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Ann Thorac Surg 1996;62:724-731
© 1996 The Society of Thoracic Surgeons
Divisions of Cardiothoracic Surgery and Cardiology, Children's National Medical Center and The George Washington University Medical Center, Washington, DC
Accepted for publication April 17, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. Between July 1989 and December 1995, 6 children were treated operatively for thoracic aortic rupture from blunt trauma at a level I pediatric trauma center. The average age was 13.2 years (range, 8 to 16 years). There were 4 females and 2 males. There were 5 motor vehicle accidents and 1 bicycle accident. Aortic injury was suspected based on the mechanism of injury and abnormal chest roentgenogram results, and was confirmed by aortography (3 cases) or chest computed tomography (2) and transesophageal echocardiography (3). Life-threatening central nervous system or gastrointestinal injuries were evaluated or treated first. Operative repair of the thoracic aorta was performed by cardiopulmonary bypass (2 patients) and clamp and sew technique (4).
Results. Aortic ruptures were complete transections at the ligamentum arteriosum in 5 of 6 (83%); the other case was a cervical arch pseudoaneurysm. Associated injuries included pulmonary contusion (100%), pelvic/long bone fractures (50%), visceral laceration/perforation (50%), central nervous system (33%), paraplegia (17%), and myocardial contusion (17%). There were no rib fractures. Four of 5 patients (80%) were not wearing seat belts, and 2 of these were ejected. The average time from injury to the operating room was 17.6 hours (range, 5 to 48 hours); the time from diagnosis to the operating room exceeded 5 hours with aortography and was less than 3 hours with chest computed tomography and transesophageal echocardiography. Each diagnostic modality accurately identified an aortic injury. The average time for cardiopulmonary bypass and for clamp and sew was 52 minutes (range, 49 to 55 minutes) and 34 minutes (range, 16 to 45 minutes), respectively. One patient with preoperative paraplegia regained partial function; there were no other patients with paraplegia. There were no deaths. All patients are alive 2 months to 7 years after repair.
Conclusions. The multiply injured child with severe blunt trauma and an abnormal chest roentgenogram requires a search for aortic injury. We believe the most effective algorithm to follow for the diagnosis of traumatic thoracic aortic rupture in the child involves selective performance of chest computed tomography and transesophageal echocardiography. Our experience suggests that the mechanism of injury, the duration to diagnosis of an aortic injury, and failure to use seat belts may contribute to morbidity. A high index of suspicion and a systematic approach to the diagnosis and to the management strategy for injuries to the thoracic aorta can contribute to a good outcome in those few children who survive the injury.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Blunt trauma to the thoracic aorta is a well-documented injury in adults [1–6]. In the pediatric age group (<17 years of age), this injury is extremely rare, and the experiences reported are limited to case reports [7–10]. Nonetheless, the prehospital mortality rate is 80% to 85% in either children or adults. Of the 15% to 20% who survive the injury, the patient with an undiagnosed aortic injury at initial evaluation will have a hospital mortality greater than 50% after 48 hours [4–6]. In addition, these patients often have multisystem injury. It has been observed that more than 80% of patients with combined cardiac and aortic injuries and more than 50% of patients with isolated aortic injury would have died if there had been no cardiovascular trauma [4]. If injuries are diagnosed in a timely fashion, however, a survival between 75% and 90% can be expected [4–6]. Therefore, given the limited information dealing with aortic injuries in children, experiences that can give insight into the epidemiology, pathophysiology, and management of these trauma victims are needed. We reviewed our experience with blunt traumatic thoracic aortic rupture (TAR) in the pediatric patient to help identify factors that may influence injury occurrence, diagnosis, management, and outcome.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The children were extricated or retrieved from the accident and transported by life-support system vehicles to the trauma bay. Each patient was stabilized according to the advanced trauma life support protocol. The trauma team included members from the emergency department, pediatric intensive care unit (PICU), anesthesiology, and pediatric surgery. Consultations from subspecialties were obtained when indicated. Life-threatening central nervous system and gastrointestinal injuries were evaluated and treated first. The usual diagnostic method for these injuries was computed tomography (CT), unless physical findings or hemodynamic instability warranted operative intervention. Trauma to the thoracic aorta was suspected because of severity of the injury mechanism (eg, high speed of collision, ejection from the vehicle, or multiple injuries) and abnormal chest roentgenogram (CXR) results. Diagnosis was confirmed by aortography or chest CT and transesophageal echocardiography (TEE). Patients were then prepared urgently for the operating room (OR).
