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Ann Thorac Surg 2003;75:1513-1517
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Management of traumatic rupture of the thoracic aorta in pediatric patients

Riyad Karmy-Jones, MDa*, Eric Hoffer, MDb, Mark Meissner, MDc, Robert D. Bloch, MDb

a Divisions of Cardiothoracic/Trauma, Harborview Medical Center, University of Washington, Seattle, Washington, USA
b Interventional Radiology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
c Vascular/Trauma, Harborview Medical Center, University of Washington, Seattle, Washington, USA

Accepted for publication November 14, 2002.

* Address reprint requests to Dr Karmy-Jones, Box 359796, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104, USA
e-mail: karmy{at}u.washington.edu


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Conclusion
 References
 
BACKGROUND: Traumatic rupture of the thoracic aorta (TRA) in the pediatric population is uncommon. Management of TRA in general has evolved to include selective nonoperative and endovascular stent graft approaches, although operative repair remains the standard.

METHODS: We conducted a retrospective chart review of patients younger than 16 years of age admitted to a single institution between March 1985 and February 2002.

RESULTS: Of 160 patients admitted with TRA, 11 were younger than 16 (11.9 ± 3.5) years of age. Concomitant injuries included closed head injury (5 patients) and acute lung injury (6 patients). All were started on ß-blockers when the diagnosis was suspected. Laparotomy was required in 3 patients and orthopedic procedures in 5 patients. Six underwent operative repair (two primary repairs), with no mortality. Cross-clamp time was 30.4 ± 2.6 minutes. One patient (operated on without bypass) was partially paralyzed. Two patients were managed nonoperatively, 1 with an intimal arch injury, who on subsequent follow-up has demonstrated healing, and 1 who died of head injury. Three patients were managed by endovascular stent grafts, 2 who died of closed head injury and 1 who at 1-year follow-up has fully recovered. The endovascular stent grafts were placed through the femoral artery in 2 patients and through an iliac conduit in 1 patient. No patient died of rupture.

CONCLUSIONS: The approach to pediatric TRA should be identical to the adult, with early institution of ß-blockers. Depending on the clinical setting, a spectrum of options should be considered, including operation, nonoperation, and endovascular stent graft, although the choice of the latter must be tempered by the lack of long-term follow-up data.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Conclusion
 References
 
Whereas urgent operative repair remains the standard for the majority of patients diagnosed with traumatic rupture of the thoracic aorta (TRA), in the adult population, there has been a trend towards interval or nonoperative management in selected cases, as well as the recognition that in certain circumstances endovascular stent grafts may be an appropriate alternative to "open" repair [1–6]. TRA is considered to occur relatively less frequently in the pediatric age group compared with the adult population, but operative repair has remained the standard management [7, 8]. Our impression has been that, despite the relative rarity of the injury, TRA in the pediatric population may be managed in a fashion similar to the contemporary manner that adult patients are managed. To this end, we reviewed our experience with pediatric patients who have experienced TRA.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Conclusion
 References
 
Patients admitted to Harborview Medical Center, a regional level I trauma center, between March 1985 and August 2001 with the diagnosis of TRA and who were younger than 16 years of age were identified by the trauma registry.

All patients who presented with a widened mediastinum on initial chest radiograph underwent angiography. Since 1999, patients with suggestive findings undergo helical computed tomography (CT) angiography. In the pediatric population, we still perform angiography when the injury is confirmed with this latter technique to determine the following features: (1) location of injury with respect to origin of the left subclavian artery; (2) distance (cm) from femoral and iliac vessels; and (3) aortic diameter at inferior and superior "landing zones." All patients without evidence of increased intracranial pressure are managed by ß-blockers until definitive treatment.

Since 1997, endovascular stent grafts have become available as an option in the management of TRA in patients who are at high risk for surgery. These include patients with cardiogenic shock, severe bilateral lung contusion that would preclude single-lung ventilation, and patients who might be candidates for full cardiopulmonary bypass, except for contraindications to systemic anticoagulation (major intracranial hemorrhage, deep lung lacerations, or multiple abdominal/pelvic injuries in whom it is not clear that all active bleeding has ceased) [1, 9, 10].

Endovascular stent grafts are placed in the operating room by combined thoracic-vascular and interventional radiology teams. The method of placement is determined by the caliber of the vessels, the distance from site of access to injury, and size of introducer required based on measurements of aortic diameter at the landing zones. Adenosine arrest is used to obtain transient cardiac standstill to allow deployment of the endovascular stent grafts. A test dose of 6 mg is given intravenously and then increased as needed until 5-second arrest is achieved. This allows proper seating of the graft and avoids the graft being pushed distally [11, 12]. Immediate postplacement angiograms are obtained to assess results, and follow-up helical CT is obtained at 48 hours or when the patient is stable with normal creatinine to confirm absence of endovascular leak.

