WEBVTT 00:00:00.940 --> 00:00:04.660 Global Cast MD, along with Cincinnati Children's 00:00:04.660 --> 00:00:06.799 Hospital, sharing knowledge to improve child 00:00:06.799 --> 00:00:09.300 health around the globe. Hello, pediatric surgery 00:00:09.300 --> 00:00:11.900 family. I'm Lizzie Lee from Cincinnati Children's 00:00:11.900 --> 00:00:14.339 Hospital Medical Center. In this video series, 00:00:14.640 --> 00:00:16.719 we'll be recapping the sessions and sharing the 00:00:16.719 --> 00:00:19.039 key highlights from our 12th annual update course 00:00:19.039 --> 00:00:21.440 in pediatric surgery, which was held in August 00:00:21.440 --> 00:00:24.660 2024. This year, we introduced a new approach 00:00:24.660 --> 00:00:27.140 to classify practice -changing ideas at our update 00:00:27.140 --> 00:00:30.710 course. Presentations now fall into three categories, 00:00:30.969 --> 00:00:33.729 green circles for established practices, blue 00:00:33.729 --> 00:00:36.369 squares for promising newer practices, and black 00:00:36.369 --> 00:00:39.409 diamonds for early adopter practices only. Today 00:00:39.409 --> 00:00:41.429 we'll talk about a vascular surgery update in 00:00:41.429 --> 00:00:44.090 pediatric trauma with Drs. Regan Williams and 00:00:44.090 --> 00:00:47.149 Katie Russell. This topic falls into the black 00:00:47.149 --> 00:00:50.490 diamond category of unproven approaches. The 00:00:50.490 --> 00:00:52.810 16 -year -old female who was in a motor vehicle 00:00:52.810 --> 00:00:55.070 accident and presented in shock. This is her 00:00:55.070 --> 00:00:59.100 imaging. She has a grade 5 splenic injury and 00:00:59.100 --> 00:01:02.820 a blunt grade 2 thoracic aortic injury. What 00:01:02.820 --> 00:01:04.900 would you do next to manage the blunt thoracic 00:01:04.900 --> 00:01:07.200 aortic injury? Deal with the life -threatening 00:01:07.200 --> 00:01:09.719 injury first, right? So take out the spleen if 00:01:09.719 --> 00:01:11.819 that has to happen. If there's head injuries, 00:01:11.959 --> 00:01:14.200 you could think about treating that first. Use 00:01:14.200 --> 00:01:16.459 beta blockers like to control pressure, but that 00:01:16.459 --> 00:01:18.859 may not be feasible if you're in an active resuscitation 00:01:18.859 --> 00:01:21.400 for this patient. Let's see the poll results 00:01:21.400 --> 00:01:23.780 from the combined live and virtual audience. 00:01:24.400 --> 00:01:26.959 48 % of the pediatric surgeons answered that 00:01:26.959 --> 00:01:29.480 they would do the endovascular repair with stent 00:01:29.480 --> 00:01:31.780 placement for this patient with thoracic aortic 00:01:31.780 --> 00:01:34.620 injury. Nobody would do an open repair on cardiac 00:01:34.620 --> 00:01:36.959 bypass. This is super interesting. Thoracic aortic 00:01:36.959 --> 00:01:39.939 injury is very, very rare in children, so you're 00:01:39.939 --> 00:01:42.219 almost never going to see it. But in a national 00:01:42.219 --> 00:01:45.180 survey, actually about 67 % were managed non 00:01:45.180 --> 00:01:47.859 -operatively, which goes in line with what we 00:01:47.859 --> 00:01:51.540 saw in our poll. 27 % were managed endovascularly 00:01:51.540 --> 00:01:54.650 and 6 % were managed open. Most pediatric surgeons 00:01:54.650 --> 00:01:56.950 hesitate to operate and place stents in very 00:01:56.950 --> 00:01:59.709 young children, but endovascular repair has been 00:01:59.709 --> 00:02:01.930 shown to have better outcomes than non -operative 00:02:01.930 --> 00:02:05.030 management. Endovascular repair may be a better 00:02:05.030 --> 00:02:06.930 treatment option for children with these injuries 00:02:06.930 --> 00:02:10.030 because they may progress. So I think that depends 00:02:10.030 --> 00:02:13.169 a lot on the age. What do y 'all do? It's a case 00:02:13.169 --> 00:02:15.490 -by -case basis. It's so infrequent. And then 00:02:15.490 --> 00:02:17.090 there's also the questions, who do you call? 00:02:17.229 --> 00:02:19.129 Is this the cardiac surgeon? Is it the vascular 00:02:19.129 --> 00:02:22.009 surgeon? Is it IR? At our institution, it is 00:02:22.009 --> 00:02:24.530 not totally consistent. Some of these thoracic 00:02:24.530 --> 00:02:26.530 aortic injuries can be missed when the patient 00:02:26.530 --> 00:02:29.169 first arrives at the ER. In this case, they were 00:02:29.169 --> 00:02:31.129 taking the patient to interventional radiology 00:02:31.129 --> 00:02:33.870 for the splenic injury. We didn't know about 00:02:33.870 --> 00:02:36.310 the thoracic aortic injury until they were in 00:02:36.310 --> 00:02:38.370 IR. There are injuries we missed because children 00:02:38.370 --> 00:02:40.289 are really small and if they have a little intimal 00:02:40.289 --> 00:02:42.849 repair. We had looked at the scans and it was 00:02:42.849 --> 00:02:45.509 the attending radiologist three hours later that 00:02:45.509 --> 00:02:48.400 found the injury. To make sure we can catch possible 00:02:48.400 --> 00:02:51.439 thoracic aortic injuries, order CT chest scans 00:02:51.439 --> 00:02:54.400 in patients whose chest x -rays show a wide mediastinum. 