Intraoperative management consisted of barbiturate and narcotic-based anesthesia and, whenever applicable, a double-lumen endotracheal tube. Hemodynamic monitoring was done by a right radial arterial line and a central venous catheter. A Swan-Ganz catheter was placed if there was evidence of myocardial contusion. Mean arterial blood pressure was maintained between 85 and 110 mm Hg. Hypothermia was achieved to 31° to 33°C by a cooling blanket (passive) or when cardiopulmonary bypass (CPB; active) was used. All patients had a Foley catheter placed to measure urine output. Mannitol, bicarbonate, and methylprednisolone were not routinely administered at induction or before or after removal of the aortic cross-clamp. Cefazolin (15 mg/kg) was given intravenously before incision.
A standard left posterolateral thoracotomy was performed to approach the aortic rupture site in 5 children, and a median sternotomy was done in 1 child with a cervical arch. Distal and proximal control was secured without entering the hematoma. Cardiopulmonary bypass or distal perfusion techniques were used in 2 children. In 1 child with a cervical arch pseudoaneurysm, the right atrium and left femoral artery were cannulated, and in another with a hematoma extending to the arch, the left atrium and left femoral artery were cannulated. Heparin (3 mg/kg) was administered for each bypass procedure. Vascular clamps were sized, and sequential occlusion of the left subclavian artery, aortic arch between the left carotid and subclavian arteries, and descending aorta was performed. The clamp on the descending aorta was placed as close as possible to the distal extent of the aortic rupture site without entering the hematoma. At all times, careful attention was given to preserve intercostal arteries and avoid injury to the vagus and recurrent laryngeal nerves. The hematoma was then incised, and the proximal and distal ends of the aorta were identified and prepared for anastomosis. A Hemashield (Meadox Medicals, Inc, Oakland, NJ) interposition graft of the largest size possible was used for the repair and was anastomosed with 4-0 Prolene (Ethicon, Somerville, NJ). If readily located, the ligamentum arteriosum was oversewn and divided. Cross-clamp removal was in the same sequence as application. Communication was maintained between the surgeon and anesthesiologist regarding blood pressure control and volume administration. At the conclusion of the procedure, the patient was transported to the PICU for management.
Definitive repair for orthopedic injuries or other trauma was performed once the patient had stabilized from the life-threatening injuries. For patients with a severely weakened condition, substantial long-bone and pelvic fractures, or residual neurologic deficit, rehabilitative therapy was instituted early. Once there was evidence of gastrointestinal function, enteral feeding was started. Thromboembolism prophylaxis involved compressive leg devices, patient rotation, and rotary bed therapy. As of July 1995, in patients who required long-term bed rest for orthopedic injuries combined with residual paraplegia or paraparesis, an empiric inferior vena cava filter (Greenfield) was placed [11]. Routine and rehabilitative care was maintained on the pediatric surgery service until discharge.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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. There were 4 female and 2 male patients. The average age was 13.2 years (range, 8 to 16 years). There were five MVAs and one bicycle accident. For the MVAs, extrication time exceeded 30 minutes in 3 patients, and 2 other patients were ejected. Four of 5 patients (80%) were unbelted passengers or drivers. The bicycle accident was the result of a collision with a stationary bus. Four of 6 patients presented to Children's National Medical Center as acute trauma. For the 2 others, 1 (MVA) was seen first at an adult center and was subsequently transferred, and the other (BCA) was evaluated at another emergency department and presented 48 hours later after having been discharged.
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) had sustained preoperative hypotension (systolic blood pressure <90 mm Hg) and paraplegia, and 2 patients (patients 5 and 6, see Table 1) had a pseudocoarctation syndrome with elevated arm pressures (systolic blood pressure >170 mm Hg) and diminished or absent lower-extremity pressures (systolic blood pressure <50 mm Hg).
