Pulmonary lacerations secondary to either blunt trauma usually as result of displaced rib fractures puncturing the lung parenchyma or penetrating injuries directly to the lung. The natural history of blunt trauma is usually spontaneous resolution, as most are small and superficial and heal without any intervention. The vast majority of lung injuries requiring surgery are caused by penetrating trauma. Deep pulmonary laceration is typically associated with rupture of the visceral pleura and is a critical condition. Deep pulmonary laceration accounts for about 50 % of patients with intrathoracic hemorrhage and often results in death. If early and appropriate treatment is based on accurate diagnosis by rapid assessment of the pathology and by diagnostic imaging (Fig. 2), deep pulmonary laceration is a treatable condition in which the lives of these patients can be saved [77, 78]. VATS has been demonstrated to be an accurate, safe and reliable alternative method for the direct evaluation of the lung injuries.

In the past, major lung resection (lobectomy and pneumonectomy) when performed after traumatic lung injuries has been associated with high morbidity and mortality rates. Simple superficial oversewing of deep penetrating lung injuries potentially lead to postoperative lethality of hemoptysis [79, 80]. Therefore, techniques that achieve hemostasis while preserving the maximal amount of pulmonary parenchyma are desirable (Fig. 3). A major advance in lung-sparing techniques for the treatment of pulmonary penetrating injuries was introduced by Gao et al. [81], and Wall et al. [82] respectively in 1994. Lung-sparing technique is an less extensive surgical techniques of repair and resection surgical including suture pneumonorrhaphy, stapled and clamp pulmonary tractotomy with selective vessel ligation, and non-anatomic resection [83]. These resection techniques are indicated for control of hemorrhage, control of small air leaks, to preserve pulmonary tissue, and/or when the pulmonary injury is amenable to reconstruction [84]. It is estimated that approximately 85 % of all penetrating pulmonary injuries can be managed with these procedures [82, 85–87]. Lung tractotomy allows for rapid exposure and selective ligation of injured pulmonary structures, and thus reduces the need for emergent lung resection [86]. Tractotomy has allowed achieving rapid hemostasis with preservation of lung tissue. Use of stapling instruments has simplified the procedure. Smaller lung resections involving peripheral portions of a lobe were performed as nonanatomic wedge resections using surgical staplers. Lobectomy and pneumonectomy was required for resection of devitalized or destroyed pulmonary tissue in severe lung injuries.

Injury to the aorta and the arch vessels can occur following blunt and penetrating trauma. Traumatic aortic injury (TAI) is the second most common cause of death after blunt trauma [88]. As many as one-third of fatalities in motor vehicle collisions can be attributed to TAI [88, 89]. Burkhart and colleagues reported that 57 % of the deaths occurred at the scene or on arrival to the hospital, 37 % died within the first 4 h of admission, and 6 % died 4 h after admission [90]. In autopsy study involving traffic accidents, 33 % of the victims had associated TAI, 80 % patients with blunt TAI die prior to hospital arrival and only 20 % in hospital [88].

The most common anatomical site of aortic injury is the medial aspect of the lumen, distal to the left subclavian artery. Injury at this site is found in about 93 % of hospital admissions and in about 80 % of autopsy studies [91]. These resulting from a combination of high shear stress, heterogeneity in the wall architecture possibly contributing to focal wall weakness and acute transient intraluminal pressure loading [92, 93]. The most common type of injury is a false aneurysm (58 %), followed by dissection (25 %) and intimal tear (20 %) [94].

For those patients with TAI, timely diagnosis and prompt aggressive blood pressure control are essential in preventing free rupture of the contained aortic injury. Digital substraction angiography (DSA) was the gold standard for diagnosis of TAI traditionally. CT angiography (CTA) is now the new standard modality for screening and definitive diagnosis of TAI [91]. The diagnosis of TAI by DSA and CTA were showed in Fig. 4. The sensitivity and negative predictive value of the CT scan in the diagnosis of blunt TAI approaches 100 % [95]. Advances in CT technology have significantly improved the sensitivity of CT for the detection of TAI. The new-generation multi-slice CT scanners with 3-dimensional reformation have almost 100 % sensitivity and specificity, a 90 % positive and 100 % negative predictive value, an overall diagnostic accuracy of 99.7 %, and provide impressive anatomical details of the aortic arch and the injury site [91, 96]. Transesophageal echocardiography (TEE) as a diagnostic tool might be useful in critically ill patients in the intensive care unit who cannot be transferred safely to the radiology suite for CT scan [91]. Additionally, with regards to long-term surveillance and more specifically the detection of endoleaks, pseudoaneurysms and stent graft material-related complications, recent clinical practice guidelines by the Task Force for the Diagnosis and Treatment of Aortic Diseases of the ESC recommend the combination of a chest X-ray with either MRI or CT scan. Although CT is currently the preferred modality, they advise considering the dangers of radiation , especially in younger patients, and suggest the use of MRI except in cases of magnetic resonance-incompatible grafts [97].

