Pediatric aortoiliac injury following blunt abdominal trauma: A case report

IntroductionThe most common mechanism of aortic injury involves motor vehicle collisions resulting in aortic disruptions, occurring almost exclusively in the chest. Injury to the abdominal aorta following blunt trauma is nearly twenty times less likely to occur than the thoracic aorta. Because of the low incidence, there are few reports regarding the presentation and repair of these particular injuries, especially in the pediatric population.Presentation of caseWe present a case of a 7-year-old boy involved in a high speed motor vehicle accident with an abdominal aorta transection at the aortic bifurcation extending into the left iliac artery. The injury was repaired using bovine pericardium with the adventitia and intima of the vessel approximated over the bovine bridge.DiscussionPrimary repair of thoracic aortic injury has been thoroughly described in the literature with good outcomes yet, abdominal aortic repair remains ambiguous. Few techniques and materials have been described with even less data surrounding the long-term outcomes.ConclusionBovine pericardium is a strong and stable acellular collagenous material with the potential to accelerate endothelialization and tissue regeneration. This remains an interesting field of research as stenosis and pseudo-coarction data have yet to be determined.     

Endovascular management of blunt abdominal aortic injury

The endovascular management of blunt aortic injuries is being used more frequently in the trauma patient. Traumatic aortic injuries usually occur in the descending thoracic aorta near the origin of the left subclavian artery. Many reports in the literature demonstrate the efficacy of endovascular repair of blunt thoracic aortic injury. We report here an unusual case of abdominal aortic dissection secondary to blunt abdominal trauma following a fall. The patient also had associated intra-abdominal injuries requiring bowel resection and repair of small bowel mesenteric lacerations. He was treated with a bifurcated abdominal endograft with an excellent result after the initial operation was performed to treat the bowel injuries.     

Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

Seat belt aorta: acute dissection and thrombosis of the abdominal aorta.

Aortic trauma mainly involves the thoracic aorta (95%), while the abdominal aorta is infrequently involved (5%). Of growing interest is the role of seat belts in abdominal aortic injuries. Although seat belts are known to cause injuries to the abdominal viscera, they rarely produce aortic trauma. We report here an acute dissection with thrombosis of the abdominal aorta leading to complete peripheral occlusion as a result of lap-type seat belt injury. The two previously reported cases of similar injuries which resulted in incomplete occlusion are reviewed. A hypothesis for the causal mechanism of these injuries is described. The authors also stress careful follow-up of all patients with seat belt injuries since other intra-abdominal vascular injuries may be present.     

Injuries of the abdominal aorta from blunt trauma.

Blunt injuries of the abdominal aorta are rarely reported in the literature. If left undiagnosed, these injuries may have catastrophic consequences. Four patients with blunt abdominal aortic lesions, identified in the authors' trauma registry, are presented in this report, along with a discussion of the pertinent literature to illustrate clinical management techniques. The mechanisms of injury include motor vehicular crashes (most frequent) with or without seatbelt use, abdominal blows, falls, and abdominal crush injuries. The spectrum of aortic lesions ranges from simple contusion or intramural hematoma to intimal disruption, false aneurysm, or frank rupture. Aortography should be performed in all stable patients with suspected aortic injury. All central-medial retroperitoneal hematomas discovered at laparotomy for blunt trauma should be explored after proximal and distal control of the aorta is obtained. Strict adherence to these principles, maintenance of standard vascular technique, and aggressive, expeditious resuscitative evaluation may improve survival.     

False aneurysm of the abdominal aorta after blunt trauma.

Injuries of the abdominal aorta due to blunt trauma are rare. So far, 33 cases have been reported in the English literature and false aneurysm formation after such injuries is even rarer. In this article, a case of false aneurysm of the abdominal aorta after blunt trauma in an acrobat which was successfully managed is reported, and the English literature for similar cases reviewed.     

Blunt Thoracic and Abdominal Vascular Trauma and Organ Injury Caused by Road Traffic Accident

OBJECTIVES: To analyse the relationship between vascular trauma and associated injuries to intra-thoracic and abdominal organs caused by traffic accidents. Design retrospective study in a university hospital. MATERIALS AND METHODS: We investigated 458 consecutive patients who were admitted with blunt thoracic and/or abdominal trauma caused by road traffic accidents between 1986 and 1999. Vascular trauma was encountered in 54 patients (12%). RESULTS: The injured vessels were located in the abdomen in 45 patients and in the chest in nine patients. Mesenteric vessels were the most frequently injured vessels (33/45) in the abdomen, while the aorta and major vessels were most frequently injured (9/9) in the chest. Injury to the large/small intestine was often associated with mesenteric vessel injury (26/27). In the 190 patients with blunt abdominal organ injury, the frequency of mesenteric vessel injury was also highest, regardless of the injured organ. Vascular reconstruction was necessary only in one of 51 patients who underwent operation. CONCLUSIONS: Our results demonstrate that the mesenteric vessels are susceptible to blunt thoracic and abdominal trauma in road traffic accidents. Vascular reconstruction may be indicated for selected patients as long as the injuries to hollow organs are assessed carefully because of their strong association with vascular injury.     

