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Abdominal Aortic Injuries: The Experience of a Level One trauma Center

Jessica Deree,MD, Edna Shenvi, Dale Fortlage,Pat Stout,RN, Bruce Potenza,MD,David B. Hoyt,MD and Raul Coimbra,MD
Trauma and Critical Care, University of California, San Diego

Objective: Abdominal aortic injuries remain one of the most frequent causes of death in the trauma population. A risk analysis of the association between potential outcome predictors and mortality was performed to identify primary predictors of mortality.
Methods: A fifteen year retrospective review of medical records and autopsy reports of trauma patients admitted with injury to the abdominal aorta was performed. The mechanism, site if injury, trauma indices, pH, base deficit, the presence or absence of retroperitoneal tamponade, and mortality rate (MR) were analyzed for a total of 48 patients. Statistical analysis was performed using the Fisher exact test, Student-T test, or Chi-square when appropriate. Statistical significance was defined as a p<0.05.
Results: The average age of admitted patients was 26.5 years. Of the 48 total patients, 39 were male and 12 were female. Twelve patients sustained a blunt mechanism of injury (MR 92%) while 34 sustained a penetrating injury (MR 64%). Mortality was significantly higher when comparing blunt injury and gunshot wounds to stab wounds (p=0.01 and p=0.001, respectively). Injury most commonly occurred in the infrarenal region (n=23, MR 60.9%), followed by the suprarenal (n=14 MR 71.4%) and diaphragmatic location (n=11 MR 91%). The overall mortality was 70.8%. Excluding those patients that were considered dead on arrival (DOA), the total mortality rate was 57.6%. The mortality rate excluding DOA patients regarding location was 35.7%, 75%, and 83.3% for infrarenal, suprarenal, and diaphragmatic injuries, respectively (Table 1). Diaphragmatic location has a significantly higher mortality rate (p<0.05), while patients the infrarenal injury has a better chance for survival (p<0.05). In reference to trauma indices, patients with an injury severity score (ISS) > 16 and a trauma score (TS) > 10 had a markedly higher risk of death (p=0.02 and p=0.001, respectively). Mortality was significantly higher in those patients presenting in shock (67% vs. 20%; p<0.005). When compared to nonsurvivors, survivors were also identified as having a smaller number of associated injuries (2 vs. 6; p<0.04), more frequent retroperitoneal tamponade (61% vs. 25%; p=0.033), less severe acidosis (pH 7.27 vs. 7.05; p<0.0001), and smaller base deficit (9.6 vs. 17.9; p=0.001).
Conclusions: Despite advances in patient transport, fluid resuscitation, and operative technique over the past fifteen years, the mortality of traumatic abdominal aortic injuries remains high. A blunt mechanism of injury, injury above the renal arteries, TS >10, ISS > 16, an increased number of associated injuries, and the presence of shock, acidosis, and free bleeding into the abdominal cavity on admission are all independent predictors of mortality. These characteristics should therefore raise a high index of suspicion for a potentially lethal aortic injury in a severely injured patient.