Hybrid open and endovascular repair of a blunt traumatic thoracic aortic injury in a 7 year old boy

Hybrid open and endovascular repair of a blunt traumatic thoracic aortic injury in a 7 year old boy

Journal of Pediatric Surgery Case Reports 46 (2019) 101217 Contents lists available at ScienceDirect Journal of Pediatric Surgery Case Reports journ...

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Journal of Pediatric Surgery Case Reports 46 (2019) 101217

Contents lists available at ScienceDirect

Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc

Hybrid open and endovascular repair of a blunt traumatic thoracic aortic injury in a 7 year old boy


Jennifer M. Brewera, Sarah Grouta, Mohiuddin Cheemab, Thomas Divinagraciab, Carissa Webster-Lakeb, Douglas Mootec, Nahum I. Kryzmand, Edward Cortlandd, Brendan T. Campbella,∗ a

Pediatric Surgery, Connecticut Children's Medical Center, Hartford, CT 06106, United States Department of Vascular Surgery, Hartford Hospital, Hartford, CT, United States c Department of Radiology, Connecticut Children's Medical Center, United States d Department of Anesthesiology, Connecticut Children's Medical Center, United States b


We describe a 7-year-old boy who sustained a blunt thoracic aortic injury following a rollover motor vehicle crash where the vehicle fell 200 feet down an embankment. The chest x-ray on arrival showed widening of the superior mediastinum, a left-sided hemothorax, and first rib fracture. The screening CTA of the chest revealed bilateral pulmonary contusions, a large left hemothorax, and evidence of aortic injury with active contrast extravasation. The patient was intubated due to respiratory distress and had a left chest tube placed. The patient became hypotensive with greater than 1.5 L of blood from the chest tube, so a resuscitative thoracotomy was performed. Bleeding was controlled with a sponge stick initially and definitively with a Satinsky vascular clamp. Next the patient was transported to the hybrid OR at the adjacent adult hospital with an open chest for endovascular graft placement. The patient was admitted to the PICU post-operatively, transferred to the floor on POD 4, and discharged home on POD 9. Aortic injury after blunt trauma in pre-adolescent children is uncommon and often fatal. Endovascular repair of traumatic thoracic aortic injury in adults is currently the standard of care, but there is a paucity of clinical data to guide management of these types of injuries in pediatric patients.

1. Case report An otherwise healthy 7-year-old male was the unrestrained passenger in a rollover car crash, where the vehicle was thrown 200 feet down an embankment. EMS transported the patient by ground to our level 1 pediatric trauma center along with 3 other children injured in the same crash. The patient's GCS was 9 on arrival to the ED. Identified injuries included: lacerations to the forehead, scalp, and shoulder, multiple left-sided rib and spinous process fractures, a manubrial buckle fracture of the sternum, and a right humeral fracture. The patient developed respiratory distress shortly after the primary and secondary surveys were performed and underwent rapid sequence intubation for airway protection and respiratory support. Labs at the time of arrival included a hematocrit of 29, and an arterial blood gas showing a pH of 7.2, pCO2 of 41.4, and a pO2 of 35. Chest x-ray showed evidence of fluid in the left pleural space, mild shift of the heart, trachea, and mediastinum to the right along with mild widening of the superior mediastinum [Fig. 1]. The injury mechanism and abnormal CXR prompted a CT scan of the head, C-spine, chest, abdomen, and pelvis with IV contrast. Cross-sectional imaging demonstrated a large left

hemothorax with a small associated pneumothorax and shift of the heart and mediastinum to the right as well as an injury to the aortic arch with evidence of pseudoaneurysm at the level of the ligamentous arteriosum consistent with blunt aortic injury. There was a focal linear area of active contrast extravasation extending from the region of the pseudoaneurysm toward the left chest suggesting active hemorrhage [Fig. 2]. Bilateral pulmonary contusions were also evident. There was no evidence of significant intra-abdominal, CNS, or cervical spine injures on cross-sectional imagining. The patient was taken to the OR for chest tube placement, central venous access, and arterial line placement to guide pharmacological blood pressure control while definitive plans were made for surgical management of the aortic injury. Rocuronium (10 mg/mL) with fentanyl (50 mg) were used for anesthesia. Following placement of a left subclavian CVL and an arterial line, an 18 French chest tube that drained 450 mL of blood was placed. Fluoroscopy showed the chest tube to be coiled inside the left pleural space. After the chest tube was repositioned it put out an additional 750 mL of blood, and the patient became hypotension. The massive transfusion protocol was initiated, and an emergent left posterolateral thoracotomy was performed

Corresponding author. E-mail addresses: [email protected] (J.M. Brewer), [email protected] (B.T. Campbell).

https://doi.org/10.1016/j.epsc.2019.101217 Received 5 April 2019; Accepted 20 April 2019 Available online 29 April 2019 2213-5766/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