Traumatic aortic injuries in the pediatric population

Background/Purpose

Blunt trauma is the leading cause of pediatric injury, but pediatric aortic injuries are rare. We undertook this study to investigate the demographics, treatment, and outcomes of children with blunt aortic injuries and report our experience over a 10-year period.

Methods

After Institutional Review Board approval, a 10-year retrospective review of all pediatric patients admitted with blunt aortic injury was performed. Patient demographics, injury details and severity score (Injury Severity Score), treatment, and outcomes were recorded.

Results

There were 11 children, with ages ranging from 7 to 19 years. The most common mechanism of injury was motor vehicle crashes (8). Initial computed tomography demonstrated all 11 injuries: 7 thoracic aortic (TA) and 4 abdominal aortic (AA) injuries. Associated injuries were common. The TA injuries included 4 transections, 2 intimal flaps, and 1 pseudoaneurysm. Three of these were managed nonoperatively. The AA injuries included 3 intimal flaps and 1 dissection. Three of these were also managed nonoperatively. There were no complications in the 4 children with AA or in the 3 children with TA managed nonoperatively. Complications in the 4 children undergoing operative repair of the TA included paraplegia, renal failure, recurrent laryngeal nerve injury, and pulmonary embolus. The mean hospital stay was 8 days. All children survived, with all but one discharged directly to home.

Conclusions

Blunt aortic injury in children is uncommon and is primarily associated with motor vehicle crashes. Injuries to the abdominal aorta were seen with restrained children vs those to the thoracic aorta that were seen in children who were unrestrained.     

Blunt gastric injuries

Gastric rupture after blunt abdominal trauma is a rare injury with few reports in the literature. The purpose of this study was to review our experience with blunt gastric injuries and compare outcomes with small bowel or colon injuries. All patients with hollow viscus perforations after blunt abdominal trauma from 1992 to 2005 at our level I trauma center were reviewed. Of 35,033 blunt trauma admissions, there were 268 (0.7%) patients with a total of 319 perforating hollow viscus injuries, 25 (0.07%) of which were blunt gastric injuries. When compared with the small bowel or colon injuries, the blunt gastric injury group had a higher Injury Severity Score (22 versus 17, P = 0.04), more patients with a chest Abbreviated Injury Score greater than 2 (36% versus 12%, P < 0.01), and a shorter interval from injury to laparotomy (221 versus 366 minutes, P = 0.017). Multivariate analysis identified five independent risk factors for mortality: age older than 55 years, head Abbreviated Injury Score greater than 2, chest Abbreviated Injury Score greater than 2, the presence of hypotension on admission, and Glasgow Coma Scale 8 or less. The results of this study suggest that mortality in patients with blunt hollow viscus injuries can be attributed to concurrent head and chest injuries, but not the specific hollow viscus organ that is injured.     

Blunt trauma to the abdominal aorta

This review of blunt trauma to the abdominal aorta is based on one case summary and 32 cases from the literature. Motor vehicle accidents caused about half of the reported cases. In 69% of the cases the diagnosis was made in the immediate or early period. Associated injuries were present in 71% of the cases. Most injuries occurred at the inferior mesenteric artery (33%) or the renal arteries (24%). Overall mortality was 27%. Lower extremity ischemia evident on physical examination may suggest the diagnosis. When blunt abdominal aortic injury is suspected without distal ischemia, aortography may be used to define or exclude the injury and further therapy. Only minimal intimal disruptions should be managed nonoperatively.     

