Global Cast MD, along with Cincinnati Children's
Hospital, sharing knowledge to improve child
health around the globe. Hello, pediatric surgery
family. I'm Lizzie 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 Drs. Regan Williams and
Katie Russell. This topic falls into the black
diamond category of unproven approaches. The
16 -year -old female who was in a motor vehicle
accident and presented in shock. This is her
imaging. She has a grade 5 splenic injury and
a blunt grade 2 thoracic aortic injury. What
would you do next to manage the blunt thoracic
aortic injury? Deal with the life -threatening
injury first, right? So take out the spleen if
that has to happen. If there's head injuries,
you could think about treating that first. Use
beta blockers like to control pressure, but that
may not be feasible if you're in an 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. This is 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 surgeon? Is it the vascular
surgeon? 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. There are 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, the 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, decreased 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 is really small stents that you can use.
And then this is 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 unoperatively, 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
T -VAR being the preferred approach for better
outcomes. T -VAR 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 radiologists 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.
along with Cincinnati Children's Hospital, sharing
knowledge to improve child health around the
globe.