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2. Discussion Blunt traumatic aortic injury (TAI) is uncommon in children compared to adults, with population studies reporting an incidence of 1% in children with blunt chest trauma [1]. The most common mechanism of TAI in children is motor vehicle crashes [2,3]. The mechanism that produce TAI often causes severe multisystem injuries, as was the case in our patient [4]. While rare, TAI is a highly lethal injury in children, with a reported mortality rate after reaching the hospital of 33–35% as compared to 46–50% for adults [1,5,6]. Trauma to the aorta usually results in laceration, transection (i.e. rupture), or pseudoaneurysm formation. Dissection as an acute sequelae of trauma is rare. A pseudoaneurysm is an aortic rupture contained by the aortic adventitia which can rapidly progress to rupture with exsanguination. The most common site of injury is the aortic isthmus (90%), which is likely due to the tethering of the aorta by the ligamentum arteriosus which forms after the patent ductus arteriosus closes during the neonatal period [7]. Recently, the gold standard for radiologic diagnosis has transitioned from aortography to contrast-enhanced chest CT [7]. Chest x-ray is often done as an initial screening test in trauma patients, and may show widening of the mediastinum, hemothorax, apical capping, 1st rib fracture, deviation of the orogastric tube to the right, and tracheal deviation in patients with TAI [8]. Typical findings suggestive of TAI on chest CT are the presence of abnormal aortic contour due to intramural hematoma, intraluminal filling defects, pseudoaneurysm, and extravasation of contrast [7]. Management of pediatric trauma patients consists of damage control and resuscitation before the patient can proceed to the OR. As many as one-third of trauma deaths are due to uncontrolled bleeding. This is preventable with prompt hemorrhage control and resuscitation that begins with the avoidance of crystalloid administration and early infusion of blood products in a balanced ratio (1:1:1 units of plasma to platelets to packed red blood cells (pRBCs)) [9]. Massive transfusion protocols are mandated by the American College of Surgeons for trauma centers. In pediatric patients, it is defined as administrating a large volume of whole blood or packed red blood cells over a given time period. In pediatric patients this means one of three things: transfusion of greater than 100% of child's total blood volume over 24 h, transfusion support to replace ongoing hemorrhage of greater than 10% of patient's total blood volume per minute, or replacement of greater than 50% of child's total blood volume by blood product in 3 h or less [9]. Common pitfalls encountered include delay or failure to activate the massive transfusion protocol, failure to reverse and/or prevent hypothermia, unnecessary protracted operative time, and failure to appropriately prioritize surgical procedures in patients with multisystem injuries. Utility of pharmacologic adjuncts and hemostasis assays in pediatric trauma patients have the potential to guide resuscitative efforts in the future, but are currently not in use [9]. Management of TAI requires surgical treatment to lower the risk of rupture and death. Maintaining normal to lower blood pressure is of paramount importance for these patients and to that end invasive blood pressure monitoring to accomplish optimal blood pressure control. This allows definitive endovascular repair to be an urgent rather than an emergent intervention. Most guidelines for adults with aortic injuries suggest maintaining systolic blood pressure between 90 and 100 mmHg and heart rate < 100 beats per minute until the injury is definitely repaired [14]. A number pharmacologic agents can be utilized to maintain low blood pressure in patients with TAI, including beta blockers (e.g., esmolol), and afterload reducers (e.g., nitroglycerine and nitroprusside). Adequate venous vascular access is important for both blood pressure control and for easy administration of blood products. Clinicians should have a low threshold for initiation of a massive transfusion protocol (MTP). Multiple studies have shown that early initiation of MTP reduces complications in both adult and pediatric populations [15,16].

Fig. 1. Initial Chest x-ray showing mediastinal widening with left sided pleural effusion and 1st rib fracture.

