American Association for the Surgery of Trauma–World Society of Emergency Surgery guidelines on the diagnosis and management of major thoracic vascular injuries

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In the United States, 7% of patients arriving at adult level 1 trauma centers are diagnosed with a torso vascular injury, and about half of these cases will present with hemorrhage.1 Hemorrhage is the leading cause of potentially preventable death following trauma.2,3 Noncompressible torso hemorrhage (NCTH) from vessels in the thorax, abdomen, and pelvis is especially lethal, with death occurring in approximately 45% of cases. Blunt and penetrating mechanisms account for 65% and 35% of NCTH, respectively.1 In one retrospective multicenter NCTH study, the chest was involved in 25% of cases. The most common bleeding vessels in the chest were the descending thoracic aorta (45%), intercostal/internal thoracic arteries (12%), ascending aorta (11%), right subclavian (7.3%), left subclavian (5%), pulmonary artery (4%), and subclavian vein (4%). The aortic arch, left and right carotid arteries, pulmonary vein, superior vena cava (SVC), and innominate vein were injured in less than 2% of cases. The most common cause of death after NCTH was exsanguination at a median time of 2 hours after presentation.4 This underscores the importance of expeditious assessment, diagnosis, and management of these patients. Thoracic vessels that are injured but are not bleeding initially may result in thrombus formation, occlusion, or delayed hemorrhage and demand similar attention. The purpose of this document is to provide the American Association for the Surgery of Trauma and the World Society of Emergency Surgery recommendations for the diagnosis and management of thoracic vascular injuries (TVIs). METHODS A computerized search was done using different databases (Medline, Embase, Cochrane). Citations were included for the period between January 2013 and January 2025 using the primary search strategy: trauma, blunt, penetrating, blood vessel, vascular injury, chest, thoracic, aorta, subclavian artery, subclavian vein, heart, pulmonary artery, pulmonary vein, innominate artery, innominate vein, aortic arch, great vessels, superior vena cava, inferior vena cava, resuscitative thoracotomy, thoracotomy, sternotomy, pericardiotomy, injury, surgery, diagnosis, operative, nonoperative, shunting, shunt, endovascular, anticoagulant, antiplatelet, focused assessment with sonography for trauma, and focused assessment with sonography in trauma, combined with and/or as well as the MeSH terms: thoracic injuries, thoracic aorta dissection, endovascular procedures, thoracotomy, and sternotomy. No search restrictions were imposed. The dates were selected to allow comprehensive published abstracts of clinical trials, consensus conferences, comparative studies, congresses, guidelines, government publications, multicenter studies, systematic reviews, meta-analyses, large case series, original articles, and randomized controlled trials. Selected older articles considered landmark papers in the field were also included. Three authors independently reviewed abstracts chosen for relevance, and any discrepancies between reviewers were settled after a discussion. The level of evidence was evaluated using a modified form of the Grading of Recommendations Assessment, Development, and Evaluation system (Table 1).5 A group of experts in the field, coordinated by a central coordinator, was contacted to express their evidence-based opinions on several issues about TVI. Based on the evidence available, the central coordinator assembled the different answers derived from a round of discussion and created a set of recommendations. The recommendations were submitted for comments multiple times using an online modified Delphi process until complete consensus was achieved. The definitive version reported herein represents the position of the expert group from both the American Association for the Surgery of Trauma and the World Society of Emergency Surgery. An executive summary of the guidelines can be found in Supplemental Digital Content (Supplementary Data 1, https://links.lww.com/TA/E993) as well as a list of abbreviations used in this article (Supplementary Data 2, https://links.lww.com/TA/E994). TABLE 1 - Modified System for GoR5 GoR Clarity of Risks/Benefit Quality of Supporting Evidence Implications 1A Strong recommendation, high-quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, applies to most patients in most circumstances without reservation 1B Strong recommendation, moderate-quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs with important limitations (inconsistent results, methodological flaws, indirect analyses or imprecise conclusions) or exceptionally strong evidence from observational studies Strong recommendation, applies to most patients in most circumstances without reservation 1C Strong recommendation, low-quality or very low-quality evidence Benefits clearly outweigh risk and burdens, or vice versa Observational studies or case series Strong recommendation but subject to change when higher quality evidence becomes available 2A Weak recommendation, high-quality evidence Benefits closely balanced with risks and burden RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values 2B Weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burden RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values 2C Weak recommendation, low-quality or very low-quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Observational studies or case series Very weak recommendation; alternative treatments may be equally reasonable and merit consideration GoR, grading of recommendations; RCT, Randomized controlled trial. RESULTS Epidemiology What Is the Incidence of Major Vascular Injury in Blunt Chest Trauma? Statement: Blunt mechanisms of injury are responsible for more than 60% of cases of TVI, but this varies by geography. The thoracic aorta is the most commonly injured vessel, followed by the innominate/subclavian arteries and the pulmonary artery in a minority of cases. Most blunt thoracic aortic injuries (BTAIs) are located distal to the takeoff of the left subclavian artery (LSA) at the level of the ligamentum arteriosum. Injuries to the ascending aorta, SVC, thoracic inferior vena cava, and azygous vein are infrequent after blunt trauma. The incidence of TVI is less than 1% in pediatric and adult civilian trauma patients who reach the hospital and is more common in adults than in pediatric patients.6–11 Blunt trauma is the cause of 62% of TVI in the United States and 77% in Australia.6,12 The epidemiology of injury prevalence and mechanism varies by geographic region. Still, it is typically related to deceleration injury resulting in a spectrum of vessel wall disruption from intimal tears to complete rupture.13 In patients sustaining TVI, the aorta is injured in approximately 80% of patients, followed by the innominate and subclavian vessels in 11% and the pulmonary vessels in 5%.6,14 The absolute incidence of TVI in trauma is much higher, as many patients do not survive to reach the hospital alive. Blunt thoracic aortic injury is the second most common cause of death in blunt trauma after head injury. It has been identified in a third of blunt traumatic fatalities, and an estimated 80% die at the scene of injury. Most injuries occur at the aortic isthmus, which extends from the origin of the LSA to the insertion of the ligamentum arteriosum. The ascending aorta is injured in less than 5% of pa

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