Patients who are considered to be at prohibitive operative risk, but whose anatomy would not allow endovascular stent graft placement, are managed by strict blood pressure control with ß-blockers, with a target systolic pressure of 120 mm Hg or 20 mm Hg less than baseline [5, 6]. Injuries are followed by serial CT angiograms for at least 1 week. Operation is either delayed until the patient is judged stable for surgery, or, in the case of arch injuries or the elderly, monitored indefinitely.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Conclusion
 References
 
Over the study period, 150 patients were admitted with the diagnosis of TRA, of whom, 11 (6%) were younger than 16 years of age (Table 1). The first three cases listed in Table 1 were admitted before 1997. The average age was 11.9 ± 3.5 years. Ten were male, 10 were injured in motor vehicle crashes, and 3 were transferred from outside institutions. All patients had abnormal chest radiographs with widened mediastinum. The diagnosis was made by helical chest CT in three cases, an aortogram was obtained in all cases, and in one, transesophageal echocardiography was required to better delineate the lesion.


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  		Table 1. Patient Characteristics

 
Six patients underwent operative repair with no mortalities (Table 1). Three patients with isolated chest injuries underwent immediate repair. One patient was transferred from another institution 3 days after injury for stabilization of pelvic fractures. On admission, an abnormal chest radiograph prompted angiography, which led to the diagnosis and operative intervention. Two patients had multiple injuries that precluded immediate repair and, after stabilization, underwent delayed operative intervention. Once hemodynamic stability had been achieved, blood pressure was controlled with ß-blockers. The cross-clamp time ranged from 19 to 35 minutes. Two patients underwent primary repair; the remainder were managed with grafts (1- to 20-mm graft, 1- to 18-mm grafts, 2- to 16-mm grafts), and in two cases (one in a patient with a 14-mm diameter, aorta, one with a 16-mm aorta), there was deliberate over-sizing by 2 mm to allow for growth. Left heart bypass using mechanical circulatory support was used in four cases, and femoral-femoral bypass in one. In the sole case in which circulatory support was not used (owing to concerns about pelvic fracture and residual coagulopathy), the patient suffered partial paralysis of the lower extremities. Cross-clamp time in this case was 29 minutes. At follow-up (range, 1 to 15 years), there have been no complications, including no evidence of coarctation or late pseudoaneurysm formation.

Three patients were managed using endovascular approaches (Table 2). Two of the patients were involved in a motor vehicle crash (MVC) and 1 was struck at high speed while riding a bicycle (PedStruck). All 3 were boys and all had multiple injuries, including closed head injury (CHI) (2), acute pulmonary contusion requiring more than 15 mm positive-end expiratory pressure and 100% oxygen to maintain PaO2 in the 50- to 75-mm Hg range (3), extraperitoneal bladder rupture (1), long bone fractures (3), and pelvic fractures (3). In addition, 2 patients developed abdominal compartment syndrome manifested by high peak airway pressure and PaCO2 greater than 75 mm Hg, 1 patient had hemoptysis, and 1 patient required embolization of active pelvic arterial bleeding.


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  		Table 2. Endovascular Procedures and Outcomes

 
In the first two cases, endovascular stent grafts were constructed because there were no commercially made stents available. By the third case, an AneuRx (Medtronic, Inc, Santa Rosa, CA) cuff was available and used. In all three instances, the delivery devices were long enough to allow trans-femoral placement; however, in the last case, the femoral artery was too small, requiring an approach through the common iliac artery. In one instance, the laceration was close to the origin of the left subclavian artery, requiring the endovascular stent grafts to be placed across the curvature of the aorta. This resulted in stent deformation and persistent filling of the pseudoaneurysm. Attempts were made to correct the endovascular leak by placing a second endovascular stent graft and then using an uncovered stent to obtain improved apposition along the lesser aortic curvature. This resulted in a diminished but persistent endovascular leak. In the other two cases, the injuries were successfully covered.

Two patients ultimately were discontinued from life support (on postprocedure days 3 and 5) because they met criteria for brain death. The third patient has been discharged after multiple orthopedic procedures and is at home with no neurologic deficit. At 16-month follow-up, he is doing well, and repeat CT angiogram at 1 year demonstrated that there was no migration and no endovascular leak. There is no evidence of coarctation clinically.

Two patients were managed nonoperatively. One patient had an intimal tear in the arch of the aortas at the level of the left common carotid. Follow-up has shown a small pseudoaneurysm at 2 weeks, but at 3 months, the injury was healed. The second patient had massive head and orthopedic injuries with documentation of severe anoxic insult and was treated with compassionate care only.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Conclusion
 References
 
Estimates of the incidence of TRA in the pediatric population vary depending on the population studied. Lowe and associates noted an incidence of 0.06% among all patients admitted after blunt trauma, whereas Spouge and colleagues described a 7.4% incidence among children admitted with blunt chest injury [8, 13]. The majority present after MVC, and not wearing seat belts may result in a higher risk [7, 14]. The mechanism of injury is similar to the adult population, and is found more commonly in autopsy studies, suggesting that the more elastic properties of the "young" aorta does not confer as a protective benefit [15]. The diagnosis is suggested by abnormal findings on chest radiography, and can be confirmed by angiogram, CT, or transesophageal echocardiography depending on institutional experience [7, 13, 14, 16]. We have greater confidence in CT angiography as our experience increases, and currently use angiography only if stent grafts are considered or if there is concern that there are associated great vessel injuries that are not clearly delineated. We also find that transesophageal echocardiography is useful in assessing small defects, or when the diagnosis is in doubt after CT angiogram or aortogram.

