Aorta: Transection vs. Dissection.....location, location, location

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Hi
I also thought that ascending aortic injuries were more common on fatal (on scene) cases but I found this nice study published on J Trauma and where this is only true for falls > 20 m (65 ft) in the study.

Ruy Cabello Pasini
Trauma Surgeon
Hospital Central Militar
MEXICO


Blunt and Penetrating Trauma of the Thoracic Aorta and Aortic Arch Branches: An Autopsy Study
ISSN: 0022-5282
Accession: 00005373-200010000-00018
Full Text (PDF) 121 K
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About this Journal ≫
Author(s):	
Dosios, Theodosios J. MD, FACS, FETCS; Salemis, Nikolaos MD; Angouras, Dimitrios MD; Nonas, and Emmanuel MD
Issue:	
Volume 49(4), October 2000, pp 696-703
Publication Type:	
[Article Titles]
Publisher:	
© 2000 Lippincott Williams & Wilkins, Inc.
Institution(s):	
>From the 2nd Department of Propedeutic Surgery (T.J.D., N.S., D.A.), Division of Thoracic Surgery, Athens University Medical School, and Athens Forensic Medicine Service (E.N.), Athens, Greece
Submitted for publication October 18, 1999.
Accepted for publication July 10, 2000.
Presented in part at the 11th Annual meeting of the European Association for Cardio-thoracic Surgery (EACTS), September 28–October 1, 1997, Copenhagen, Denmark.
Address for reprints: Theodosios J. Dosios, MD, 2, Chatzigianni Mexi Street, 115 28 Athens, Greece; E-mail: dosiosth at internet.gr.

Abstract
Background: Due to the highly lethal nature of trauma of the thoracic aorta and aortic arch branches (TA-AAB), autopsy studies are essential for the investigation of its epidemiologic characteristics.

Methods: The reports of 11,446 consecutive medicolegal autopsies were reviewed. Among 1,980 injury-related fatalities, 251 victims (12.7%) with 302 TA-AAB injuries were found. Several trauma variables were recorded and their relations were examined.

Results: Blunt TA-AAB injuries were recorded in 86.4% of the victims. They were located mainly at the aortic isthmus and distal descending thoracic aorta and were accompanied to a great extent by extrathoracic trauma. The vast majority of penetrating lacerations were located at the ascending aorta, arch, and arch branches and were mostly associated with other lethal intrathoracic injuries. All penetrating trauma victims died before reaching the hospital, whereas 5.5% of the blunt trauma victims were admitted to the hospital alive.

Conclusion: Major differences between blunt and penetrating TA-AAB injuries were revealed, regarding their location, patterns of concomitant injuries, and victims’ survival time. Patients injured in motor vehicle crashes, as opposed to various other causes of trauma, were found to have the best chances of reaching the hospital alive.


Trauma of the thoracic aorta and aortic arch branches (TA-AAB) is highly lethal, as most victims die at the scene of the accident. Autopsy studies are, therefore, the only reliable means to investigate trauma patterns, accident mechanisms, and other pertinent variables of this dramatic injury.

According to Sailer, 1 the first reference to traumatic rupture of the thoracic aorta was made by Vesalius in 1557. However, it was only after the classic study by Parmley et al. in 1958 2 that the natural history of this injury was appreciated. Unfortunately, the autopsy studies on blunt trauma of the thoracic aorta thereafter are relatively sparse and their results are diverse, whereas autopsy studies specifically dealing with penetrating injuries of the thoracic aorta or injuries of the aortic arch branches are virtually absent. Therefore, we carried out the present study in an attempt to delineate the current epidemiologic profile of different modes of TA-AAB injury, both blunt and penetrating. This knowledge may prove useful in the development of prevention measures, as well as in the diagnosis and management of this injury for the few patients who arrive at the hospital alive.

MATERIALS AND METHODS
The records of 11,446 consecutive medicolegal autopsies performed within a 3-year period (1.1.1994–31.12.1996) at the Athens Forensic Medicine Service were retrospectively examined. This service covers a total population of approximately 4 million. Among 1,980 cases of injury-related deaths, 251 victims (12.7%) with blunt and penetrating TA-AAB injuries were recorded. Data collected from the postmortem reports of these 251 fatalities, including brief data of the events before death, were analyzed. In Greece, all trauma deaths are referred to local forensic medicine services for postmortem examination, unless death occurs in the hospital and its cause has meanwhile been firmly established.

