Traumatic thoracic aortic rupture in the pediatric patient

Traumatic thoracic aortic rupture is a rare injury in the pediatric patient. Experiences with thoracic aortic rupture in patients less than 17 years of age are needed to help identify factors that can influence injury occurrence, diagnosis, management, and outcome.

Between July 1989 and December 1995, 6 children were treated operatively for thoracic aortic rupture from blunt trauma at a level I pediatric trauma center. The average age was 13.2 years (range, 8 to 16 years). There were 4 females and 2 males. There were 5 motor vehicle accidents and 1 bicycle accident. Aortic injury was suspected based on the mechanism of injury and abnormal chest roentgenogram results, and was confirmed by aortography (3 cases) or chest computed tomography (2) and transesophageal echocardiography (3). Life-threatening central nervous system or gastrointestinal injuries were evaluated or treated first. Operative repair of the thoracic aorta was performed by cardiopulmonary bypass (2 patients) and clamp and sew technique (4).

Aortic ruptures were complete transections at the ligamentum arteriosum in 5 of 6 (83%); the other case was a cervical arch pseudoaneurysm. Associated injuries included pulmonary contusion (100%), pelvic/long bone fractures (50%), visceral laceration/perforation (50%), central nervous system (33%), paraplegia (17%), and myocardial contusion (17%). There were no rib fractures. Four of 5 patients (80%) were not wearing seat belts, and 2 of these were ejected. The average time from injury to the operating room was 17.6 hours (range, 5 to 48 hours); the time from diagnosis to the operating room exceeded 5 hours with aortography and was less than 3 hours with chest computed tomography and transesophageal echocardiography. Each diagnostic modality accurately identified an aortic injury. The average time for cardiopulmonary bypass and for clamp and sew was 52 minutes (range, 49 to 55 minutes) and 34 minutes (range, 16 to 45 minutes), respectively. One patient with preoperative paraplegia regained partial function; there were no other patients with paraplegia. There were no deaths. All patients are alive 2 months to 7 years after repair.

The multiply injured child with severe blunt trauma and an abnormal chest roentgenogram requires a search for aortic injury. We believe the most effective algorithm to follow for the diagnosis of traumatic thoracic aortic rupture in the child involves selective performance of chest computed tomography and transesophageal echocardiography. Our experience suggests that the mechanism of injury, the duration to diagnosis of an aortic injury, and failure to use seat belts may contribute to morbidity. A high index of suspicion and a systematic approach to the diagnosis and to the management strategy for injuries to the thoracic aorta can contribute to a good outcome in those few children who survive the injury.