Many patients are nearly adult sized. There is some variability, however, with a trend towards smaller aortic and femoral vessel size, and shorter femoral-injury site distances, which may have impact on operative or stent graft approaches. Operative repair remains the standard, and mechanical circulatory support is favored but not mandated [7]. As in the adult population, some patients can undergo primary repair, but the majority are reconstructed with grafts [7, 13, 14, 17]. It is difficult to determine whether the more common use of grafts reflects injury severity or practice bias. As is common with the adult population, commonly, there are multiple associated injuries [7, 14]. This may prompt temporization with ß-blockers [16].

Endovascular stent grafts are becoming accepted as a reasonable option in the management of traumatic rupture of the thoracic aorta in adults. The earliest experience was gained in the setting of "subacute" or chronic pseudoaneurysms after trauma [18–20]. There is increasing experience that endovascular stent grafts can be used as an emergent approach when there are associated injuries that could complicate thoracotomy and direct repair [2, 3, 21, 22]. Initial experience was gained with constructed grafts, but these are cumbersome and appear less reliable than commercially available devices [2, 22–25]. In the adult, available endovascular stent grafts are designed for use in the infrarenal position, and therefore, introducers are often too short for placement in the proximal descending aorta and require a retroperitoneal iliac or trans-abdominal aortic approach [26]. The Excluder (W.L. Gore, Flagstaff, AZ) and Talent (Medtronic Inc) devices are designed for thoracic aortic use and may be more malleable and thus able to create a tighter seal if placed partially across the aortic curvature than the more rigid first-generation devices [2, 27, 28]. Unfortunately, these are not currently available in the US outside of clinical trials.

There has been concern that as most devices require a 1- to 2-cm landing zone, injuries near the origin of the left subclavian artery may require the endovascular stent graft to cross the artery, thus leading to limb ischemia. As a practical matter, the risk of clinically significant ischemia is small and should not preclude this approach in critical patients [29]. However, persistent back perfusion into the peri-stent area can lead to persistent type II endovascular leak. Both of these considerations have led to investigators electively performing carotid-subclavian bypass in stable patients, with or without proximal subclavian ligation [23, 27]. In the acute trauma setting, in a patient with multiple injuries, persistent small endovascular leak can be addressed electively when the patient stabilizes.

Interventional approaches have been used in neonatal and pediatric cases of coarctation of the aorta [30, 31]. The long-term impact of placing a stent in the still-growing thoracic aorta is not known; however, in older children, the aortic diameter approaches adult dimensions. Complications of endovascular stent graft for thoracic aortic pathology that have been described include occlusion of left main stem bronchus, erosion into adjacent structures, persistent leak, and left upper-extremity ischemia. Other theoretical risks include rupture of the containing hematoma, arch perforation by the stiff introducer, entrapment of the introducer in an extremely curved arch, and long-term impact of the chronic inflammatory response incited by the endovascular stent graft [21, 32–34]. Paralysis, a rare complication of endovascular stent grafts for long thoracic aneurysms, should not be a risk for traumatic lesions that are short and lie in the proximal descending thoracic aorta [18, 19, 26, 35].

In our three pediatric cases, because of the patients’ smaller statures, the delivery devices were of sufficient length to allow femoral placement, but in the third case, the femoral artery was too small for the graft delivery device. Premade stent grafts that are readily available to all centers require an aortic diameter of less than 30 mm. The bulk of TRAs in both adult and pediatric patients are smaller than this. The majority are 16 to 20 mm in diameter at the landing zones, as in our three cases.

A third option is nonoperative management with ß-blockers to control blood pressure ("hypotensive management") [1, 5, 6]. This may not be an acceptable option in patients with closed head injury, especially if there is evidence of increased intracranial pressure such that ß-blockers and lower systemic arterial pressure may profoundly impact cerebral perfusion pressure [9]. Serial follow-up should be performed to determine if there is a persistent pseudoaneurysm or ongoing expansion despite medical therapy that might prompt earlier intervention [6].


   Conclusion
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Conclusion
References
 
The management of TRA in the pediatric population has evolved in a pattern similar to the adult population. Operative repair with careful blood pressure control in the preoperative setting remains the standard. However, in select cases, either endovascular stent grafts or nonoperative management may be suitable. In general, these approaches would be considered if the patient has cardiopulmonary injuries that would preclude safe exposure. The choice between stent grafts and nonoperative management is then determined by the specific anatomy of injury, graft availability, and the presence of closed head injury. Technical issues specific to the pediatric population include an assessment of the optimal route of access for the delivery device, taking into consideration the size of the access vessels and distance from the proposed access to the injury site.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Conclusion
 References
 

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