Blunt abdominal aortic trauma in paediatric patients

Endovascular Treatment With a Balloon-Expandable Covered Stent in a Polytrauma 12-Year-Old Patient With Traumatic Abdominal Aortic Rupture

Βlunt trauma is a common injury in children; however, blunt abdominal aortic trauma is extremely rare and is accompanied by high rates of morbidity and mortality. We report our initial experience with the endovascular management of an abdominal aortic rupture in a 12-year-old boy after he was involved in a motor vehicle accident. The patient was a backseat-restrained passenger. Upon admission, he had a Glasgow Coma Scale of 15, was hemodynamically stable, and complained of abdominal pain. The computed tomography revealed a rupture in the abdominal aorta along with a distally extending pseudoaneurysm, free fluid in the peritoneal cavity, and a large retroperitoneal hematoma. The rest associated injuries were a Grade III splenic injury, a retroclival epidural hematoma in the first cervical vertebra level, a right clavicle fracture, a bilateral minor pneumothorax, along with bilateral pulmonary lacerations and contusions in the thoracic vertebrae. Given the extent of the intraabdominal injuries and the risk for open laparotomy, the decision to proceed with endovascular stenting instead of open surgical repair was made. The patient tolerated the procedure well and an angiography confirmed the result. The postoperative period was uneventful and the associated injuries were treated conservatively without complications. Although blunt abdominal aortic trauma is extremely rare in children, endovascular management seems to be a new and feasible therapeutic approach.

Endovascular Repair of Traumatic Infrarenal Aortic Injury in an 8-Year-Old

The patient is an 8 year-old male presenting to outside facility following high-speed motor vehicle collision in which he was a restrained passenger. CT imaging at that time demonstrated a traumatic infrarenal aortic pseudoaneurysm, extensive pneumoperitoneum and free fluid, and an unstable L2 vertebral body fracture. He underwent exploratory laparotomy with small bowel resection prior to transfer. The patient was left in discontinuity and temporary closed. Vascular surgery was consulted upon arrival to tertiary care children's hospital. The decision was made to proceed with emergent endovascular repair. An aortogram confirmed the location of the aortic disruption well below the renal arteries, superior to the bifurcation. An 11 mm × 5 cm Viabahn covered stent was placed across the injury with adequate proximal and distal seal. This is a case of seatbelt-related pediatric infrarenal aortic injury in the setting of polytrauma. Endovascular repair was pursued in this damage-control setting.

Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations

Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.

The mechanism and therapy of aortic aneurysms

Aortic aneurysm is a chronic aortic disease affected by many factors. Although it is generally asymptomatic, it poses a significant threat to human life due to a high risk of rupture. Because of its strong concealment, it is difficult to diagnose the disease in the early stage. At present, there are no effective drugs for the treatment of aneurysms. Surgical intervention and endovascular treatment are the only therapies. Although current studies have discovered that inflammatory responses as well as the production and activation of various proteases promote aortic aneurysm, the specific mechanisms remain unclear. Researchers are further exploring the pathogenesis of aneurysms to find new targets for diagnosis and treatment. To better understand aortic aneurysm, this review elaborates on the discovery history of aortic aneurysm, main classification and clinical manifestations, related molecular mechanisms, clinical cohort studies and animal models, with the ultimate goal of providing insights into the treatment of this devastating disease. The underlying problem with aneurysm disease is weakening of the aortic wall, leading to progressive dilation. If not treated in time, the aortic aneurysm eventually ruptures. An aortic aneurysm is a local enlargement of an artery caused by a weakening of the aortic wall. The disease is usually asymptomatic but leads to high mortality due to the risk of artery rupture.

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

OBJECTIVE

Blunt abdominal aortic injury in pediatrics is a rare clinical entity with which most vascular surgeons have minimal experience. Evidence for management recommendations is limited. Herein we report a single institution's experience in the care of pediatric abdominal aortic injuries.

METHODS

This is a retrospective review of consecutive pediatric patients diagnosed with blunt traumatic abdominal aortic injury at our institution between 2008 and 2019.