The terms “injury” or “laceration” were considered synonymous and are used alternatively in this report. The TA-AAB injuries or lacerations were classified according to their location into injuries of: (1) both the ascending aorta and aortic arch, which for practical purposes are presented together under the name ascending part of the aorta, (2) the aortic arch branches, including the intrathoracic portions of the brachiocephalic artery and the subclavian and common carotid arteries, (3) the aortic “isthmus,” defined as the proximal descending aorta within 1 cm from the origin of the left subclavian artery, and (4) the distal descending thoracic aorta, involving the thoracic aorta more than 1 cm distally to the origin of the left subclavian artery.

Victims’ sex and age, cause and mechanism of accident, time of death, total number and location of TA-AAB lacerations, as well as the coexisting thoracic and extrathoracic injuries were recorded and their relationships examined. Time of death was categorized for practical purposes as: death at the scene of the accident, death during transportation, and death in the hospital. Coexisting injuries were grouped into injuries of the chest wall, intrathoracic organs, abdominal organs, head, spine and/or spinal cord, and pelvis and extremities. The coexisting thoracic injuries were analytically recorded as rib fractures, sternal fractures, injuries of the thoracic spine and/or spinal cord, rupture of intrapericardial vessels, rupture of extrapericardial vessels, heart rupture, lung injuries, hemopneumothorax, esophageal injuries, and rupture of the trachea and bronchi. In cases of motor vehicle fatalities, information on vehicular speed, seat belt use and
 driver’s blood alcohol level were not generally available and were not studied.

Statistical Analysis
Results are expressed as mean ± SEM. Continuous variables were analyzed using the Student’s t test for independent variables, whereas in several instances, continuous variables were divided into categories for contingency table analysis. For categorical data, the [chi]2 test with Yates correction factor or the Fisher’s exact test, where appropriate, were utilized. Statistical significance was assumed at a p value of < 0.05.

RESULTS
There were 188 men (74.9%) and 63 women (25.1%), with a mean age of 44.2 ± 1.4 years (41.4 ± 1.4 years in male victims and 52.6 ± 2.7 years in female victims;p = 0.0001). Thirty-four victims (13.6%) sustained penetrating trauma, either stab or gunshot wounds, and the remaining 217 (86.4%) sustained blunt trauma, mainly induced by motor vehicle crashes (MVCs). Among all injury-related deaths, TA-AAB lacerations were recorded in 12.7% of the victims (blunt lacerations in 10.9% and penetrating in 1.8%). The incidence of TA-AAB trauma among the total number of autopsied cases was 2.2% (1.9% for blunt and 0.3% for penetrating TA-AAB trauma).

The victims’ demographic features in relation to the cause of accident are shown in Table 1. MVC victims were found to be younger than the other blunt trauma victims (p = 0.0008). In addition, there were a significantly greater number of men involved in MVCs in comparison with other blunt trauma victims (p = 0.001). Within the MVC group, motorcycle crash victims were found to be much younger than automobile crash victims (mean age, 28.9 ± 2.5 vs. 45.7 ± 1.9 years, respectively;p = 0.00001), with a remarkably intense male preponderance (male to female ratio was 17.5 in motorcycle vs. 2.9 in automobile crash victims;p = 0.01). However, the differences in age and sex between blunt and penetrating trauma, as well as between stab and gunshot victims, failed to prove statistically significant, as a result of the small number of patients that have suffered penetrating injuries.



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[Email Jumpstart To Image]	Table 1. Demographic Features of TA-AAB Trauma Victims in Relation to Cause of AccidentMVC, motor vehicle crash; NS, not significant.a Male to female ratio.b Statistical significance of M/F ratio.
Blunt Trauma
The main cause (72.8%) of blunt trauma was MVC, i.e., automobile and motorcycle crashes, which could be characterized as high-speed collisions. The mechanism of motorcycle crashes was collision with another vehicle in 4 cases, a crash into trees, posts, fences, etc. in 10 cases, and overturning in 23 cases. The remaining blunt trauma fatalities (27.2%) were mostly the result of occupational accidents and were caused by falls from height (>4 m) or compression by heavy pieces of machinery, blocks of stones, etc. Two pedestrians who were struck by a train were also included in this category, since it was considered that their deaths were not the result of high-speed collisions, and the nature and extent of their injuries were much more similar to those resulting from falls or compression.

