Scholarly article on topic 'Traumatic abdominal aortic rupture treated by endovascular stent placement in an 11-year-old boy'

Traumatic abdominal aortic rupture treated by endovascular stent placement in an 11-year-old boy Academic research paper on "Clinical medicine"

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Abstract of research paper on Clinical medicine, author of scientific article — Véronique Andrey, Vincent Bettschart, Nicolas Ducrey, Christophe Constantin, Bernard Genin

Abstract Traumatic aortic injury is extremely rare in children and only a few case reports can be found in the literature concerning the management of such lesions. In adults, endovascular stents are widely used, but in children this treatment is controversial. We report the case of an 11 year-old boy with a traumatic rupture of the abdominal aorta, treated successfully in our hospital by the placement of an endovascular stent. We discuss the management, imaging, and treatment of such lesions as described in the literature.

Academic research paper on topic "Traumatic abdominal aortic rupture treated by endovascular stent placement in an 11-year-old boy"

journal of Pediatric Surgery

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Journal of Pediatric Surgery CASE REPORTS

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Traumatic abdominal aortic rupture treated by endovascular stent placement in an 11-year-old boy

Véronique Andreya*, Vincent Bettschartb, Nicolas Ducreyc, Christophe Constantin d, Bernard Genina

a Service of Pediatric Surgery, Department of Pediatrics, Centre Hospitalier du Valais Central, 1950 Sion, Switzerland b Service of Visceral Surgery, Department of Surgery, Centre Hospitalier du Valais Central, 1950 Sion, Switzerland cDepartment of Internal Medicine, Centre Hospitalier du Valais central, 1950 Sion, Switzerland d Department of Diagnostic and Interventional Imagery, Centre Hospitalier du Valais Central, 1950 Sion, Switzerland

ARTICLE INFO

ABSTRACT

Article history: Received 30 January 2013 Received in revised form 4 March 2013 Accepted 5 March 2013

Traumatic aortic injury is extremely rare in children and only a few case reports can be found in the literature concerning the management of such lesions. In adults, endovascular stents are widely used, but in children this treatment is controversial. We report the case of an 11 year-old boy with a traumatic rupture of the abdominal aorta, treated successfully in our hospital by the placement of an endovascular stent. We discuss the management, imaging, and treatment of such lesions as described in the literature.

© 2013 Elsevier Inc. All rights reserved.

Key words: Aortic Trauma Stent

Traumatic rupture of the aorta is very rare in children and only 5% of all cases affect the abdominal portion of the aorta. Only a few case reports can be found in the literature and no clear consensus is established concerning the management of such lesions. Open surgery has been for years the traditional procedure, but endo-vascular treatment appeared to be a good non-invasive alternative. This procedure is widely used in adults but in children the use of endovascular stents remains extremely rare and controversial with an uncertain long-term outcome.

1. Case report

An H year-old boy was involved in a high-speed car accident with death of an occupant on impact. The patient was a front-seat passenger wearing a 3-points seat belt. He was brought by ambulance to our emergency center. On arrival he was tachycardic but normotensive. The GCS was 15 and the child was complaining only of abdominal pain. Physical examination revealed a tender abdomen with an obvious seat-belt sign. A FAST (Focus Assessment

* Corresponding author. Service de Chirurgie Pédiatrique, Centre Hospitalier du Valais Central, 1950 Sion, Switzerland. Tel.: +41 27 603 46 62; fax: +41 27 603 46 51.

E-mail address: veroniqueandrey@gmail.com (V. Andrey).

2213-5766/$ — see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.epsc.2013.03.010

with Sonography in Trauma) exam revealed the presence of free intraabdominal fluid and the patient was immediately brought to the CT-scan.

The CT-scan showed a massive intraperitoneal hemorrhage with a probable leak from the superior mesenteric artery. It also revealed a retroperitoneal bleeding associated to a 2.8 cm intimal flap located in the infrarenal aorta. No other lesions were seen on the thorax or on the spine (Fig. 1).

The patient was taken to the operating room and a median laparotomy was performed. It revealed a massive intraabdominal bleeding coming from a vascular tear affecting a small branch of the superior mesenteric artery, which was ligated. Because of multiple intestinal lesions, a small intestine resection of 80 cm was performed with a termino-terminal anastomosis. During the procedure a rapid extension of the retroperitoneal hematoma was noticed and a Doppler ultrasound revealed a complete rupture of the aorta, which was bleeding in the retroperitoneum. Considering the contamination risk secondary to the intestinal tears, it was therefore decided to proceed to the placement of a vascular stent through the aortic lesion. According to a damage control surgery attitude, a VAC-dressing system was placed upon the laparotomy to allow a second look within 24 h and the child was brought to the arteriography facility.

An aortography was performed with a 10 F catheter introduced in the femoral artery and confirmed the aortic rupture (Fig. 2a).

Fig. 1. CT scan: intraperitoneal hemorrhage associated to an intimal flap in the aorta and a retroperitoneal bleeding.

A covered stent (Fluencyl® 12—60) was placed just below the renal arteries ending above the aortic bifurcation (Fig. 2b).

After the procedure, the patient was taken to the intensive care unit (ICU) and the abdominal cavity was revised 24 h later. No bleeding or intestinal lesions were noticed and the abdominal wall was definitely closed. A new CT-scan confirmed the good position of the stent and the absence of complications. He was extubated right after the second intervention and left the ICU the following day.

After one week of parenteral nutrition, oral nutrition was rein-troduced on the 6th day and was well tolerated. On the 3rd day an anti-aggregation therapy with aspirin was introduced and he didn't present any postoperative complication. He was discharged after the 17th day.