RESULTS

Sixteen pediatric patients (50% male) were identified, ranging in age between 4-17 years. All were involved in motor vehicle collisions and were restrained passengers with a seatbelt sign. Five patients (31%) were hypotensive en route or upon arrival. Seven patients (44%) were transferred from another hospital. The median Injury Severity Score (ISS) was 34 (Interquartile range, IQR 19-35). The infrarenal aortic injuries were stratified according to the aortic injury grading classification: n=5/2/7/2 (grades 1-4, respectively). Concurrent non-aortic injuries included solid organ (63%, n=10), hollow viscus (88%, n=14), brain (25%, n=4), hemo/pneumothorax (25%, n=4), spine fractures (81%, n=13), and non-spine fractures (75%, n=12). In total, 56% of patients (n=9/16) required aortic repair: three needed immediate revascularization for distal ischemia. The remaining six patients (38%) underwent a delayed repair with a median time to repair of 52 days (range 2-916 days). Half of delayed repairs occurred during the index hospitalization. On repeat axial imaging, the three delayed-repair patients were found to have enlarging pseudoaneurysms or flow-limiting dissections and subsequently underwent repair during index hospitalization. Only one patient underwent endovascular repair. No deaths occurred, and the median follow-up length was 7 months (IQR 3-28 months) in this study population. All postoperative patients demonstrated stable imaging without requiring further intervention. Seven patients, whose injury grades ranged between 1 and 3, were observed. Their repeat imaging demonstrated either stability or resolution of their aortic injury. Remarkably, half of patients were lost to follow up after discharge or following their first postoperative clinic visit.

CONCLUSIONS

Delayed aortic intervention can be safely performed in the majority of pediatric patients with blunt abdominal aortic injuries with preserved distal perfusion to the lower extremities. This suggests that transfer to a tertiary center with vascular expertise is a safe and feasible management strategy. However, progression of aortic injuries was seen as early as within 48 hours and as late as 30 months post injury, underscoring the importance of long-term surveillance. Unfortunately, in this cohort, 50% of the children were lost to follow up, highlighting the need for a more structured surveillance strategy.

CT features of blunt abdominal aortic injury: an infrequent but life-threatening event

Blunt injury to the abdominal aorta is a rare but potentially fatal event. Despite being much less common than thoracic aorta involvement, it carries high morbidity and mortality. Computed tomography (CT) has become the standard method for evaluating the trauma patient and can provide a rapid accurate diagnosis of aortic injury. Depending on the magnitude of the traumatic forces, aortic injuries may be present in blunt abdominal trauma and appear as a spectrum of disease ranging from small intraluminal defects to full-thickness circumferential ruptures. We classify lesions into four groups as it has been reported in the literature: intimal flap (grade I), intramural hematoma (grade II), pseudoaneurysm (grade III), and rupture (grade IV). Radiologists play a crucial role in the evaluation and care of these patients since imaging findings significantly affect clinical management. The purpose of this paper is to describe the different types of traumatic injury to the abdominal aorta, highlighting the key imaging findings on computed tomography (CT).

Isolated middle sacral artery rupture after blunt abdominal trauma in a pediatric patient

Blunt abdominal aortic injuries are very rare in childhood. In these injuries, abdominal aorta and intra-abdominal organs can be damaged to various degrees. In this article, we report a unique pediatric case of isolated middle sacral artery injury following trauma.

Management of Seat Belt-type Blunt Abdominal Aortic Trauma and Associated Injuries in Pediatric Patients

BACKGROUND

"Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may concentrate forces in a band-like pattern across the abdomen, resulting in the triad of hollow viscus perforation, spine fracture, and aortoiliac injury. We report 4 cases of pediatric seat belt-type aortic trauma and review management strategies for the aortic disruption and the associated constellation of injuries.

METHODS

-approved, retrospective review of all pediatric patients requiring surgical intervention for seat belt-type constellation of abdominal aortic/iliac and associated injuries over a 5-year period. Blunt thoracic aortic injuries were excluded.