Thoracic aortic injury was suspected on CXR because of a widened mediastinum in 5 of 6 patients, a hemothorax in 2 of 6 patients, and a loss of aortic knob contour in 1 of 6 patients. There were no rib fractures. These findings were confirmed by aortography in 3 patients and by chest CT and/or TEE in another 3 patients. Aortography was the initial diagnostic study of choice in 1 patient to rule out TAR before 1990, before application of TEE. One other patient had aortography performed at an adult trauma center, and the other had aortography performed because of obstruction of the esophageal probe by a bulging cervical arch pseudoaneurysm (patient 3, see Table 1). For the hemodynamically stable child, the subsequent diagnostic study after CXR was a helical (or spiral) chest CT. Chest CT accurately diagnosed TAR by demonstrating an aortic transection near the aortic isthmus with mediastinal hematoma in 2 patients. The exact location of the tear, however, could not be delineated. These patients, plus 1 patient in the PICU after exploratory celiotomy, had TEE. Transesophageal echocardiography identified full-thickness TAR distal to the left subclavian artery in 3 of 3 patients, determined the extent and location of the periaortic hematoma, identified 1 patient with a myocardial contusion, and ruled out associated valvular injury in all others. Overall, the average time from injury to the OR was 17 hours (range, 5 to 48 hours). Excluding the 1 patient with the bicycle accident who presented 48 hours after the initial injury, the average time from injury to the OR was 10.8 hours (range, 5 to 18 hours). Once the aortic injury was suspected, the time from diagnosis to the OR was more than 5 hours with aortography and less than 3 hours with chest CT and TEE.
At operation, all TARs were surrounded by a hematoma. The patient with the cervical arch pseudoaneurysm had a partial tear in the abnormal arch, whereas all other tears (5 of 6) were complete transections separated by 1 to 5 cm from the ligamentum arteriosum (aortic isthmus). In 2 of these latter patients, we visualized an expanding mediastinal hematoma, flaccid or pulseless distal descending aorta, and active bleeding within the chest cavity. All patients had repair requiring interposition grafting with prosthetic material. The patient with the cervical arch pseudoaneurysm had the injury site bypassed; all other grafts were placed in situ. For the 2 patients who had CPB or distal perfusion techniques, the average aortic cross-clamp time was 52 minutes (range, 49 to 55 minutes). For the 3 patients who had repair by the clamp and sew technique, the average cross-clamp time was 34 minutes (range, 16 to 45 minutes). There were no intraoperative complications, and all operative findings correlated with the preoperative diagnostic data.
Immediate postoperative complications included prolonged ventilation and pneumonia (1), transient unilateral vocal cord paralysis (1), delayed gastric perforation (1), paraplegia (1), paraparesis (2), prolonged ileus (1), pancreatitis (1), and fungal central line infection (1). Six of nine complications occurred in 1 patient. No patient experienced renal failure, and none had adult respiratory distress syndrome or required tracheostomy. There were no clinically detected episodes of deep venous thrombosis or pulmonary embolism. For the 2 patients who had a Greenfield filter placed (patients 5 and 6, see Table 1), there was no inferior vena cava clot seen at venography, nor were there any procedure-related complications. The average days in the PICU and hospital were 7.2 (range, 1 to 15 days) and 24.8 (range, 7 to 48 days), respectively. There were no hospital deaths.
There were no residual long-term central nervous system deficits related to head trauma. The patient with preoperative paraplegia remained paraplegic at discharge; however, with rehabilitative therapy this child has regained limited lower-extremity motor function. This patient was transferred from another institution, had a period of more than 5 hours from aortography to the OR, had sustained preoperative hypotension, and had repair with a cross-clamp time of 40 minutes. The 2 patients with postoperative paraparesis each had elevated arm pressures (systolic blood pressure >170 mm Hg), a decrease in the motor function of the lower extremities, and a decrease or loss of the femoral pulses (pseudocoarctation syndrome) before transport to the OR. These 2 patients had their aortic injury diagnosed with chest CT and TEE and were in the OR less than 3 hours after the diagnosis. Each had the aorta repaired by the clamp and sew technique, with an average clamp time of 42.5 minutes. These same 2 patients were also noted to have a flaccid distal aorta at thoracotomy. For these 3 patients, the average time from injury to the OR was 10.3 hours (range, 5 to 18 hours). The remaining patient whose injury was repaired by the clamp and sew technique had a time from injury to the OR of 16 hours, did not have evidence of a pseudocoarctation syndrome, was diagnosed by TEE, had a cross-clamp time of 16 minutes, and showed no neurologic sequelae. The 2 patients repaired by distal perfusion techniques involved one acute trauma (aortic rupture) and one delayed presentation (cervical arch pseudoaneurysm). The time from injury to diagnosis was 7 and 48 hours, respectively. Both patients were diagnosed with aortography. Neither patient had a change in preoperative examination, and each had a pulse in the distal aorta at operation. There were no neurologic sequelae in these 2 patients. Thus, for the entire group, 3 of 6 patients (50%) had a spinal myelopathy, but there were no patients with new postoperative paraplegia. At 2 months to 7 years of follow-up, all patients are alive. Both patients with postoperative paraparesis continue to recover motor function, with 1 patient currently limited to ankle braces.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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). It also has been suggested that a majority of aortic injuries result from auto versus pedestrian accidents [8, 10], but our series and other reports [9, 12, 13] indicate that the majority of injuries result when an unrestrained passenger is involved in an MVA. Eighty percent of the children in our series were unrestrained passengers, and 2 of 5 (40%) of these were ejected.
