Aortic Injury In Children Research Articles

Aortic Injury From High-Speed Deceleration Against a Lap Belt in a 10-year-Old.

Traumatic aortic injuries in children and adolescents are rare, and even more rare are blunt traumatic injury to the abdominal aorta in this population. Therefore, there are few reports discussing the presentation and repair of such injuries, especially within the pediatric population. We report the successful repair of traumatic abdominal aortic transection in a 10-year-old female after a high speed MVC. She arrived in extremis with a seatbelt sign and was taken emergently for damage control laparotomy with subsequent postoperative CT findings of aortic transection/dissection at L3 with active extravasation. She immediately underwent open thrombectomy of the bilateral iliac arteries, and repair of her aortic injury with a 12 × 7mm Hemashield interposition graft extending just distal to the IMA and 1cm proximal to the aortic bifurcation. There are little data regarding long-term outcomes of pediatric patients undergoing different aortic repair techniques, and further research is needed.

Trends and Outcomes in Management of Thoracic Aortic Injury in Children, Adolescent, and Mature Pediatric Patients Using Data from the National Trauma Data Bank

Thoracic aortic injury (TAI) is rare in the pediatric population. Thoracic endovascular aortic repair (TEVAR) is the recommended standard of care for treatment in the adult population given its association with lower rates of mortality and morbidity than traditional open repairs for treatment of TAI. However, there are unique anatomic challenges in treating pediatric patients with TEVAR which may impact the outcomes and pediatric guidelines. We aimed to compare current management trends and outcomes between different pediatric age groups using data from the National Trauma Data Bank (NTDB). We analyzed the NTDB from 2007 to 2019 using International Classification of Diseases (ICD)-9 and -10 codes to identify patients with a TAI. We excluded patients older than 21years and any patients who died in the emergency department. The pediatric patients were stratified by age group: children (1-11years), adolescent (12-17years), and mature (18-21years) patients. Patient characteristics compared included injury mechanism and severity, TAI intervention, and outcomes between the 3 groups using bivariate analysis (analysis of variance for parametric and Kruskal-Wallis for nonparametric variables). These characteristics and outcomes were also compared by TAI intervention and injury mechanism. ICD-9 and -10 procedural codes were used to identify patients who underwent TEVAR, open aortic repair (OAR), or both. The modified Poisson regression was performed with relative risk (RR) to evaluate our primary outcome measure-mortality during the trauma admission. A total of 2,431 pediatric TAI were identified in the NTDB that met the inclusion criteria. This included 134 children (5.5%), 733 adolescent (30.2%), and 1,564 mature (64.3%) patients. Children had significantly lower median Injury Severity Scores (34.1) than the adolescent (38) or mature population (36.1) (P=0.001). The mechanism of injury differed between age groups. Children had higher rates of blunt trauma (90.3% children, 89.6% adolescent, and 86.8% mature patients) and mature patients had higher rates of penetrating trauma (6% children, 10.1% adolescent, and 12.5% mature patients) (P<0.001). TAI management also differed significantly between pediatric age groups. Mature patients had significantly higher rates of TEVAR (3% children, 25.2% adolescent, and 29.2% mature patients) and children were most likely to be treated with nonoperative management (NOM) (94% children, 67.9% adolescent, and 64.8% mature patients) (P<0.001). Patients who were treated with TEVAR were discharge home most frequently (31.8% NOM, 54.1% TEVAR, 44.3% OAR, 22.2% both TEVAR and OAR). Upon modified Poisson regression analysis, patient age was not associated with an increased risk of in-hospital mortality. Intervention with TEVAR (RR: 0.22, 95% CI: 0.15-0.33, P<0.001) and OAR (RR: 0.58, 95% CI: 0.36-0.93, P=0.024) were associated with a lower risk of mortality than NOM. TAI is less prevalent in children compared to adults. TEVAR for TAI is associated with lower risk of in-hospital mortality compared to both NOM and OAR without differences between pediatric subgroups. Further studies should be completed to determine the most appropriate management guidelines.

