Penetrating traumatic aortic arch injury: a unique case report presentation.

Introduction: Penetrating traumatic aortic arch injuries are rare due to the protective effect of surrounding structures. The choice between open surgical repair and endovascular repair depends on several factors including the patient's hemodynamic status, anatomical considerations, and available expertise. However, these injuries remain associated with significant mortality, emphasizing the need for swift intervention and careful patient selection. Long-term follow-up is also essential to monitor potential complications such as stent migration or endoleaks in cases managed with endovascular repair. Importance: This case report highlights the challenges in managing delayed presentations of penetrating traumatic aortic arch injuries, emphasizing the importance of a multidisciplinary approach and the potential for nonoperative management in carefully selected patients. Case presentation: A 38-year-old male presented to a regional hospital 1 day after sustaining a left precordial stab wound. Initial assessment revealed hemodynamic instability (hypotension, tachycardia), and a left-sided hemothorax requiring drainage. Imaging (chest X-ray, computed tomography [CT] angiography) revealed an acute traumatic aortic injury involving the distal aortic arch near the left subclavian artery origin, characterized by an intimal flap, mural thrombus, a small pseudoaneurysm, and a mediastinal hematoma. Clinical discussion: After stabilization and transfer to a Level 1 trauma center, the patient was managed conservatively with serial CT angiography monitoring. Over a period of several weeks, the pseudoaneurysm remained stable without evidence of expansion, ultimately leading to successful nonoperative management. The patient was discharged with ongoing outpatient follow-up. Conclusion: This case demonstrates the successful nonoperative management of a delayed presentation of penetrating traumatic aortic arch injury. Careful patient selection, close multidisciplinary monitoring, and serial imaging are essential components of this approach. While this less invasive strategy avoids the risks associated with open or endovascular procedures, close monitoring for complications and timely intervention remain critical for optimal outcomes. Further research is needed to better define the indications for and outcomes of conservative management in such cases.