Splenic Trauma in Scotland: Demographics and Outcomes

Background Splenic trauma is a common organ injury following blunt abdominal trauma. In order to establish the contemporary epidemiology of blunt splenic trauma in Scotland and to detect risk factors associated with patient outcomes, analysis of a multi-center database of trauma patients was performed. Methods The study used data from a prospectively collated multicenter trauma database containing the details of 52,215 trauma patients admitted to participating Scottish hospitals over an 11-year period. Results 672 (1.3%) patients (530 males, 142 females) with splenic trauma were identified; of them, 579 (86.2%) had blunt trauma and 93 (13.8%) had penetrating trauma. The mean age of patients with blunt splenic trauma was 35.7 years (33.8 years for males, 42.0 years for females). Increasing age and female sex was significantly associated with mortality. The most common mechanism for injury was road traffic accidents (71%). In the series, 93.8% of patients had concomitant injuries including head injuries (46.5%), thoracic injuries (37.7%) and liver injuries (30%). A total of 299 (51.6%) patients proceeded to laparotomy, and 256 (44.2%) patients required ICU support. The overall mortality was 33.5%, and the median Injury Severity Score was 48 in patients who died, compared to 22 in those who survived. Increased mortality was associated with concomitant aortic, cardiac, or abdominal injuries. A number of independent risk factors were associated with increased risk of mortality, including concomitant injuries, increased age, and increased Injury Severity Score. Conclusions The incidence of splenic trauma is low, but it accounts for significant mortality. Outcome in the present study was worse in those with advanced age and associated injuries.     

Aortic Trauma in Scotland – A Population Based Study

OBJECTIVES: This population-based study aims to determine the incidence, mechanisms and outcomes of aortic trauma in patients from Scotland between 1992-2002. METHODS: Patients with aortic trauma were identified from the Scottish Trauma Audit Group database. Demographics, mechanism of injury, initial management and outcome were analysed. RESULTS: 165 (0.3%) patients suffered trauma to the thoracic or abdominal aorta. Of these, 130 (79%) patients had an injury of the thoracic aorta, 33 (20%) an injury of the abdominal aorta and two (1%) had injuries of both. There were 123 (75%) men and 42 (25%) women with a median (range) age of 36 (14-90) years. Blunt trauma was responsible for 121 (73%) injuries, of which road traffic accidents were the most common mechanism. A further 44 (27%) aortic injuries were due to penetrating trauma, of which assault was the most common cause. The median (range) Injury Severity Score was 43 (16-75). Ninety (55%) patients died in the emergency department while 59 (32%) underwent attempted operative repair. The operative mortality was 35 (59%) of 59 patients and overall mortality 141 (86%) of 165 patients. CONCLUSIONS: The incidence of aortic trauma presenting to Scottish hospitals is low. The majority of patients do not survive to surgical repair and operative and overall mortality remain prohibitive.     

Seat belt aorta

This review of 11 cases of seat-belt associated blunt abdominal aortic trauma, includes nine cases reported in the literature and two new cases. Lap-type seat belts were the cause of this injury in eight of the 11 patients (73%). Clinical presentation was acute in 73% of the cases, with symptoms of acute arterial insufficiency, or an acute abdomen or neurologic deficits. Chronic manifestations, such as, persistent abdominal pain, claudication, abdominal mass with a bruit and decreased distal pulses, presented as late as nine months after the injury occurred. The mechanism producing the injury is discussed and a classification system for the different types of abdominal aortic injuries is put forth. Circumferential intimal disruption was the most common aortic defect. The majority of these were located distal to the inferior mesenteric artery. Diagnosis involves a high degree of suspicion in a victim wearing a seat belt with neurologic deficits, signs of acute arterial insufficiency, or a pulsatile abdominal mass. The mortality rate was 18% (2/11 patients), and occurred in patients wearing lap belts. Overall outcome depends on prompt recognition followed by appropriate surgical intervention.     

Mechanical circulatory support decreases neurologic complications in the treatment of traumatic injuries of the thoracic aorta.

The surgical treatment of traumatic injuries of the thoracic aorta is controversial because a number of technical approaches have been recommended. Despite the technique employed, spinal cord ischemia continues to be a persistent problem. Nineteen patients with confirmed aortic injuries secondary to blunt trauma were treated at the Yale-New Haven (Conn) Medical Center from 1984 to 1991. The patients were analyzed in two groups: group 1 (n = 10) underwent repair using mechanical circulatory support and group 2 (n = 9) underwent repair without mechanical circulatory support. Sixteen patients survived. Three patients died of complications of multiple trauma. The groups were comparable with respect to aortic cross-clamp time, preoperative systolic blood pressure, and Injury Severity Score. Three patients in the nonmechanical support group developed neurologic complications (P less than .05). No patient in the mechanical support group had a neurologic complication. We believe that mechanical circulatory support reduces the incidence of neurologic complications following traumatic injuries of the thoracic aorta and should be used whenever clinically feasible.     

Analysis of 46 intra-abdominal aortic injuries from blunt trauma: case reports and literature review

Blunt trauma causing aortic injury is infrequent and primarily involves the thoracic aorta. Abdominal aortic injury after blunt trauma is much less frequent and has a varied presentation. Within a 3-month period, our trauma unit diagnosed and treated two cases of abdominal aortic injury secondary to blunt trauma. One was a belted passenger in a motor vehicle accident, and one was secondary to a crush injury. The addition of these two cases brings the number found in the literature to 46. Reviewing these cases has emphasized the need for prompt recognition and treatment of this vascular catastrophe.     