A single-center experience on the management of pediatric blunt aortic injury

ObjectiveBlunt abdominal aortic injury in children is a rare clinical entity with which most vascular surgeons have minimal experience. The evidence for management recommendations is limited. We have reported a single institution’s experience in the care of pediatric abdominal aortic injuries. MethodsWe performed a retrospective review of consecutive pediatric patients who had been diagnosed with blunt traumatic abdominal aortic injury at our institution from 2008 to 2019. ResultsA total of 16 pediatric patients (50% male) were identified. They ranged in age from 4 to 17 years. All had been involved in motor vehicle collisions and had been restrained passengers with a seatbelt in use. Five patients (31%) were hypotensive en route or on arrival. Seven patients (44%) had been transferred from another hospital. The median injury severity score was 34 (interquartile range, 19-35). The infrarenal aortic injuries were stratified using the aortic injury grading classification (five, two, seven, and two with grade 1, 2, 3, and 4, respectively). Concurrent nonaortic injuries included solid organ (63%; n = 10), hollow viscus (88%; n = 14), brain (25%; n = 4), hemothorax or pneumothorax (25%; n = 4), spine fractures (81%; n = 13), and nonspine fractures (75%; n = 12). Of the 16 patients, 9 (56%) had required aortic repair. Three had required immediate revascularization for distal ischemia. The remaining six patients (38%) had undergone delayed repair, with a median interval to repair of 52 days (range, 2-916 days). One half of the delayed repairs were performed during the index hospitalization. On repeat axial imaging, the three patients who had undergone delayed repair were found to have enlarging pseudoaneurysms or flow-limiting dissections and had subsequently undergone repair during the index hospitalization. Only one patient had undergone endovascular repair. No deaths occurred, and the median follow-up was 7 months (interquartile range, 3-28 months) for our study population. All postoperative patients demonstrated stable imaging findings without requiring further intervention. Seven patients, whose injury grades had ranged from 1 to 3, were observed. Their repeat imaging studies demonstrated either stability or resolution of their aortic injury. However, one half of the patients had been lost to follow-up after discharge or after their first postoperative clinic visit. ConclusionsDelayed aortic intervention can be safely performed for most pediatric patients with blunt abdominal aortic injuries with preserved distal perfusion to the lower extremities. This finding suggests that transfer to a tertiary center with vascular expertise is a safe and feasible management strategy. However, the progression of aortic injuries was seen as early as within 48 hours and as late as 30 months after injury, underscoring the importance of long-term surveillance. However, in our cohort, 50% of the children were lost to follow-up, highlighting the need for a more structured surveillance strategy.

Blunt abdominal aortic injury in children associated with lap belts.

Blunt abdominal aortic injury in children associated with lap belts.

Balloon expandable covered stents as primary therapy for hemodynamically stable traumatic aortic injuries in children.

To expand on the limited available literature regarding the use of balloon expandable covered stents for the treatment of traumatic aortic injuries (TAI) in the pediatric population. Although endovascular grafts have largely replaced surgery for TAI repair, there are significant limitations to the use of these grafts in pediatric patients. Multicenter, retrospective chart review of pediatric patients with TAI following blunt chest wall trauma. Procedural characteristics, follow-up, and reinterventions are described. Six covered stents implanted in five patients. Median patient age was 12 years (11-13 years) and median weight 50 kg (44-54 kg). Procedural success was achieved in all cases. No procedural or postprocedural complications were noted. Median follow-up time was 24 months (11-36 months). Balloon expandable covered stent treatment of pediatric patients with TAI is a feasible alternative to open surgical repair, and preferred over endovascular grafts due to graft size limitations and the large delivery systems.

Traumatic Aortic Injuries in Children – A Single Institution 22-year Experience

Traumatic Aortic Injuries in Children – A Single Institution 22-year Experience

Percutaneous Balloon-Expandable Covered Stent Implantation for Treatment of Traumatic Aortic Injury in Children and Adolescents

Surgical treatment of pediatric acute traumatic aortic injury (TAI) after blunt chest trauma is standard of care. Use of endovascular stent grafts for treatment of TAI in adults is common but has important limitations in children. We sought to describe the use of balloon-expandable covered endovascular stents for treatment of TAI in children and adolescents. Participants of the multicenter Coarctation of the Aorta Stent Trial (COAST) had access to investigational large-diameter, balloon-expandable, covered stents (covered Cheatham-platinum stents; NuMed, Inc., Hopkinton, New York) on an emergency-use basis. From 2008 through 2011, 6 covered stents were implanted in 4 patients at 3 COAST centers for treatment of TAI. Median patient age was 13.5 years (range 11 to 14) and weight was 58 kg (40 to 130). All patients sustained severe extracardiac injuries that were judged to preclude safe open surgical repair of TAI. Median aortic isthmus and stent implantation balloon diameters were 16.4 mm (13.2 to 19) and 19 mm (16 to 20), respectively. Stent implantation was technically successful in all attempts. Complete exclusion of aortic wall injury was achieved in all cases. There were no access site complications. At a median follow-up of 24 months, there was 1 early death (related to underlying head trauma) and 1 patient with recurrent aortic aneurysm who required additional stent implantation. In conclusion, balloon-expandable covered-stent implantation for treatment of pediatric TAI after blunt trauma is generally safe and effective. Availability of this equipment may alter the standard approach to treatment of pediatric TAI.