Twenty-nine blunt trauma victims (13.4%) had multiple TA-AAB injuries; 24 (11.1%) had two injuries (6.3% in MVC vs. 23.7% in falls and compression;p = 0.0006) and the remaining 5 (2.3%) had 3 to 8 injuries each (0.6% in MVC vs. 6.7% in falls and compression, p = 0.02). The remaining 188 (86.6%) blunt trauma victims had one TA-AAB injury each (93.0% in MVC vs. 69.5% in falls and compression;p = 0.00001). The location of blunt TA-AAB injuries in relation to the cause of accident is presented in Table 2. The anatomic distribution of TA-AAB injuries did not differ significantly between MVCs and other blunt trauma cases, notwithstanding the lower frequency of lacerations in the distal descending aorta of MVC victims (p = 0.1). Likewise, within the group of MVCs, no significant difference of the anatomic distribution of TA-AAB injuries was found between automobile and motorcycle crashes. Pedestrians involved in automobile crashes tended to have more injuries
 of arch branches than automobile occupants did (17.6% vs. 4.6%;p = 0.04), but less lacerations of the isthmus (50.0% vs. 67.8%;p = 0.04). Yet, the overall anatomic distribution of TA-AAB injuries was not significantly different between pedestrians and automobile occupants. Regarding falls, the height did not appear to influence the anatomic distribution of TA-AAB lacerations (Table 2).



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[Email Jumpstart To Image]	Table 2. Blunt Trauma: Anatomic Location and Average Number of TA-AAB Injuries per Victim in Relation to Cause of AccidentMVC, motor vehicle crash.a Sum of percentages in each row may exceed 100 as a result of multiple TA-AAB injuries recorded in several victims (sum of percentages = IPV × 100).b IPV, average number of TA-AAB injuries per victim.
Penetrating Trauma
Penetrating injuries included stab wounds (15 victims) and gunshot wounds (19 victims). Twenty-eight penetrating trauma victims (82.4%) had one TA-AAB injury (80.0% in stab vs. 84.2% in gunshot wounds; nonsignificant difference), whereas the remaining six victims (17.6%) had two injuries each (20.0% in stab vs. 15.8% in gunshot wounds; nonsignificant difference). The location of penetrating TA-AAB lacerations is shown in Table 3. Lacerations of the ascending part of the aorta were more frequent in gunshot wounds (p = 0.009), whereas lacerations of the arch branches were much more frequent in stab wounds (p = 0.004). The injury of isthmus and distal descending aorta, however, appeared quite infrequent in both types of penetrating trauma.



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[Email Jumpstart To Image]	Table 3. Penetrating Injuries: Anatomic Location and Mean Number of TA-AAB Injuries per Victim in Relation to Cause of Accidenta Sum of percentages in each row may exceed 100 as a result of multiple TA-AAB injuries recorded in several victims (sum of percentages = IPV × 100).b IPV, average number of TA-AAB injuries per victim.
By comparing blunt with penetrating trauma, it was evident that the anatomic distribution of TA-AAB lacerations differed significantly between the two groups (p = 0.000000). Lacerations of the ascending part of the aorta and aortic arch branches were much more common in penetrating trauma, whereas injuries of the isthmus and distal descending aorta were much more frequent in blunt trauma (Tables 2 and 3).

