Traumatic aortic isthmus transection with pseudoaneurysm formation and massive mediastinal hematoma: management challenges in resource-limited countries: case report

Background Blunt thoracic aortic injury (BTAI) is rare but highly lethal, particularly at the aortic isthmus. Survival depends on early diagnosis, rapid resuscitation, and timely definitive intervention, which is challenging in resource-limited settings. Case presentation A 35-year-old male presented 30 min after a high-impact road traffic accident in traumatic haemorrhagic shock (BP 80/50 mmHg, HR 120 bpm, RR 30/min, SpO₂ 86%). Examination revealed bilateral hemopneumothorax, rib fractures, and subcutaneous emphysema. Initial management included oxygen, bilateral chest tubes, IV fluids, and massive transfusion (5 units each of PRBC, FFP, platelets). Contrast-enhanced CT demonstrated a full-thickness aortic transection 2.5 cm distal to the left subclavian artery, forming a pseudoaneurysm with mediastinal hematoma. Despite aggressive resuscitation and attempted transfer to a tertiary vascular centre, the patient died 12 h post-injury. Discussion Temporary survival in severe BTAI is possible with aggressive resuscitation and mediastinal tamponade. Delays in imaging, referral, and vascular expertise in resource-limited settings significantly reduce survival. Policy-level interventions (trauma networks, pre-hospital EMS) and practice-level strategies (standardized resuscitation, hypotensive protocols, protocolized transfer) are critical. Conclusion Resuscitation can extend survival in catastrophic BTAI, but definitive surgical repair is essential. Strengthening trauma systems and referral pathways is vital in low-resource settings.