Pediatric vs adult vascular trauma: a National Trauma Databank review

Introduction The purpose of this study was to examine nationwide data on vascular injuries in children and to compare pediatric and adult patients with respect to the incidence, injury mechanisms, and outcomes. Methods This is a National Trauma Databank analysis based on dataset version 7.0 (spanning a 5-year period ending December 2006). Pediatric patients under the age of 16 with at least one reported diagnosis of a vascular injury were compared to the adult cohort aged 16 and greater with a vascular injury. Results During the study period, of 251,787 injured patients younger than 16 years, 1138 (0.6%) had a vascular injury. The incidence in patients 16 years or older was significantly higher, at 1.6% ( P < .01). Compared to the adult vascular patients, pediatric patients had a significantly lower Injury Severity Score (16.8 ± 14.9 vs 26.3 ± 16.7, P < .001) and encountered less frequently penetrating injuries (41.8% vs 51.2%, P < .001). The most commonly injured vessels in the pediatric population were vessels of the upper extremity (424 patients or 37.9%). The overall incidence of thoracic aortic injuries in children was seven-fold lower compared to the incidence in adults (0.03% vs 0.21%). After adjusting for confounding factors, pediatric patients demonstrated improved survival following vascular injuries (adjusted odds ratio, 0.60; 95% CI, 0.45-0.79; P < .001). No significant difference was identified in the rate of amputation between pediatric and adult patients who had sustained upper or lower extremity vascular injuries. Conclusion Vascular trauma in the pediatric population is uncommon, occurring in only 0.6% of all pediatric trauma patients. Although less frequent than adults, a significant proportion was due to penetrating injury. Vessels of the upper extremity were the most commonly injured and were associated with low mortality. Injuries of the thoracic aorta are rare. Overall, pediatric patients had an improved adjusted mortality when compared to adults.

Endovascular stenting of blunt thoracic aortic injury in an 11-year-old

Blunt traumatic thoracic aortic injury in children is very rare. Open surgical repair is the definitive treatment. Thoracic endovascular aortic repair (TEVAR) for trauma has been performed in adults with good outcomes. Its use has been adopted in pediatric population, and its role is evolving. We report a successful TEVAR in a critically injured 11-year-old boy. To our knowledge, this is the youngest patient to be successfully treated with TEVAR.

Traumatic aortic injuries in the pediatric population

Background/Purpose Blunt trauma is the leading cause of pediatric injury, but pediatric aortic injuries are rare. We undertook this study to investigate the demographics, treatment, and outcomes of children with blunt aortic injuries and report our experience over a 10-year period. Methods After Institutional Review Board approval, a 10-year retrospective review of all pediatric patients admitted with blunt aortic injury was performed. Patient demographics, injury details and severity score (Injury Severity Score), treatment, and outcomes were recorded. Results There were 11 children, with ages ranging from 7 to 19 years. The most common mechanism of injury was motor vehicle crashes (8). Initial computed tomography demonstrated all 11 injuries: 7 thoracic aortic (TA) and 4 abdominal aortic (AA) injuries. Associated injuries were common. The TA injuries included 4 transections, 2 intimal flaps, and 1 pseudoaneurysm. Three of these were managed nonoperatively. The AA injuries included 3 intimal flaps and 1 dissection. Three of these were also managed nonoperatively. There were no complications in the 4 children with AA or in the 3 children with TA managed nonoperatively. Complications in the 4 children undergoing operative repair of the TA included paraplegia, renal failure, recurrent laryngeal nerve injury, and pulmonary embolus. The mean hospital stay was 8 days. All children survived, with all but one discharged directly to home. Conclusions Blunt aortic injury in children is uncommon and is primarily associated with motor vehicle crashes. Injuries to the abdominal aorta were seen with restrained children vs those to the thoracic aorta that were seen in children who were unrestrained.

