance and natural course. Radiology. 2011; 258: 705-13.

54

Gutschow SE, Walker CM, Martínez-Jiménez S, Rosado-de-Christenson ML, Stowell J, Kunin JR. Emerging concepts in intramural hematoma imaging. Radiographics. 2016; 36: 660-74.

55

Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, et al. Insights from the international registry of acute aortic dissection: a 20-year experience of collaborative clinical research. Circulation. 2018; 137: 1846-60.

56

Nienaber CA, von Kodolitsch Y, Petersen B, Loose R, Helmchen U, Haverich A, Spielmann RP. Intramural hemorrhage of the thoracic aorta. Diagnostic and therapeutic implications. Circulation. 1995; 92: 1465-72.

57

Song JM, Kim HS, Song JK, Kang DH, Hong MK, Kim JJ, et al. Usefulness of the initial noninvasive imaging study to predict the adverse outcomes in the medical treatment of acute type A aortic intramural hematoma. Circulation. 2003; 108 Suppl 1: II324-8.

58

Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018; 39: 739-49d.

59

Isselbacher EM, Preventza O, Hamilton Black J 3 rd , Augoustides JG, Beck AW, Bolen MA, 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; 146: e334-482.

60

Stanson AW, Kazmier FJ, Hollier LH, Edwards WD, Pairolero PC, Sheedy PF, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg. 1986; 1: 15-23.

61

Hayashi H, Matsuoka Y, Sakamoto I, Sueyoshi E, Okimoto T, Hayashi K, et al. Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. Radiographics. 2000; 20: 995-1005.

62

Oderich GS, Kärkkäinen JM, Reed NR, Tenorio ER, Sandri GA. Penetrating aortic ulcer and intramural hematoma. Cardiovasc Intervent Radiol. 2019; 42: 321-34.