A Race Against Time: Collaborative Emergency and Cardiothoracic and Vascular Surgery-Led Endovascular Repair in Traumatic Aortic Transection with Polytrauma

Case Report

Initial presentation and assessment

A 38-year-old male was brought to the emergency department following a high-energy two-wheeler accident. On arrival, he was conscious and oriented (Glasgow Coma Scale [GCS] 15/15) and haemodynamically stable. 

Primary survey: No airway compromise, equal bilateral breath sounds, no external bleeding. 

Secondary survey: Scalp abrasions, no abdominal tenderness, and right thigh deformity with shortening, suggesting femoral fracture. The emergency medicine physician initiated advanced trauma life support (ATLS)– based stabilisation, including oxygen supplementation, fluid resuscitation and blood transfusion.

Imaging and diagnostic findings

Contrast-enhanced computed tomography (CECT)polytrauma revealed:

• Aorta:

Acute transection with limited dissection 4–6 cm distal to the left subclavian artery, forming a contained pseudoaneurysm with mediastinal haematoma compressing the oesophagus

• Thoracic findings:

Mild haemopericardium, bilateral pulmonary contusions, and thrombus extending to the pulmonary artery bifurcation

• Brain:

Small bilateral frontal contusions without mass effect

• Musculoskeletal:

Comminuted right femoral shaft fracture with posterior displacement

Emergency and surgical management

Recognising the imminent risk of rupture, the emergency medicine team activated the multidisciplinary trauma protocol, alerting the CTVS, orthopaedics, and neurosurgery teams. After stabilisation, the patient was shifted to the hybrid operating suite for emergency TEVAR on 27^th September 2025.

Procedure details

• Access:

Right femoral artery open exposure and left femoral artery catheterisation

• Device:

Medtronic Endurant stent graft (24/24/100 mm)

• Result:

Successful sealing of the pseudoaneurysm;no endoleak; haemodynamics normalised intraoperatively 

The patient was extubated the next morning and remained stable under intensive monitoring. Neurosurgical management of frontal contusions was conservative. After stabilisation, ORIF with intramedullary nailing of the right femur was performed by the orthopaedics team. Within 30 hours post-ORIF, the patient developed irritability and desaturation. Computed tomography pulmonary angiography (CTPA) ruled out pulmonary embolism; fat embolism syndrome was diagnosed clinically. Conservative management with oxygen, fluids, and corticosteroids led to steady improvement. The patient was discharged in a fully alert and haemodynamically stable condition, requiring assistance with ambulation.

Discussion

Traumatic aortic transection represents a critical challenge in emergency trauma care. Mortality remains high without rapid diagnosis and intervention^v In this case, early recognition by the emergency physician, guided by mechanism-based suspicion, was pivotal. Activation of the hybrid trauma response ensured simultaneous stabilisation and endovascular repair within hours, demonstrating exemplary emergency–CTVS synergy. Endovascular repair (TEVAR) has now replaced open repair as the standard of care for descending thoracic aortic injuries due to its reduced risk of bleeding, paraplegia, and mortality.^7,8 The multidisciplinary collaboration extended beyond surgery — orthopaedic, neurosurgical, and internal medicine teams coordinated seamlessly, allowing safe sequential management of injuries. Continuous postoperative vigilance for complications like fat embolism was crucial to overall recovery.⁹ This case exemplifies modern trauma management principles — speed, system activation, and multidisciplinary precision — that transform outcomes in previously unsurvivable injuries.

Patient Consent

Written informed consent for publication of this case and accompanying clinical details was obtained fromthe patient and family.