Coexisting Injuries
A large number of major coexisting thoracic and extrathoracic injuries were recorded. Only eight of the 251 victims (3.2%) had no concomitant injuries. Seven of them had suffered stab wounds and one had a gunshot wound. Each one of the remaining 243 victims (96.8%), including all blunt trauma victims, had one or more concomitant injuries. The average number of coexisting injuries per victim was 6.7 ± 0.3 in MVCs versus 10.1 ± 0.7 in falls and compressions (p = 0.000001), and 2.3 ± 0.9 in stabs versus 6.5 ± 1.0 in gunshots (p = 0.005). Although MVC and gunshot victims had a similar number of coexisting injuries, their anatomic distribution was dissimilar. The majority (94.2%) of coexisting injuries of gunshot victims were located in the chest. The same is true for the stab victims: 77.1% of the coexisting injuries were located in the chest. An average of 5.4 ± 0.9 and 1.6 ± 0.5 concomitant intrathoracic injuries per victim were recorded in gunshot
 and stab victims, respectively. In contrast, the coexisting injuries of MVC victims, as well as those of victims of falls and compression, included a great deal of extrathoracic trauma. At least one extrathoracic injury was recorded in 94.9% of blunt trauma victims. The abdomen was the predominant site of extrathoracic trauma, with an average of 1.7 ± 0.1 and 2.1 ± 0.2 abdominal injuries per victim recorded in MVCs and falls and compression, respectively (Fig. 1). Liver and spleen were the most frequently injured abdominal organs (Table 4). Injuries of the thoracic cage, i.e., sternal, rib, and thoracic spine fractures, were also more common in blunt trauma (mean, 1.0 ± 0.1 vs. 0.4 ± 0.1;p = 0.00002). In contrast, “lethal intrathoracic injuries,” defined as heart rupture and lacerations of major vessels other than TA-AAB, were more frequent in penetrating (mean, 1.9 ± 0.5) than in blunt trauma (mean, 0.9 ± 0.1) (p = 0.01). At least one such
 coexisting lethal thoracic injury was recorded in 40.0% of stab victims, 78.9% of gunshot victims, 49.1% of victims of falls and compression, but in only 17.7% of MVC victims (Fig. 2). Analysis of coexisting thoracic injuries in relation to the location of TA-AAB lacerations revealed a significantly greater number of lethal intrathoracic injuries in victims with “ascending part” aortic lacerations (mean, 2.2 ± 0.4) in comparison with those without ascending part aortic lacerations (mean, 0.6 ± 0.1) (p = 0.0000009) (Fig. 3). In addition, ascending part aortic lacerations were associated with a greater number of sternal fractures (mean, 0.3 ± 0.05 vs. 0.1 ± 0.02 in “nonascending” lacerations;p = 0.001) and lung injuries (mean, 0.7 ± 0.06 versus 0.4 ± 0.03;p = 0.002).



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[Email Jumpstart To Image]	Fig. 1. Location of coexisting injuries in relation to the cause of accident. Numbers in y-axis represent the average number of injuries per victim per location.

 
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[Email Jumpstart To Image]	Table 4. Frequency of Coexisting Injuries of Abdominal Organs in Blunt and Penetrating TA-AAB TraumaCI, confidence interval.


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[Email Jumpstart To Image]	Fig. 2. Coexisting thoracic injuries in relation to the cause of accident. Numbers on the y-axis represent the average number of coexisting injuries per victim per anatomic location (RF = rib fracture, SF = sternal fracture, ITS = injury of the thoracic spine, RIV = rupture of intrapericardial great vessels, REV = rupture of extrapericardial great vessels, HR = heart rupture, LI = lung injury, HP = hemo/pneumothorax, RTB = rupture of trachea and/or bronchi, EI = esophageal injury).


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[Email Jumpstart To Image]	Fig. 3. Coexisting thoracic injuries in relation to the anatomic location of TA-AAB lacerations. Numbers on the y-axis represent the average number of coexisting injuries per victim per anatomic location (RF = rib fracture, SF = sternal fracture, ITS = injury of the thoracic spine, RIV = rupture of intrapericardial great vessels, REV = rupture of extrapericardial great vessels, HR = heart rupture, LI = lung injury, HP = hemo/pneumothorax, RTB = rupture of trachea and/or bronchi, EI = esophageal injury).
Time of Death
All penetrating trauma and 94.5% of blunt trauma victims succumbed at the scene of the accident or during transportation (nonsignificant difference) (Table 5). Only one victim of fall arrived in the hospital alive, but he was in extremis and died of severe head injury 60 minutes after admission. In contrast, 11 MVC victims (7.0%) survived to reach the hospital alive and died within 10 minutes to 48 hours after their arrival in the emergency room (ER). One patient died during an emergency thoracotomy of exsanguinating hemorrhage, and another died 3 hours after repair of an isthmus laceration due to severe coagulopathy and uncontrollable hemorrhage. The remaining nine patients expired before definitive repair of their thoracic aortic injuries were attempted. Analyses of these deaths revealed that: (1) one patient died in the ER of severe brain injury, (2) one patient died in the ER of ascending aorta intrapericardial rupture and cardiac tamponade, (3) two
 patients died during emergency laparotomy for massive intraperitoneal bleeding, the cause of their deaths not related to their aortic injuries, (4) one patient had a laparotomy that followed aortography but preceded aortic repair and died of aortic rupture, (5) one patient died while aortography was being performed, (6) two patients died in the intensive care unit before aortogram; both had severe closed-head injuries and one had already had a splenectomy during an emergency laparotomy, and (7) one patient with a probably unsuspected descending aortic injury died after open reduction of a femur fracture. The last four patients died of aortic rupture.


