Blunt aortic injury in a 17 year old

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A 17 year old white male is involved a car versus tree
and taken to an outside hospital.

A CT of the chest, abdomen and pelvis is obtained and
reveals a left diaphragmatic rupture and grade III
splenic laceration in the abdomen as well as several
pelvic fractures.

In the chest, what appears to be a Stanford type B
aortic dissection is noted a few centimeters distal to
the left subclavian artery (Image).  No periaortic or
mediastinal hematoma is seen.  Just proximal to that a
small outpouching is seen projecting toward the left
pulmonary artery, resembling a ductus diverticulum
(Image).  The dissection carries on throughout the
descending aorta into the abdomen and terminates at
the aortoiliac bifurcation.  The celiac appears to be
perfused from the false lumen (Image).  Though no
images are available, the SMA and left renal artery
are perfused through the true lumen and the right
renal and IMA are perfused through the false lumen. 
In addition he has a left pneumothorax and multiple
left sided rib fractures.  

He is taken to the OR at the outside hospital to
repair his ruptured diaphragm and to undergo a
splenorraphy.  A left chest tube is placed.

When seen on transfer, he is extubated breathing two
liters nasal cannula oxygen on an Esmolol drip.  His
chest tube is draining 190ml of serosanguinous fluid
over the last four hours.  Midline incision intact,
abdomen tender but otherwise unremarkable.  Initially
his hemoglobin was 8.3, but then fall to 6.8 eight
hours later.  The Esmolol is turned off and he
receives two units of blood.  

The vascular surgeon and cardiothoracic surgeon agree
that there is no surgical intervention necessary at
this time.

This sort of aortic injury is poorly described in the
literature and no data is available to make a firm
evidence based decision.

Questions:

1.  What would you do?  Open repair?  Endovascular
repair?  Conservative management?

2.  Is there a transmural injury to the aorta which
involves the adventitia, or does the injury follow
that of NON-traumatic aortic dissection pattern?  Does
the absence of mediastinal hematoma influence the your
view?

3.  What is the natural history of a traumatic aortic
dissection in a 17 year old male if conservatively
managed?

Thanks in advance.

Ben Reynolds, PA-C
Pittsburgh, PA
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