Update Course Rewind: Vascular Trauma Management 2024

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm Lizzy Lee from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year, we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories: green circles for established practices, blue squares for promising newer practices, and black diamonds for early adopter practices only. Today, we'll talk about a vascular surgery update in pediatric trauma with Doctors Reagan Williams and Katie Russell. This topic falls into the black diamond category of unproven approaches. This 16-year-old female who was in a motor vehicle accident and presented in shock. This is her imaging. She's a grade five splenic injury and a blunt grade two thoracic aortic injury. What would you do next to manage the blunt thoracic aortic injury? Deal with a life-threatening injury first, right? So, take out the spleen if if that has to happen. If there's head injuries, you could think about treating that first. You use beta blockers, you like to control pressure, but that may not be feasible if you're in active resuscitation for this patient. Let's see the poll results from the combined live and virtual audience. 48% of the pediatric surgeons answered that they would do the endovascular repair with stent placement for this patient with thoracic aortic injury. Nobody would do an open repair on cardiac bypass. It's super interesting. Thoracic aortic injury is very, very rare in children, so you're almost never going to see it. But in a national survey, actually about 67% were managed non-operatively, which goes in line with what we saw in our poll. 27% were managed endovascularly, and 6% were managed open. Most pediatric surgeons hesitate to operate and place stents in very young children, but endovascular repair has been shown to have better outcomes than non-operative management. Endovascular repair may be a better treatment option for children with these injuries because they may progress. So, I think that depends a lot on the age. What do y'all do? It's a case by case basis. It's so infrequent and then there's also the questions, who do you call? Is this the cardiac surgeons, is it the vascular surgeons, is it IR? At our institution it is not totally consistent. Some of these thoracic aortic injuries can be missed when the patient first arrives at the ER. In this case, they were taking the patient to interventional radiology for the splenic injury. We didn't know about the thoracic aortic injury until they were in IR. They're injuries we missed because children are really small, and if they have a little intimal repair, we had looked at the scans and it was the attending radiologist three hours later that found the injury. To make sure we can catch possible thoracic aortic injuries, order CT chest scans in patients whose chest x-rays show a wide mediastinum. You definitely need to scan the chest if you're worried about the chest x-ray. There is mediastinal widening on the chest x-ray, that is a concern for some kind of great vessel injury that definitely needs a CTA of the chest. In this patient case, Dr. Russell consulted the vascular surgeon as the next step. The vascular surgeon recommended placing a stent in this child for endovascular repair. I looked at this paper, a 10 year review that actually shows TVAR is very safe in children. TVAR stands for thoracic endovascular aortic repair. It's a minimally invasive procedure that treats an aneurysm in the upper part of your aorta. decreases mortality, decrease risk of spinal cord injury from doing an open procedure and it gets them out of the hospital faster. During TVAR, a stent graft is used to prevent the aneurysm, a weak bulging area in the aorta, from bursting. I've been working a lot with the SVS and the society for vascular surgeons and there's really small stents that you can use. And then this was a 16-year-old. So, 16-year-olds are really close to adults and if you look at the adult SVS recommendations, it would 100% be for endovascular repair. If a pediatric patient comes in with a thoracic aortic injury, consider getting it repaired by interventional radiology or vascular surgery, depending on the individual institution. The younger children were more likely to be managed non-operatively. But you can use an endovascular repair if you need to in those children. You just have to use a really small stent. In summary, in patients with thoracic aortic injury, managing life threatening injuries takes priority with endovascular repair like TVAR being the preferred approach for better outcomes. TVAR is particularly effective in older children and adolescents, offering a less invasive alternative to open surgery with reduced risk of complications. For suspected thoracic aortic injuries, CT chest scans are essential, following chest x-rays that show mediastinal widening. Collaboration with vascular surgeons or interventional radiologist is important for treatment decisions. However, remember that this is still in the early adopter stage and is not yet universally accepted as the standard of care. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.