RESULTS

We identified 4 patients, ranging from 2 to 17 years of age, who required surgical correction of seat belt-type aortoiliac trauma and associated injuries: 3 abdominal aortas and 1 left common iliac artery. The majority (3/4 patients) were hemodynamically unstable at emergency room presentation, and all underwent computed tomography angiography of the chest/abdomen/pelvis during initial resuscitation. Injuries of the suprarenal and proximal infrarenal aorta were accompanied by unilateral renal artery avulsion requiring nephrectomy. Presumed or proven spinal instability mandated supine positioning and midline laparotomy, with medial visceral rotation utilized for proximal injuries. Aortoiliac injuries requiring repair were accompanied by significant distal intraluminal prolapse of dissected intima, with varying degrees of obstruction. Conduit selection was dictated by the presence of enteric contamination and the rapid availability of an autologous conduit. The sole neurologic deficit was irreparable at presentation.

CONCLUSIONS

Seat belt aortoiliac injuries in pediatric patients require prompt multidisciplinary evaluation. Evidence of contained aortoiliac transection, major branch vessel avulsion, and bowel perforation mandates immediate exploration, which generally precedes spinal interventions. Lesser degrees of aortoiliac injuries have been managed with surveillance, but long-term follow-up is needed to fully validate this approach.

Aortic Transection after Blunt Abdominal Trauma in a Child

Abdominal aortic injury secondary to blunt abdominal aortic trauma (BAAI) is rare in children but frequently occurs in association with other injuries, including bowel injury and vertebral fracture. We present a case of a 14-year-old boy who sustained a partial transection of the infrarenal aorta with a lumbar chance fracture and small bowel injury after a motor vehicle accident. Repair was performed with bowel resection followed by Dacron graft interposition. We reviewed the literature on BAAI in children with a focus on the method of repair of these injuries.

Management and Evolution of a Wallstent Migration in a Pediatric Blunt Traumatic Abdominal Aortic Injury

Blunt traumatic abdominal aortic injury in children is a rare but a severe condition. The clinical manifestation often involves other intra-abdominal visceral injuries and vertebral fractures. The best therapeutic management is still unclear with few reported endovascular cases treated. The following is the case of a 13-year-old male with an aortic abdominal dissection, spleen laceration, jejunal contusion, and hemoperitoneum after a motor vehicle collision. An endovascular approach was decided upon after the progression of the intimal aortic tear. A self-expanding stent was implanted into the injured position with an immediate proximal migration to the visceral aorta. It was decided not to retrieve the stent because of added comorbidity, and an open repair of the dissection was performed using a graft bypass. The patient has completed a 6-year image surveillance without complications or growth alterations. To our knowledge, this is the first reported childhood case of an intraoperative stent migration during the endovascular treatment of a blunt traumatic abdominal aortic injury. The possible cause of the complication and the management of these kinds of injuries are reviewed in detail in this article.

[Six years later - long-term follow-up after rare injury in childhood]

The present case shows the long-term follow-up of a rare injury due to blunt abdominal trauma in childhood. The patient suffered from a traumatic transsection to the A. iliaca communis, which was restored by the combination of a direct suture with a venous autologous patch. A six-year follow-up when the boy was mature with a height of180 cm showed an unremarkable MRI angiography without any sign of stenosis. Due to the limited number of experiences with this rare injury reported in the literature, there is a lack of consensus on the suture technique and use of patches or grafts. The demonstrated technique supplies a possible treatment for this rare injury to infantine arteries.

Endovascular management of lap belt-related abdominal aortic injury in a 9-year-old child

Blunt abdominal aortic trauma is a rare occurrence in children with only a few patients having been reported in the literature. Most such cases have been described in the context of lap belt injuries. We report a 9-year-old boy who suffered lap belt trauma to the abdomen during a high-speed road traffic accident resulting to the well-recognized pattern of blunt abdominal injury, that is, the triad of intestinal perforation, fractures of the lumbar spine, and abdominal aortic injury. The latter presented with lower limb ischemia due to dissection of the infrarenal aorta and right common iliac artery. Revascularization was achieved by endovascular means using 2 self-expanding stents in the infrarenal aorta and the right common iliac artery. This case is one of the few reports of lap belt-related acute traumatic abdominal aortic dissection in a young child and highlights the feasibility of endovascular management in the pediatric population.