Once the diagnosis is made, treatment must be properly timed. In general, minimal aortic injuries (intimal tear of less than 1 cm with no or minimal peri-aortic haematoma) receive conservative management [98]. Treatment of patients with TAI may be interventional surgical or conservative therapy dependent on clinical judgment on an individual basis [99]. The timing of repair according to the extent of injury on the thoracic aorta and the presence or absence of other injuries [100]. With regards to the best timing of intervention, the decision should be made based on the presence and severity of symptoms and related complications, comorbidities and the presence or absence of other injuries [100].

Prevention of free rupture by means of rigorous blood pressure control is the most urgent priority. The risk of free rupture is highest in the first few hours after the injury, with 90 % of ruptures occurring within the first 24 h [91]. Without rigorous blood pressure control, risk of rupture is about 12 %, and rigorous blood pressure control reduces the risk to about 1.5 % [101, 102]. Systolic blood pressure should be kept as low as tolerated, in most patients at about 90–110 mmHg. In elderly or head-injury patients, optimal systolic pressure might be slightly higher [91]. It is important to avoid excessive administration of intravenous crystalloid, as controlled hypotension is preferred to avoid blood pressure elevation and to decrease the likelihood of aortic rupture [103]. β-blockers and antihypertensive are the most commonly used modalities to modulate the systolic blood pressure [91, 103].

Interventional treatment for blunt TAIs can be either open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR) . The TEVAR has been widely rapidly adopted as an alternative to the OSR for treatment of traumatic aortic injury (Fig. 5). TEVAR is minimally invasive compared to surgery and can be performed soon after the establishment of diagnosis prior to management of other concomitant severe injuries. TEVAR is an effective option for the treatment of blunt TAI, numerous reports have demonstrated that blunt TAI have benefits of lower blood loss, shorter hospital stay, and reduced mortality rate, which confirming the increased utilization of TEVAR as the primary approach in selected trauma patients. Unlike aneurysmal disease, TAI is usually a focal lesion in the setting of a relatively younger and healthier aorta. As a result, a properly sized, delivered, and deployed device may have a potentially lower rate of long-term complications compared with other aortic pathologies [104].

The first case report of endovascular stent-graft treatment of a blunt TAI was published in 1997 [105]. Recently published observational studies and meta-analyses favor the use of the endovascular method as definitive treatment over open surgery in patients with TAI and support delaying repair of the injuries where possible. Azizzadeh and colleagues described an estimated odds ratio of 0.33 for complications including in-hospital mortality with TEVAR compared with open repair (OR), similar costs, and similar length of hospital stay [106]. In 2014, Branco et al. after a 9 year analysis of the same data bank, described favorable outcomes of the endovascular approach compared with OR in terms of in-hospital mortality (12.9 % vs. 22.4 %) and sepsis (5.4 vs. 7.5 %) [107]. Estrera et al. found that TEVAR was statistically superior to OR with cross-clamping but not to OR with distal aortic perfusion, in terms of survival (4, 31 and 14 % respectively). In the same study survival at 1 and 5 years post-intervention was 76 and 75 % respectively for OR, and 92 and 87 % for TEVAR [108]. According to Di Eusanio and colleagues, Delayed repair was used as first-line treatment for blunt TAIs and was associated with a very low mortality (3.9 %), mortality and paraplegia rates were not different comparing TEVAR and OR groups [109]. At midterm follow-up (median follow-up 2.3 years, range 0–7 years), TEVAR is an effective and durable option for the treatment of TAI in properly selected patients [104]. The incidence of in-hospital mortality, stroke, and paraplegia were 5.0, 2.4 and 0 %, respectively. The rates of device-related adverse events (2.4 %), secondary procedures (4.8 %), and open conversion are rare (2.4 %). Survival was 95 % at 30 days, 88 % at 1 year, 87 % at 2 years, and 82 % at 5 years. The late outcomes (mean, 103.9 months) following open and endovascular repair of TAI was reported by Patel shows that the overall crude mortality rate was 14.7 % and freedom from aortic reintervention at 4 years was higher after open repair (DTAR 100 % vs. TEVAR 94 %; P = 0.03) [110]. A recent study by Canaud et al. [111] described data of follow-up of minimum 10 years post-TEVAR (mean 11.6 years) with very encouraging results. The authors showed that the favorable outcomes of TEVAR over OR in terms of mortality and complications last over time, follow-up computed tomography scans did not reveal any stent-graft migration or collapse, or secondary endoleaks [111]. The findings support the use of TEVAR over OR for patients with TAI. However, there are no RCTs conducted to determine whether use of TEVAR for the treatment of blunt TAI is associated with reduced mortality and morbidity when compared to conventional open repair. To perform a randomized controlled trial to clarify optimal management of blunt TAI would be very challenging to complete, mainly because of the natural history of the condition, usually seen in combination with other life-threatening injuries, the requirement for urgent intervention and the potential difficulties surrounding consent [112]. Despite lack of RCT evidence, clinicians are moving forward with endovascular treatment of blunt TAI on the basis of meta-analyses and large clinical series. Recent clinical practice guidelines of the Task Force for the Diagnosis and Treatment of Aortic Diseases of the ESC, that advise the use of TEVAR in suitable anatomies (Level of Evidence: C). There are still some unresolved issues and areas of concern.