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Our experience also emphasizes the need for continued reassessment of the physical examination, as the presence of a pseudocoarctation syndrome preoperatively correlated with compromised perfusion distal to the aortic injury at operation and was associated with postoperative neurologic morbidity. Thus, although the frequency of TAR differs in children and adults, multisystem trauma may be common to both. The features of TAR in the pediatric patient that should raise suspicion are the mechanism of injury, the CXR abnormalities, and the presence of a pseudocarctation syndrome.
Pathophysiology
The pathophysiology of blunt TAR has been explained as the result of four separate forces that may have an impact on the location and severity of the aortic rupture: (1) horizontal deceleration, (2) vertical deceleration, (3) extreme chest compression, and (4) a severe crushing injury [4, 5]. When these forces are applied, increases in aortic pressure also likely contribute to the aortic disruption. Each mechanism can apply to the child in an MVA depending on location, constraint as a passenger, or whether the child is ejected, although horizontal deceleration is classically attributed to explain TAR from MVAs in children or adults.
When exposed to a sudden horizontal deceleration, the relatively immobile descending aorta, held in the vertebral sulcus by intercostal vessels, ligamentum arteriosum, and overlying mediastinal pleura, decelerates at a different rate compared with the fairly mobile heart and aortic arch. This results in a shearing stress that has a maximal force at the aortic isthmus, adjacent to the ligamentum arteriosum [4, 5]. This analysis of forces explains why adults experiencing horizontal deceleration, as commonly seen in the MVA victim, have more than 90% of TAR occurring at the aortic isthmus. Our report also confirms this analysis, as 100% of the children involved in an MVA sustained complete aortic transection at the aortic isthmus. Though these anatomic and physical properties explain how TAR occurs in children and adults, it does not explain why the injury occurs so infrequently in children.
Some reports have suggested that the high compliance of the chest wall in children helps distribute the forces away from the aorta, whereas others imply that the lack of atherosclerosis in the pediatric aorta protects the intima against the various forces [7, 10]. These may be some of the explanations, but it could also be postulated that the elasticity of the pediatric chest prevents the child from sustaining a dramatic blunt force. The impact from a sudden collision, as can occur in the child who is a passenger or in one who is ejected in an MVA, can result in a transient compression of the heart and mediastinum against the spine, displacing the relatively mobile aortic arch upward relative to a fixed or slightly downward displacement of the pulmonary artery and ligamentum arteriosum, creating an abrupt shearing and bending stress at the aortic isthmus.
The lack of atherosclerosis in the pediatric aorta implies that the integrity of the intima is maintained. There is evidence of atherosclerotic plaques or calcium in the aorta beginning in the third decade. This pathologic feature may make the adult aorta more susceptible to the stresses of deceleration forces. Though unproven, the histologic makeup of the intima and medial layers of the pediatric aorta may be more distensible and stronger, allowing it to withstand greater tension. In general, the intima and media withstand relatively low levels of stress and pressure, with the adventitia being most resistant to rupture. This important anatomic feature is what contains the hematoma or pseudoaneurysm after TAR and allows the 15% to 20% who survive the injury to make it to the hospital. Hospital death results when the subadventitial or mediastinal hematoma can no longer be maintained by the adventitia or mediastinal pleura and ruptures into the chest cavity, resulting in fatal hemorrhage. Although the frequency of injury in adults relative to children has yet to be explained by pathophysiologic features, it is clear that it is the strength of the aortic adventitia that can preserve life after TAR.