 
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[Email Jumpstart To Image]	Table 5. Time of Death of TA-AAB Trauma Victims in Relation to the Cause of AccidentMVC, motor vehicle crash.
The overall survival time of MVC victims was longer than that of victims of falls and compression (p = 0.01). Nevertheless, the small number of autopsied victims who reached the hospital alive prevented us from substantiating a significant difference between MVCs and other blunt injuries in this clinically important group of victims. In contrast, all penetrating TA-AAB injuries proved fatal to all patients before reaching the hospital. Finally, the MVC group, in comparison with all the others, had a significantly longer overall survival time (p = 0.006) and a significantly greater proportion of victims reaching the hospital alive (p = 0.02).

The analysis of time of death with regard to the anatomic location of TA-AAB lacerations revealed that a greater percentage of victims with injuries of the isthmus or distal descending thoracic aorta reached the hospital alive, in comparison with those injured at the ascending part of the aorta or arch branches (p = 0.04) (Table 6). In addition, multiple TA-AAB lacerations were recorded in 16.1% of the victims who died at the scene of the accident, in 3.5% of those who died during transportation, but in none of those who reached the hospital alive. However, these differences were not statistically significant. In contrast, the time of death was found related to the number of coexisting injuries. The victims who died at the scene had an average of 7.7 ± 0.3 coexisting injuries versus 5.3 ± 0.4 of those who died during transportation (p = 0.02) and 4.4 ± 0.7 of those who reached the hospital alive. The average number of concomitant injuries of victims
 who survived to the hospital was significantly less than the average number of those who died before reaching the hospital (p = 0.04).


 
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[Email Jumpstart To Image]	Table 6. Time of Death of Victims in Relation to Anatomic Location of TA-AAB Injuries
DISCUSSION
The present study delineates several epidemiologic features of TA-AAB injuries, and, to our knowledge, it is the first autopsy series substantiating major dissimilarities between blunt and penetrating TA-AAB trauma patterns. After reviewing the English- language literature that followed the publication of Parmley et al., 2 we found 18 autopsy studies on TA-AAB trauma. 3–20 Sixteen studies treat exclusively blunt trauma of the thoracic aorta, one deals with blunt and penetrating major vascular injuries of the torso, including neck and abdominal vessels, 16 whereas both blunt and penetrating thoracic vascular injuries are addressed only in series by Bergman et al. of pediatric trauma fatalities. 12 Among 322 autopsy cases, Bergman et al. reported 26 children (8.1%) with 31 injuries to major thoracic vessels, including 16 injuries of the thoracic aorta. Twenty-five of these 26 victims died within 6 hours after the accident. However, the small number of
 cases probably prevented the authors from analyzing the injury data and comparing blunt to penetrating trauma.

The differences of epidemiologic profiles of blunt versus penetrating TA-AAB injuries, as demonstrated by the current analysis, refer to the anatomic location of vascular lacerations, the prognosis, and the number and distribution of associated injuries. The isthmus and distal descending thoracic aorta were the most common sites of blunt TA-AAB lacerations. The greater part (94.9%) of blunt trauma victims had extrathoracic associated injuries, 26.2% had lethal concomitant intrathoracic injuries, and eventually 5.5% were admitted to the hospital alive. In contrast, penetrating TA-AAB lacerations were almost exclusively located at the ascending part of the aorta and the arch branches. All penetrating trauma victims succumbed at the scene of the accident or during transportation, 61.7% of them having at least one lethal coexisting intrathoracic injury.

Despite the paucity of autopsy studies, relevant clinical series seem to concur with the very poor prognosis of penetrating TA-AAB injuries, as indicated by the present study. Improved trauma care and prehospital resuscitation have not altered the mortality rate of these injuries, as most of the “fortunate” victims who reach the hospital alive have unrecordable blood pressure on admission. 21,22 In contrast, a survival rate of up to 71.9% has been recently reported for patients with blunt traumatic laceration of the thoracic aorta. 23 However, it must be noted that the proportion of patients who survive to reach a hospital is underestimated in the present study, as apparently the analysis included neither those who ultimately survived this catastrophic injury nor the victims who died in the hospital and were not submitted to autopsy. Presuming that 10 to 20% of patients with blunt TA-AAB trauma reach the hospital alive, 2,10 there were a total of 228
 to 256 cases of blunt TA-AAB injuries in Metropolitan Athens during the study period. The resulting incidence of this injury is 1.9 to 2.1 cases per 100,000 inhabitants per year, quite similar to the number reported by Søndenaa et al. 14 and Feczko et al. 15 several years ago.

