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Trends and Outcomes in Management of Thoracic Aortic Injury in Children, Adolescent, and Mature Pediatric Patients using Data from the National Trauma Data Bank

Published:September 19, 2022DOI:https://doi.org/10.1016/j.avsg.2022.09.034

      Abstract

      Objectives

      Thoracic aortic injury (TAI) is rare in the pediatric population. Thoracic Endovascular Aortic Repair (TEVAR) is the recommended standard of care for treatment in the adult population given its association with lower rates of mortality and morbidity than traditional open repairs for treatment of TAI. However, there are unique anatomic challenges in treating pediatric patients with TEVAR which may impact the outcomes and pediatric guidelines. We aimed to compare current management trends and outcomes between different pediatric age groups using data from the National Trauma Data Bank (NTDB).

      Methods

      We analyzed the NTDB from 2007-2019 using ICD-9 and -10 codes to identify patients with a TAI. We excluded patients older than 21 years old and any patients who died in the emergency department. The pediatric patients were stratified by age group: children (1-11 years), adolescent (12-17 years), and mature (18-21 years). Patient characteristics compared included injury mechanism and severity, TAI intervention, and outcomes between the three groups using bivariate analysis (ANOVA for parametric and Kruskal-Wallis for non-parametric variables). These characteristics and outcomes were also compared by TAI intervention and injury mechanism. ICD-9 and -10 procedural codes were used to identify patients who underwent TEVAR, open aortic repair (OAR), or both. Modified Poisson regression was performed with relative risk (RR) to evaluate our primary outcome measure: mortality during the trauma admission.

      Results

      A total of 2,431 pediatric TAI were identified in the NTDB that met the inclusion criteria. This included 134 children (5.5%), 733 adolescent (30.2%), and 1,564 mature (64.3%) patients. Children had significantly lower median injury severity scores (ISS) (34.1) than the adolescent (38) or mature population (36.1) (P=.001). The mechanism of injury differed between age groups. Children had higher rates of blunt trauma (90.3% children, 89.6% adolescent, 86.8% mature) and mature patients had higher rates of penetrating trauma (6% children, 10.1% adolescent, 12.5% mature) (P<.001). TAI management also differed significantly between pediatric age groups. Mature patients had significantly higher rates of TEVAR (3% children, 25.2% adolescent, 29.2% mature) and children were most likely to be treated with non-operative management (NOM) (94% children, 67.9% adolescent, 64.8% mature) (P<.001). Patients who were treated with TEVAR were discharge home most frequently (31.8% NOM, 54.1% TEVAR, 44.3% OAR, 22.2% both TEVAR and OAR). Upon modified Poisson regression analysis, patient age was not associated with an increased risk of in-hospital mortality. Intervention with TEVAR (RR 0.22, 95% CI 0.15-0.33, P<.001) and OAR (RR 0.58, 95% CI 0.36-0.93, P=.024) were associated with a lower risk of mortality than NOM.

      Conclusion

      TAI is less prevalent in children compared to adults. TEVAR for TAI is associated with lower risk of in-hospital mortality compared to both NOM and OAR without differences between pediatric subgroups. Further studies should be completed to determine the most appropriate management guidelines.

      Keywords

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