Endovascular stenting is now the mainstay of treatment.98,99 While endograft sizing has improved, the major question is long-term outcome in younger patients. Open repair of the descending aorta is accomplished using partial left heart bypass to prevent spinal cord and splanchnic ischemia and reduce left ventricular afterload (Fig. 7-57).100 Nonoperative management for grade I intimal aortic injuries is accomplished with antiplatelet agents and blood pressure control.

Descending BAI may require urgent intervention. However, operative intervention for intracranial or intra-abdominal hemorrhage or unstable pelvic fractures takes precedence. To prevent aortic rupture, pharmacologic therapy with a selective β1-antagonist, esmolol, should be instituted in the trauma bay, with a target SBP of <100 mmHg and heart rate of <100/min.