Transesophageal echocardiography (TEE) is a rapid, reliable and safe investigation in patients with aortic disruption, which can guide immediate therapeutic intervention. We present the TEE characteristics of partial aortic disruption.
A 58-year-old hypertensive female was admitted to a peripheral hospital with complaints of chest pain. Investigation on admission showed normal electrocardiogram, chest X-ray, biochemical parameters and cardiac enzymes. Ten hours later, hemoglobin dropped to 6.5 g/dl and chest X-ray revealed a large homogenous opacity in the left thorax with widened mediastinum [Figure 1]. Hemodynamic instability ensued hence, she was transferred to our hospital. She presented to us in hemorrhagic shock. After initial resuscitation, TEE (multi-plane 5 MHz transesophageal probe GE Vingmed Ultrasound, Horten, Norway) was performed. The aorta was examined serially, ascending aorta appeared normal with no dissection flap seen. On following the arch towards the descending thoracic aorta, we found a discontinuity in the aortic wall at around 28 cm from incisor [Figure 2]. The site and nature of the abnormality was suggestive of partial aortic disruption at the level of the isthmus and blood flow was noticed through the discontinuity in the aortic wall [Figure 2] and [Figure 3], [Video 1] . Aortic contour was also deformed [Video 2] . During the emergent surgery, aortic disruption was confirmed at the level of isthmus. The aortic disruption was repaired with Dacron interposition graft. After surgery, she developed disseminated intravascular coagulopathy and succumbed.
Figure 1: Chest X-ray showing widened mediastinum, left hemithorax opacity and tracheal deviation to the right side
Aortic disruption is a fatal emergency.  There are several mechanism proposed including: (1) rapid deceleration leading to shearing stress to the aorta; (2) aortic compression between the sternum and the thoracic spine; (3) direct load leading to deep medial tears due to the aortic wall strains. ,, 50% of the survivors die in next twenty four hours.  The most common site of aortic disruption is isthmus being tethered by ligamentous arteriosum.  Computed tomography (CT) aortogram have been a gold standard for the diagnosis; however, it requires mobilization of the patient to the radiology department and is a time consuming process.
Diagnostic accuracy of TEE for aortic dissection is comparable to the CT and magnetic resonance imaging. Largest series by Smith etal., had shown 100% sensitivity and 98% specificity of TEE for aortic disruption.  TEE is also indicated as a first line investigation in a suspected case of acute aortic syndrome. A suspected case of aortic disruption with significant hemodynamic instability should preferentially undergo TEE in the emergency department to enable early intervention. However, one should rule out esophageal injury before TEE. Complete aortic disruption leads to immediate death due to rapid exsanguination. The survivors report to the hospital due to contained hematoma leading to the development of an aortic pseudoaneurysm. Berenfeld etal., described echocardiographic characteristic of such a pseudoaneurysm.  Vignon etal., described four distinct types of aortic disruption based on TEE findings: 1. Traumatic aortic intimal tears; 2. Total aortic disruption; 3. Subtotal aortic disruption; and 4. Partial aortic disruption.  In intimal tears, there is no involvement of intimal and medial layers and is managed conservatively. While total aortic disruption involves entire aortic circumference, the subtotal involves more than two third of the aortic circumference. In partial aortic disruption, there is a limited discontinuity of the intimal and the medial layers as was seen in our case, which can be confused as entry point of aortic dissection. TEE provides high quality images due to high frequency ultrasound waves and proximity of the probe to the aorta. TEE provides reliable, rapid and safe diagnosis in such patient facilitating early therapeutic intervention. Acute aortic disruption can be treated safely with endovascular stent graft. 
Vignon P, Guéret P, Vedrinne JM, Lagrange P, Cornu E, Abrieu O, et al. Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption. Circulation 1995;92:2959-68.