Diagnosis
Once the patient with multisystem trauma is suspected of having TAR, it is imperative to make or exclude the diagnosis with a method that is expedient and effective. The method for diagnosis of TAR has evolved over the past 3 to 5 years in adults. The CXR findings that raise the index of suspicion have been cited numerously [4, 5, 13], but as in the adult patient, a negative CXR in the child with multisystem trauma and a severe mechanism of injury is enough to warrant other diagnostic tests. Aortography traditionally has been the "gold standard" to diagnose an acute aortic injury in both children and adults [4, 5, 9, 10, 13]. Recently, dynamic or helical CT [15, 16] and TEE [17–20] have become effective tools for both screening and diagnosis of TAR. Although helical chest CT cannot determine the precise location of the rupture site and cannot reliably rule out an injury compared with aortography, in the hemodynamically stable patient with abnormal CXR results or with a mechanism of injury to suggest TAR, it can provide effective and rapid screening [15, 16]. In our experience, chest CT has either established the diagnosis or revealed a mediastinal hematoma warranting a study to confirm or define the injury. We are hesitant, however, to rely solely on chest CT to diagnose or exclude an aortic injury in those patients for whom we have a high index of suspicion because the sensitivity remains inferior to that of either aortography or TEE. Thus, in the hemodynamically stable child whose chest CT results suggest an aortic injury, an immediate TEE is performed either in the PICU or the OR.
Transeophageal echocardiography has become an established and reliable method to diagnose and define the aortic injury at institutions with experience and expertise [17–20]. The advantages of this method of diagnosis for TAR in the pediatric population are that it avoids femoral artery puncture; does not rely on invasive radiology support, which may not always be available; is transportable and rapid; and is performed by cardiologists with experience at evaluating cardiac and great vessel anatomy. We have found TEE extremely helpful in planning our operative approach by accurately identifying the location of the aortic tear in addition to assessing cardiac anatomy and function. Since 1990, we have used TEE to evaluate 10 children suspected of having an aortic injury after blunt trauma. Seven TEEs were negative, and the three positive studies are reported herein. To date, we have had no false-positive or false-negative studies. Our experience also suggests that the combination of chest CT and TEE versus aortography allows a more rapid diagnosis, thereby decreasing the time from diagnosis to the OR, which could have a clinical impact on those patients with TAR who have evidence of lower-extremity neurologic or vascular compromise. Another benefit is in the hemodynamically unstable patient who requires emergency operation. A TEE study can be performed rapidly in the OR, and a diagnosis can be established that could influence the required operative approaches. However, in cases that are equivocal or cannot be diagnosed by chest CT and TEE, aortography should be performed to complete the search for TAR.
Contraindications to TEE include esophageal trauma, previous esophageal operation, a chronic esophageal pathologic process that precludes safe passage of the probe, an unstable cervical spine injury, or an aortic injury that results in a hematoma that is compressing the esophagus, as seen in 1 of our patients with a cervical arch pseudoaneurysm. Therefore, although we have not eliminated aortography as a method to diagnose TAR, it is not our initial choice for establishing the diagnosis of an aortic injury. Our current approach for diagnosing TAR in the child is shown in Figure 1. As our experience and that of others grows with such an approach, we will continue to assess its effectiveness and reliability. As with all algorithms, there must be flexibility that is based on clinical experience and judgment, and a search for an aortic injury is not complete unless the diagnosis is established or reliably excluded.
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Based on our experience thus far in the pediatric patient with TAR, 50% of the children had preoperative evidence of spinal myelopathy, with 1 patient presenting with paraplegia. Thus, our goals at operation have been to ensure survival, to repair the aorta safely, and to restore distal perfusion as rapidly as possible without added risk or morbidity. It is with this rationale, and our experience thus far in children, that we believe the clamp and sew technique can minimize dissection, allow rapid control of the aorta, avoid heparin, and ultimately restore native flow to the distal aorta in a time frame equivalent to that of distal perfusion techniques.