through the fifth intercostal space. The lung was retracted inferiorly and anteriorly, torrential bleeding was identified in the aorta just distal to the left subclavian artery, the bleeding was initially controlled with direct pressure using a sponge stick. With the sponge stick controlling hemorrhage at the point of aortic injury, a large side biting Satinsky vascular clamp was utilized to establish temporary bleeding control without occluding the descending thoracic aorta. These maneuvers allowed for the patient to be stabilized while the adult cardiovascular surgery team was mobilized and plans were made to proceed urgently with Thoracic Endovascular Aortic Repair (TEVAR). Once the patient arrived in the hybrid OR suite, he was carefully placed supine and a right femoral cutdown was performed. The small size of the femoral artery and descending thoracic aorta, precluded the use of standard sized endovascular grafts. Instead, a Gore iliac excluder measuring 16 mm × 14.5 mm x 7 cm endoprosthesis delivered on a 12 French shaft was used to cover the area of injury. The clamp was removed and there was no evidence of bleeding in the operative field, and follow-up angiogram showed no extravasation of contrast [Fig. 3]. The right femoral arteriotomy was primarily closed. The patient received a total of 9 units of packed RBCs, 7 units of FFP, and 2 units of platelets intraoperatively. The patient was transferred to the PICU post operatively. He initially required aggressive ventilator and fluid support. His hematocrit 2 h after the massive transfusion protocol was stopped was 25.9. He was extubated on POD 2. Chest tube was placed to water seal on POD 3. He was transferred to the floor on POD 4. He maintained adequate urine output post-op and his blood counts remained stable. His chest tube was removed on POD 7. He was discharged home on POD 9 on daily aspirin (81 mg). The patient was seen for outpatient follow up after discharge and had no evidence of left upper extremity, visceral, or lower extremity vascular compromise. A repeat CT scan of the chest was performed at 6 months post injury, which demonstrated stable appearance of the endovascular graft in the descending aorta with no evidence of endoleak, migration or thrombosis [Fig. 4].


Journal of Pediatric Surgery Case Reports 46 (2019) 101217

J.M. Brewer, et al.

Fig. 2. A: Axial CT showing aortic pseudoaneurysm and hemothorax. B: Coronal CT showing contrast extravasation and hemothorax.

Fig. 3. CT Composite post stent.

Recent studies as well as EAST guidelines recommend endovascular repair of TAI in adults, with a meta-analysis done by EAST showing that for all available studies, overall mortality was lower for endovascular as compared with open repair (8% vs. 19%) [10]. However, no randomized-controlled trials comparing endovascular versus open repair have been performed. Furthermore, while the use of endovascular repair is increasing and case reports of successful endovascular repairs in children with TAI do exist, there are no long-term studies regarding outcomes or published guidelines regarding recommendations for management of TAI in pediatric patients [6,11–15]. Pediatric patients with TAI present some specific challenges to endovascular repair including: the use of the femoral artery is largely hindered by children's femoral artery being too small for the large devices, a smaller curvature of the aortic arch, and a smaller aortic diameter. The low incidence of TAI and these challenges make the procedure more complicated in children [14,15]. Furthermore, using endovascular repair eliminates the need for anticoagulation and eliminates need for cross clamp of the aorta [15]. Another possible surgical treatment could have been to control the bleeding with a pledgeted suture at the site of injury. Although this was a possible approach, if the aorta at this site failed to hold suture it could have resulted in catastrophic bleeding that would have been challenging to control. There are several small case series and case reports of long term outcomes following endovascular repair for coarctation of the aorta in pediatric patients. There were higher rates of early femoral vessel injury

Fig. 4. CT image of post stent placement 6 months later.

or aortic thrombosis and restenosis due to vessel growth requiring stent re-dilation. There were also higher rates of stent fractures higher in the pediatric population when compared to adolescents [17]. Therefore, pediatric patients who undergo stenting should be closely followed with a comprehensive cardiovascular exam yearly. Although no studies have compared outcomes between open and endovascular repair in pediatric patients with TAIs, the endovascular approach can be considered in the pediatric patient that presents with aortic injury at pediatric trauma centers with a multi-disciplinary team available to care for the patient.

Funding No funding or grant support. 3

Journal of Pediatric Surgery Case Reports 46 (2019) 101217

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Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient. All authors attest that they meet the current ICMJE criteria for Authorship. Conflict of interest Conflict of Interest for Endovascular repair of a traumatic thoracic aortic injury in 7 year old boy: an unusual pediatric injury and review of literature. Financial disclosures The following authors have no financial disclosures (JB, SG, MC, TD, CWL, DM, NIK, EC, BTC). References [1] Eddy a C, Rusch VW, Fligner CL, Reay DT, Rice CL. The epidemiology of traumatic rupture of the thoracic aorta in children: a 13-year review. J Trauma 1990;30(8):989–91. discussion 991-2 http://www.ncbi.nlm.nih.gov/pubmed/ 2388309. [2] Anderson SA, Day M, Chen MK, et al. Traumatic aortic injuries in the pediatric population. J Pediatr Surg 2008;43(6):1077–81. https://doi.org/10.1016/j. jpedsurg.2008.02.030. [3] Pearson EG, Fitzgerald CA, Santore MT. Pediatric thoracic trauma: current trends. Semin Pediatr Surg 2017;26(1):36–42. https://doi.org/10.1053/j.sempedsurg. 2017.01.007. [4] Balci AE, Kazez A, Eren Ş, Ayan E, Özalp K, Eren MN. Blunt thoracic trauma in children: review of 137 cases. Eur J Cardio-thorac Surg 2004;26(2):387–92. https:// doi.org/10.1016/j.ejcts.2004.04.024.