At one year follow-up, the patient has no limitation for physical activities. The radiologic control with ultrasound demonstrated a stent in good position without any change in diameter compared to the native aorta. The lumen is 1.2 cm without intimal hyperplasia and the flow is physiological without any turbulences (Fig. 3).

2. Discussion

Traumatic rupture of the aorta is very rare in children and only 5% of all cases affect the abdominal portion of the aorta [1,2]. This

lesion is associated with a high mortality rate. The main cause of such trauma is high-speed car accidents, especially when the child wears a 2 points-lap-belt or an improperly adjusted 3 points-seat-belt. Other cases may be encountered in bike or motorbike accidents. A few cases have also been described in patients victims of child abuse, especially in young children [1-8].

The mechanism of injury during a car accident is a combination of direct and indirect forces. The spine is hyper-flexed on the lap belt or ventral portion of a 3 points-seat-belt and the aorta is compressed between the belt and the spine [1,2,9].

Comparatively, these lesions are less frequent than in adults, because the aorta is free of atherosclerosis and is therefore more resistant [10]. Most commonly, these injuries occur at the level of the inferior mesenteric artery (30-40%). Other common locations are at the level of the renal arteries (20-30%) and between the inferior mesenteric artery and the aortic bifurcation (20%). The presentation of the lesions includes contusion, intramural hematoma, intimal dissection, pseudoaneurysm and rupture [1,7].

Due to its retroperitoneal protected position, the abdominal aorta is rarely injured alone. The most common associated injuries are small-bowel injuries with a mesenteric laceration, lumbar spine injuries (most often chance fracture) and parietal lesions such as hematoma and transection of the rectus abdominal muscles [9]. In case of such lesions it's important to consider the risk of aortic injury. Even if the classical triad of blunt abdominal trauma with acute lower extremity vascular insufficiency and lower extremity paralysis is characteristic, many cases are less evident and the diagnosis can be delayed with life threatening consequences.

Considered as gold standard for many years, the arteriography has progressively been replaced by the CT-scan. This non-invasive technique has been reported to detect aortic lesions with an accuracy of 100% [11].

There is no consensus in the literature concerning the optimal management of blunt abdominal aortic injuries. In adults, endo-vascular stent placement seems to be the most appropriate alternative in stable patients, whereas hemodynamically unstable patient should be managed with conventional surgery. The conservative approach has no place in the management of adult abdominal aortic blunt trauma. Several case reports have described the successful use of endovascular stent placement for blunt abdominal aortic trauma without significant complications [11 —13 ]. Despite these encouraging results, long-term follow-up is necessary to assess the effectiveness of this therapy [14,15]. Due to the small number of cases, no comparative studies can be found in the literature.

Fig. 3. Doppler-US at one year: physiological flow.

However, concerning the more frequent thoracic aortic trauma in adults, the endovascular approach is associated with improved outcome compared with open repair. It is associated with a decreased risk of graft infection and a lower mortality rate [16].

In the pediatric population, the situation is even less clear. The surgical approach remains the gold standard procedure for the management of blunt abdominal aortic trauma with good results, either by direct reparation or with endograft placement [5—8].

A few case reports described successful management of simple contusion or small intimal disruption with a conservative approach. In theses cases, patients are treated with aspirine and followed by ultrasound imaging [2—4].

Recently, the use of endograft stenting appeared in the management of pediatric blunt aortic trauma [1,17]. A few cases of pediatric blunt thoracic aortic injuries have been successfully managed by endovascular stent but despite encouraging results, this approach remains controversial and the long-term outcome is unknown [18—20].

The use of endovascular stent for pediatric blunt abdominal aortic trauma is even less frequent and to our knowledge only one case report has described such a procedure [21]. This approach has several advantages: first the procedure is less invasive with an improved recovery time and, since the lesions are frequently associated with intestinal injuries, it avoids the contamination of the retroperitoneum and prevents the risk of infection. The high risk of contamination during surgical repair in this situation is reported by several authors [11,12,22—24].

The results of this approach are encouraging and the short-term outcome is excellent but the long-term outcome is unknown. It is important to consider the difficulties that can be encountered during the procedure itself regarding the availability of appropriate material for the small size of the aorta and the caliber of access vessels [1,17,25].

The effects of a stent on a growing aorta are unknown. This technique has potential disadvantages including endoleaks, stent migration with growth, long-term patency or occlusion of branch vessels. Some authors are confident whereas others are worried about the long-term outcome for children with growing vessels and a long life expectancy [2,3,18].

The Luminal diameter of an adult aorta is generally between 1.6 and 2.0 cm. In our patient, the lumen is 1.2 cm, thus in the normal range for his age. In case of any symptoms due to arterial insufficiency appearing as the child grows, the stent could further be

dilated up to a size of 1.4 cm. Furthermore, it is important to note that a narrowing <50% doesn't cause arterial insufficiency, even during physical activity.

3. Conclusion

In summary, blunt abdominal aortic injuries are very rare in children and the diagnosis can therefore be missed. These lesions frequently occur in high-speed car accidents due to a flexion-traction mechanism. Aortic lesions are frequently associated with lumbar spine fracture and bowel injury and in the presence of such lesions, it's important to consider the risk of an aortic injury. The CT-scan is the exam of choice to diagnose aortic injuries but the management is controversial. Endovascular techniques offer promising results but a long-term follow-up is necessary to assess the safety of this technique in children.

Conflict of interest

Funding source

References

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