Risk factors for blunt thoracic aortic injury in children

Background/Purpose

Because blunt thoracic aortic injury is rare in children, a high index of suspicion is needed to identify this injury. The purpose of this study was to use a large national trauma database to define the risk factors for blunt thoracic aortic injury in children.

Methods

Using the National Trauma Database, the authors compared patient demographics, mechanism of injury, and associated injuries between children sustaining blunt trauma with and without a thoracic aortic injury. Factors independently associated with this injury were identified using multivariate methods.

Results

Among 26,940 children with a blunt mechanism of injury, 34 (0.1%) children sustained a thoracic aortic injury, 14 (41%) of whom died. Thoracic aortic injuries were independently associated with age, injury sustained as an occupant in a motor vehicle crash, and severe injuries (Abbreviated Injury Scale value of ≥3) involving the head, thorax (other than aorta), abdomen, and lower extremities.

Conclusions

Older children involved in a motor vehicle crash with severe head, torso, and lower extremity injuries are a group at high risk for injury to the thoracic aorta. These easily identifiable risk factors may facilitate more rapid identification of this rare and potentially fatal injury.     

Traumatic Rupture of the Thoracic Aorta

Traumatic rupture of the thoracic aorta is a life threatening situation, and may be secondary to several mechanisms; mainly penetrating or iatrogenic lesions and blunt trauma. Although penetrating mechanisms predominate, the number of patients with aortic disruption due to blunt trauma has continued to increase. This paper shows an overview focusing on the pathogenesis, diagnosis, timing and type of treatment regarding traumatic injuries of the thoracic aorta; it also reports the experience of one single center that deals with these lesions.

The major difficulty in the evaluation data on blunt aortic injury is that retrospective reviews often group together patients with all types of aortic lesions, comparing outcomes for injuries in different locations, with diverse methods of repair and different surgeons and/or institutions.     

Traumatic rupture of the thoracic aorta

Traumatic rupture of the thoracic aorta is a life threatening situation, and may be secondary to several mechanisms; mainly penetrating or iatrogenic lesions and blunt trauma. Although penetrating mechanisms predominate, the number of patients with aortic disruption due to blunt trauma has continued to increase. This paper shows an overview focusing on the pathogenesis, diagnosis, timing and type of treatment regarding traumatic injuries of the thoracic aorta; it also reports the experience of one single center that deals with these lesions. The major difficulty in the evaluation data on blunt aortic injury is that retrospective reviews often group together patients with all types of aortic lesions, comparing outcomes for injuries in different locations, with diverse methods of repair and different surgeons and/or institutions.     

Management of major acute thoracic vascular injuries

This report concerns thirty-nine cases of thoracic vascular injury. There were twenty-one cases of great vessel injuries in area I (thoracic inlet and upper thorax) including the ascending aorta (one), innominate artery (six), left common carotid artery (two), aortic arch (one), left subclavian artery (four), right subclavian artery (one), superior vena cava (two), innominate veins (one), and axillary arteries (three). Six were due to blunt trauma and fifteen were due to penetrating trauma including tracheal-innominate artery fistulas. There were seven injuries in area II (pulmonary arteries and veins). In area III there were eleven injuries of the descending thoracic aorta. Nine of these ruptured secondary to blunt trauma, one was a penetrating injury of the heart and aorta, and one was a penetrating aortic injury with a bullet embolus.A discussion is presented of the surgical approaches for the different vascular injuries of the thorax including different methods of repair of ruptures of the descending thoracic aorta.     

Complete occlusion after blunt injury to the abdominal aorta

BACKGROUND: Injury to the abdominal aorta after blunt trauma is uncommon. When this injury results in complete vessel occlusion, the presentation is dramatic. Timely intervention is essential. METHODS: After a case report, we examined all reported cases of complete occlusion after blunt injury to the abdominal aorta and reviewed the cause, presentation, and management of this injury. RESULTS: Complete vessel occlusion arises from intimal injury. The most frequent mechanism is compression from a seat belt or steering wheel during a motor vehicle crash. Patients present with absent femoral and distal pulses in association with lower extremity neuropathy. Intervention commonly involves bypass grafting of the abdominal aorta. CONCLUSION: Complete occlusion after blunt trauma to the abdominal aorta is rare. Neurologic deficits most commonly arise from peripheral nerve ischemia. Reperfusion within 6 hours confers a greater chance of limb salvage and neurologic recovery.