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Traumatic descending thoracic aortic pseudoaneurysm — MRCEM SBA MCQ

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HardTraumaTraumatic descending thoracic aortic pseudoaneurysmMRCEM SBA

A 38-year-old driver is assessed at a major trauma centre after a high-speed collision. He is alert and remains haemodynamically stable. CT angiography shows an 18 mm pseudoaneurysm arising from the descending thoracic aorta immediately distal to the left subclavian artery, with a small surrounding haematoma but no free contrast extravasation. No other injury requires an operation. The aortic team and endovascular facilities are available. What is the most appropriate definitive management of the aortic injury?

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Correct answer: E — Arrange thoracic endovascular stent-graft repair.

The deceleration mechanism and CT angiogram establish blunt thoracic aortic injury. Crucially, the finding is a pseudoaneurysm, not a small isolated intimal lesion. Haemodynamic stability and the absence of free extravasation allow a planned definitive intervention; they do not make surveillance the best strategy. NICE recommends an endovascular stent graft for blunt thoracic aortic injury, and a systematic review supports its use for pseudoaneurysm-grade injuries. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) A and B are tempting because observation and aortic impulse control can have roles in selected lower-grade injuries; neither is the best *definitive* plan for this pseudoaneurysm. Impulse control may be used while repair is arranged. C would be considered if an endovascular repair were unsuitable or unavailable, but it is not preferred here. D adds a diagnostic step despite an established diagnosis on CT angiography and would delay the management decision. The appropriate plan is therefore to involve the available aortic team in thoracic endovascular stent-graft repair. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations))

Reference: NICE NG39: Major trauma: assessment and initial management, recommendation 1.5.43 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations Treatment Strategies And Outcomes Of Thoracic Aortic Blunt Injuries In Adults: A Systematic Review (2024) — https://pubmed.ncbi.nlm.nih.gov/38971993/