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Tue May 6 03:14:07 BST 2008

ken I, like you, have not jumped on the CTA bandwagon for vascular trauma, although in the long run I think it will replace catheter based angiography. i just havent found the data convincing. lots of anecodatal reports, lots of focused prejudicial patient selection, etc. This case did however show the value of CTA. 

after the aortogram,? esophagogram and venogram,?the cause of the bleeding had not been identifed. Since he appeared to have stopped bleeding and remained stable, he was brought to CT to evaluate his thoracic spine injury. Contrary to the plan, the chief resident asked for the spine CT with contrast media and that turned into a CTA.

The CTA showed that there was a large residual hematoma in the mediastinum and through and through penetrations of the aorta. The anterior hole was situated about five millimeters directly below the origin of the left commoon carotid artery. The bullet traversed inside the lumen of the aorta to exit the posterior wall of the top of the descending aorta.(see attached)

I was struck by the quality of the images and by the beautiful way the relationships were illustrated. The cardiothoracic surgeon said that his comprehension of the injury was enhanced and that led to a more assertive surgical plan.

I am surprised that the aortogram was normal and the CT was positive. It is a very rare event that such injuries do not manifest better than this. I suspect that thrombus contained the injries and that the resuscitation increased his blood pressure and that led to popping the clot.

to my surgical colleagues, i am curious about how they would approach this injury. pump? bypass? clamp and sew? simple suturing?

sal

-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Mon, 5 May 2008 8:41 pm
Subject: Re: interesting zone I GSW

I have been BURNED so many times by a CTA that I have totally lost faith in  
them.     I see the same problem at many other institutions  where the present 
cases to me when I am a visiting professor.     CTA for Chest vascular injury 
is a VOMIT.  

k

In a message dated 5/5/2008 12:41:17 P.M. Central Daylight Time,  
paran620 at green.co.il writes:

I think  I would have started with a CT-angio in the first  place.

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interesting zone I GSW