Management Of Pediatric Blunt Abdominal Aortic Injuries
Sooyeon Kim, MD, J Gregory Modrall, MD, Fatemeh Malekpour Ghorbani, MD, Michael Siah, MD, Bala Ramanan, MBBS, MS, Shirling Tsai, MD, Carlos H. Timaran, MD, Melissa L. Kirkwood, MD.
University of Texas Southwestern, Dallas, TX, USA.
Objectives:Pediatric blunt abdominal aortic injury is rare, and most vascular surgeons have minimal experience. Evidence for management recommendations is limited. Methods: This is a retrospective review of consecutive pediatric patients with blunt traumatic abdominal aortic injury at our institution between 2008-2019. Results:Sixteen patients (50% male), 4-17 years old, were involved in motor vehicle collisions. Thirty-one percent were hypotensive en route or upon arrival. Forty-four percent were transfers. The median Injury Severity Score (ISS) was 34 (IQR 19-35). All but one were infrarenal. Aortic injuries were stratified according to the SVS criteria: Grade 1, n=5(31%); Grade 2, n=2(13%); Grade 3, n=5(31%); Grade 4, n=4(25%). Concurrent non-aortic injuries included solid organ (63%,n=10), bladder and bowel (88%,n=14), brain (25%,n=4), hemo/pneumothorax (25%,n=4), spine (81%,n=13), and non-spine fractures (75%,n=12). In total, 56% (n=9/16) required aortic repair: one grade-2 and two grade-4 injuries needed immediate revascularization for distal ischemia with either aortic thrombectomy with bovine patch (n=1/3) or PTFE interposition graft (n=2/3). Six patients (38%) underwent delayed repair with a median delay of 52 days (range 2-916); half of these occurred during the index hospitalization. During surveillance, these patients were found to have worsening pseudoaneurysms or flow-limiting dissections with evidence of inadequate distal perfusion at risk for claudication, tissue healing, or impaired limb growth. Most repairs were either aortic endarterectomy with bovine patch (n=4) or rifampin-soaked Dacron graft (n=1). One 17-year-old underwent a Gore Excluder Limb placement (16x14.5x7cm) for pseudoaneurysm due to a hostile abdomen 20 days after injury. No deaths occurred. Median follow-up was 7 months (IQR 3-28). All postoperative patients demonstrated stable imaging (range 1 month-5 years). Seven non-operative patients, with grades 1-4, did not have bleeding or distal ischemia and were observed. Their repeat imaging demonstrated either stability or resolution (range <1-9 months). Fifty-four percent were lost to follow up after discharge or following their first clinic visit. Conclusions: Delayed intervention can be safely performed for most pediatric blunt abdominal aortic injuries. This suggests that transfer to a tertiary center with vascular expertise is safe and feasible. However, injury progression was seen as early as within 48 hours and as late as 31 months post injury, underscoring the importance of long-term surveillance. Unfortunately, half were lost to follow up, highlighting the need for more structured surveillance.
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