Risk factors for blunt thoracic aortic injury in children

Background/Purpose Because blunt thoracic aortic injury is rare in children, a high index of suspicion is needed to identify this injury. The purpose of this study was to use a large national trauma database to define the risk factors for blunt thoracic aortic injury in children. Methods Using the National Trauma Database, the authors compared patient demographics, mechanism of injury, and associated injuries between children sustaining blunt trauma with and without a thoracic aortic injury. Factors independently associated with this injury were identified using multivariate methods. Results Among 26,940 children with a blunt mechanism of injury, 34 (0.1%) children sustained a thoracic aortic injury, 14 (41%) of whom died. Thoracic aortic injuries were independently associated with age, injury sustained as an occupant in a motor vehicle crash, and severe injuries (Abbreviated Injury Scale value of ≥3) involving the head, thorax (other than aorta), abdomen, and lower extremities. Conclusions Older children involved in a motor vehicle crash with severe head, torso, and lower extremity injuries are a group at high risk for injury to the thoracic aorta. These easily identifiable risk factors may facilitate more rapid identification of this rare and potentially fatal injury.

Traumatic aortic injuries in children: radiologic evaluation.

The purpose of this study was to evaluate the radiographic findings in children with traumatic aortic injuries and discuss the imaging techniques currently available for diagnosis. A retrospective review of 10,886 children examined because of blunt trauma from 1987 to April 1996 identified seven patients (0.064%) who sustained traumatic aortic injuries. The mechanism of injury, location of aortic injury, additional injuries suffered, trauma scores, sequences of radiologic evaluation, imaging findings, treatment, and outcome were recorded for each child. Six children had pathologically proven aortic ruptures, and the remaining child had an intimal injury diagnosed with contrast-enhanced helical CT and confirmed with transesophageal echocardiography. All seven children were victims of motor vehicle accidents (six passengers, one pedestrian), all had injuries of the aortic isthmus, and all had additional severe injuries. The mean trauma score, injury severity score, and probability of survival were 14, 39, and 75%, respectively. Imaging techniques included chest radiography (n = 7), conventional CT (n = 1), helical CT (n = 3), aortography (n = 2), and transesophageal echocardiography (n = 3). The initial outcomes included death (n = 1), paraplegia (n = 1), paraparesis (n = 2), and recovery without morbidity (n = 3). Traumatic aortic injuries are rare in children. The most common findings on plain films are a left apical cap, pulmonary contusion, aortic obscuration, and mediastinal widening. Helical CT and transesophageal echocardiography can be used in the diagnosis of traumatic aortic injuries in children.

Blunt thoracic aortic injury in children

Thoracic aortic injury (TAI) in children secondary to blunt chest trauma is rare and less well documented than TAI in adults. To further establishe the incidence and radiographic manifestations of this severe injury, we reviewed our experimence with TAI in children over an 8-year period. We performed a computer search from the Trauma Registry at our level I trauma center for all cases of TAI among patients 16 years of age or younger who were admitted after sustaining blunt chest trauma between August 1984 and September 1992. We reviewed our records of all thoracic aortograms performed on children for blunt trauma during this same time period. Indication for angiography was determined by review of chest radiographs and medical records of all patients who underwent thoracic aortography. We reviewed medical records and all available chest radiographs, computed tomography (CT) examinations, and thoracic aortograms of children diagnosed with TAI. Of 308 children admitted with blunt chest trauma, 26 (8.4%) underwent angiography to exclude aortic or great vessel injury. Of these 26 patients, three (11.5%) were diagnosed with TAI, and one patient demonstrated a traumatic pseudoaneurysm of the proximal left subclavian artery. The incidence of TAI among children who sustained blunt chest trauma was 1.0% in our series. All three patients with TAI in our series were male, ages 10–12 (mean: 11 years). Chest radiographs on two of the patients with TAI revealed mediastinal widening, ill-defined aortic outline, shift of the trachea and nasogastric tube, and depression of the left main stem bronchus. The chest radiograph in one patient with TAI was technically inadequate. CT demonstrated abnormalities in two patients. Angiographic findings were similar to those seen in adults. TAI in children is rare, occurring in 1% of children sustaining blunt chest trauma in our series. Our findings support previous reports that the plain film, CT, and angiographic findings with this injury resemble those found in adults.

Aortic Arch Rupture in a Child Following Minor Blunt Trauma

We report the case of a seven-year-old boy who sustained near-total transection of the aortic arch following apparently minor blunt injury. The radiological and operative findings and the successful outcome of urgent surgical repair support an aggressive approach to the diagnosis and management of suspected aortic injuries in children.