Although the incidence of paraplegia after repair of TAR in adults ranges between 0% and 30% [4–5, 24, 25], there remains no prospective study comparing distal perfusion and clamp and sew techniques, and neither technique has proved to be without mortality or paraplegia [4–6, 21, 24, 25]. We concur with a philosophy suggested by Mattox [22, 23] that no approach should be abandoned or condemned, but that emphasis should be placed on the severity and complexity of the aortic injury. The development of a spinal myelopathy (paraplegia or paraparesis) in the 3 pediatric patients we have reported does not appear to be attributable directly to either technique; therefore, the causes of spinal myelopathy in the pediatric patient may be multifactorial.
Factors that have been implied to cause spinal myelopathy are sustained preoperative or perioperative hypotension, the pseudocoarctation syndrome, interruption of critical intercostal arteries, the location and extent of the injury, duration to repair of the injury, and associated spinal fractures or dislocations [24, 25]. The mechanism is presumably ischemia to the spinal cord resulting from an interruption of critical blood flow. It is interesting that in the 3 patients who had postoperative spinal myelopathy, each also had preoperative changes in the lower-extremity vascular and neurologic status, preoperative hypotension or pseudocoarctation syndrome, and an average time from injury to the OR of more than 10 hours. In these patients, there were also the operative findings of an expanding mediastinal hematoma and flaccid distal aorta, suggesting the absence of critical arterial flow below the aortic injury. Some authors [21, 26] have advocated institution of pharmacologic therapy until other life-threatening injuries are treated or until contraindications to aortic repair subside. Our experiences in children presenting with TAR, though few, favor an urgent attempt at revascularization to attenuate or prevent factors that could contribute to spinal cord ischemia.
It is interesting that the children with spinal myelopathy have demonstrated both short- and long-term recovery from the deficits. There have been limited reports of neurologic and functional improvements in patients who have sustained postoperative paraplegia or paraparesis [25]. It remains to be shown whether children can sustain spinal cord ischemia longer than adults or whether the pediatric spinal cord has more protective or regenerative capacities. There are both experimental and clinical data to suggest that hypothermia, steroids, calcium channel blockers, and thiopental anesthesia may protect the spinal cord from warm ischemia or reperfusion injury [24]. However, there is unlikely to be a prospective study determining the efficacy and dosage for any method. Detecting or monitoring spinal cord injury with somatosensory evoked potentials in trauma patients with TAR currently has both practical and theoretic limitations, although it may be useful in gauging the recovery process [24, 25]. Therefore, our understanding of the pathophysiology of spinal cord ischemia in TAR is incomplete, as well as of the best approach for operative and medical therapy. We must continue to investigate this process experimentally and clinically as it pertains to TAR and to share our experiences, so that collectively we may further reduce the unpredictable and dreadful complication of spinal myelopathy.
Conclusions
Traumatic thoracic aortic rupture remains a well-documented injury in the adult patient who sustains blunt trauma. Nonetheless, no single institution or surgeon has a large experience, and we rely on case reports, small series, or combined data bases to develop management strategies for these severely injured patients. Evolving concepts regarding diagnosis, operative repair, and perioperative management continue to appear in the literature [20–22, 24, 26]. However, TAR is an extremely rare event in the pediatric patient, accounting for 0.1% to 1.0% of all children who sustain blunt chest trauma [8, 10]. There are fewer than 10 cases reported in the surgical literature and no report exceeding 2 patients [7–10]. Thus, management strategies in children with TAR are often extrapolated from the adult literature. Although this is often helpful and applicable, there remains a need for experiences in children with TAR to be reported and discussed so that the natural history and treatment strategies can be better understood and advanced. With 6 additional pediatric cases of TAR, our experience helps identify factors that give insight into the causes, pathophysiology, and management of these trauma victims. The reported surgical experience that selectively discusses TAR in the pediatric patient (less than 17 years of age) is listed in Table 2.
In summary, the injured child with abnormal CXR results or a severe mechanism of injury requires a search for TAR. Our experience suggests that the mechanism of injury, the duration to diagnosis of an aortic injury, the duration of the diagnostic method, and failure to use seat belts may contribute to morbidity. We believe that the most effective algorithm to follow for the diagnosis of TAR in children is selective performance of chest CT and TEE. Our preference for operative repair remains the clamp and sew technique in the child with multiple trauma. A high index of suspicion and a systematic approach to the diagnosis and to the management strategy for injuries to the thoracic aorta can contribute to a good outcome in those few children who survive the injury.
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Footnotes |
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