00:02:54.620 --> 00:02:56.979 You definitely need to scan the chest if you're 00:02:56.979 --> 00:02:59.319 worried about the chest x -ray. There is mediastinal 00:02:59.319 --> 00:03:01.860 widening on the chest x -ray. That is a concern 00:03:01.860 --> 00:03:04.360 for some kind of great vessel injury that definitely 00:03:04.360 --> 00:03:07.620 needs a CTA of the chest. In this patient case, 00:03:07.879 --> 00:03:10.259 Dr. Russell consulted the vascular surgeon as 00:03:10.259 --> 00:03:12.520 the next step. The vascular surgeon recommended 00:03:12.520 --> 00:03:15.180 placing a stent in this child for endovascular 00:03:15.180 --> 00:03:17.560 repair. I looked at this paper, the 10 -year 00:03:17.560 --> 00:03:19.919 review, that actually shows TVAR is very safe 00:03:19.919 --> 00:03:23.300 in children. TVAR stands for thoracic endovascular 00:03:23.300 --> 00:03:26.120 aortic repair. It's a minimally invasive procedure 00:03:26.120 --> 00:03:28.439 that treats an aneurysm in the upper part of 00:03:28.439 --> 00:03:31.159 your aorta. Decreases mortality, decreased risk 00:03:31.159 --> 00:03:33.400 of spinal cord injury from doing an open procedure, 00:03:33.599 --> 00:03:35.240 and it gets them out of the hospital faster. 00:03:35.599 --> 00:03:38.300 During TVAR, a stent graft is used to prevent 00:03:38.300 --> 00:03:40.840 the aneurysm, a weak bulging area in the aorta, 00:03:40.919 --> 00:03:43.319 from bursting. I've been working a lot with the 00:03:43.319 --> 00:03:46.180 SVS and the Society for Vascular Surgeons, and 00:03:46.180 --> 00:03:48.360 there is really small stents that you can use. 00:03:48.500 --> 00:03:50.699 And then this is a 16 year old. So 16 year olds 00:03:50.699 --> 00:03:52.939 are really close to adults. And if you look at 00:03:52.939 --> 00:03:55.439 the adult SVS recommendations, it would 100 % 00:03:55.439 --> 00:03:58.460 be for endovascular repair. If a pediatric patient 00:03:58.460 --> 00:04:01.080 comes in with a thoracic aortic injury, consider 00:04:01.080 --> 00:04:03.580 getting it repaired by interventional radiology 00:04:03.580 --> 00:04:05.879 or vascular surgery, depending on the individual 00:04:05.879 --> 00:04:08.400 institution. The younger children were more likely 00:04:08.400 --> 00:04:11.599 to be managed unoperatively, but you can use 00:04:11.599 --> 00:04:13.580 an endovascular repair if you need to in those 00:04:13.580 --> 00:04:15.199 children. You just have to use a really small 00:04:15.199 --> 00:04:17.740 stent. In summary, in patients with thoracic 00:04:17.740 --> 00:04:20.259 aortic injury, managing life -threatening injuries 00:04:20.259 --> 00:04:23.139 takes priority, with endovascular repair like 00:04:23.139 --> 00:04:25.040 T -VAR being the preferred approach for better 00:04:25.040 --> 00:04:28.000 outcomes. T -VAR is particularly effective in 00:04:28.000 --> 00:04:30.740 older children and adolescents, offering a less 00:04:30.740 --> 00:04:33.180 invasive alternative to open surgery with reduced 00:04:33.180 --> 00:04:36.449 risk of complications. For suspected thoracic 00:04:36.449 --> 00:04:39.170 aortic injuries, CT chest scans are essential 00:04:39.170 --> 00:04:41.870 following chest x -rays that show mediastinal 00:04:41.870 --> 00:04:44.970 widening. Collaboration with vascular surgeons 00:04:44.970 --> 00:04:47.610 or interventional radiologists is important for 00:04:47.610 --> 00:04:50.930 treatment decisions. However, remember that this 00:04:50.930 --> 00:04:53.529 is still in the early adopter stage and is not 00:04:53.529 --> 00:04:56.050 yet universally accepted as the standard of care. 00:04:59.480 --> 00:05:02.019 along with Cincinnati Children's Hospital, sharing 00:05:02.019 --> 00:05:04.040 knowledge to improve child health around the 00:05:04.040 --> 00:05:04.300 globe.