In this series, blunt TA-AAB lacerations were found in 10.9% of injury-related fatalities, which is in accordance with the incidence reported in the literature. 3,4,15,16 If this number is weighed against the 0.23% incidence of thoracic aortic injury among 63,507 hospitalized trauma patients, as reported by Hunt et al., 24 the lethality of this injury can be recognized. However, the incidence of blunt TA-AAB trauma among the total number of autopsied cases was 1.9% in the present study, almost double that reported by Strassman in 1947. 25 High-speed MVCs probably account for this increase, as automobile and motorcycle crashes were responsible for 72.8% of deaths caused by TA-AAB trauma in our series. This is similar to the percentage reported by Feczko et al. (73%) 15 and Greendyke (83%). 3 Young men were found to be MVC-prone and this especially applies to motorcycle crashes. The male to female ratio of blunt TA-AAB trauma victims was 2.68 in this
 series, ranging between 2.1 and 3.8 in different studies. 7,9,11,15

It is generally acknowledged that the aortic isthmus is the most common site of blunt TA-AAB injury. 2,18,23 We found 59.4% of the total blunt TA-AAB lacerations located at this site. This percentage was 67.8% for the automobile occupants, but significantly less (50.0%) for the pedestrians involved in automobile crashes. The latter, however, had significantly more injuries of arch branches than did automobile occupants. In addition, a rather large number of blunt lacerations to the ascending part of the aorta and arch branches were recorded, as opposed to the relatively small number of such injuries encountered in clinical practice. This discrepancy, also noted by Prêtre and Chilcott, 26 is probably the result of the grave immediate prognosis of injuries located at these sites (Table 6), to a certain extent owing to the frequent lethal concomitant intrathoracic injuries. In the current series, only one patient with laceration of the ascending aorta was
 admitted alive, but he died in the ER of free aortic rupture and cardiac tamponade.

Regarding penetrating injuries, their usual location at the ascending part of the aorta and the arch branches somewhat elucidates the reasons for their dismal prognosis. The low incidence of penetrating injuries of the descending thoracic aorta has also been reported in clinical series. 27

TA-AAB lacerations were multiple in 13.4% of blunt trauma cases (similar numbers having been reported by others) 15,18 and in 17.6% of penetrating trauma cases. Multiple TA-AAB lacerations seem to be a negative prognostic factor, since all victims with such injuries were dead on admission.

Numerous concomitant injuries were recorded in the vast majority (96.8%) of victims, potentially contributing to or constituting the cause of their death. This is also in accordance with previous reports. 9,10,14,18,24 As resulted from the analysis of the small number of deaths occurring in the hospital, their cause was directly related to TA-AAB injury only in two thirds of the cases, head and abdominal injuries being the cause of death in one third. This emphasizes the fact that associated injuries can be just as lethal as TA-AAB trauma, and treatment priorities should be modulated on an individual basis. The distribution of coexisting injuries was dissimilar between blunt and penetrating trauma, the former including a significant number of extrathoracic injuries. Associated thoracic trauma included major injuries of the heart and intrathoracic great vessels other than TA-AAB in 26.2% of blunt trauma victims, but in 61.7% of penetrating. Although each
 one of these intrathoracic injuries was highly lethal and it is unlikely to encounter in the hospital a live patient with a combination of such injuries, the possible multiplicity of the lesions should always be kept in mind in the clinical setting. The high incidence of coexisting lethal intrathoracic injuries in penetrating trauma patients is another factor responsible for their dismal prognosis.

In conclusion, this study substantiates major differences of injury patterns between blunt and penetrating TA-AAB trauma. Most of penetrating TA-AAB lacerations are located at the ascending part of the aorta and arch branches and are associated with additional lethal intrathoracic injuries and a very poor prognosis. The injuries to the ascending part of the aorta seem to occur relatively frequently in blunt trauma as well. However, their dismal immediate prognosis renders them rather rare in the clinical setting. Blunt TA-AAB trauma mainly involves the isthmus and distal descending thoracic aorta and is associated with a large number of extrathoracic injuries and a better prognosis. MVC victims constitute the subgroup with the best prognosis. In MVCs, TA-AAB injuries involve the isthmus and distal descending aorta in 85.4% of the cases, multiple TA-AAB lacerations are infrequent, lethal intrathoracic associated injuries are relatively few, and, hence,
 the average survival time is long enough to allow several patients to reach the hospital alive.

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