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Aortic Transection after Blunt Abdominal Trauma in a Child
Journal Pre-proof Aortic transection following blunt abdominal trauma in a child. Shivik Patel, MD, Claudie McArthur Sheahan, MD, Danielle D. Fontenot, MD, Malachi Gerard Sheahan, MD PII:
S0890-5096(20)30151-5
DOI:
https://doi.org/10.1016/j.avsg.2020.01.095
Reference:
AVSG 4897
To appear in:
Annals of Vascular Surgery
Received Date: 28 July 2019 Revised Date:
11 January 2020
Accepted Date: 13 January 2020
Please cite this article as: Patel S, McArthur Sheahan C, Fontenot DD, Sheahan MG, Aortic transection following blunt abdominal trauma in a child., Annals of Vascular Surgery (2020), doi: https:// doi.org/10.1016/j.avsg.2020.01.095. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
1
Title:
2
Aortic transection following blunt abdominal trauma in a child.
3 4
Authors:
5 6
Shivik Patel, MD Louisiana State University Health Sciences Center
7 8
Claudie McArthur Sheahan, MD Louisiana State University Health Sciences Center
9 10
Danielle D Fontenot, MD University of South Florida
11 12
Malachi Gerard Sheahan, MD Louisiana State University Health Sciences Center
13 14
Corresponding Author:
15 16 17 18 19
Claudie McArthur Sheahan, MD Louisiana State University Health Sciences Center 433 Bolivar Street New Orleans, LA 70112
20 21 22 23 24 25 26 27 28 29 30 31 32 33
34
Abstract:
35 36 37 38 39 40
Abdominal aortic injury secondary to blunt abdominal aortic trauma (BAAI) is a rare in children but frequently occurs in association with other injuries, including bowel injury and vertebral fracture. We present a case of a 14-year-old boy who sustained a partial transection of the infrarenal aorta with a lumbar chance fracture and small bowel injury following a motor vehicle accident. Repair was performed with bowel resection followed by Dacron graft interposition. We reviewed the literature on BAAI in children with a focus on the method of repair of these injuries.
41
Introduction:
42 43 44 45 46
Pediatric BAAI is a rare and frequently fatal event with few surgical cases available for comparison in the literature. 1 When BAAI does occur, it is usually associated with other injuries.2 Trauma to the aorta associated with seat belt use was first described by Dajee et al3, and a triad of injuries including lumbar Chance fractures, bowel injury, and aortic injury associated with seat belt use in children has been described.2 Informed consent to publish this case was obtained from the patient’s father.
47
Case Report:
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74
A 14-year-old boy was brought to the emergency department of an outside hospital following a high-speed motor vehicle accident. The child was a rear passenger restrained in a two-point lap-belt. At the time of presentation physical examination revealed a transverse line of ecchymosis consistent with a “seatbelt sign”. A contrast-enhanced CT of the abdomen was obtained which showed a Chance fracture at the L3 level and a filling defect at the aortic bifurcation extending into the right common iliac artery (figure 1a, 1b). A small amount of fluid was noted in the pelvis without contrast extravasation. No free-air was noted. The patient was hemodynamically stable with normal pulses and was subsequently transferred to our facility for further management. On evaluation the patient reported mild abdominal discomfort with suprapubic tenderness and mild abdominal distension. He remained hemodynamically stable and neurologically intact. He was taken to the OR for a concern for bowel injury as well as planned repair of the aorta. At laparotomy, several mesenteric injuries were repaired and an internal hernia was reduced. This segment of bowel appeared congested. There was a serosal tear of a nearby segment of small bowel. An 8 cm of involved small bowel was resected and reanastomosed primarily with an EEA-stapler without spillage of bowel contents. The abdomen was irrigated with antibiotic solution and we focused our attention on the aorta. The retroperitoneum appeared free of hematoma initially, and the aorta was dissected from the inferior mesenteric artery to the iliac bifurcation bilaterally. A longitudinal arteriotomy revealed a transection of approximately 50% of the circumference of the aorta along the posterolateral wall. The transection was through both intima and media (figure 2a). Primary repair was not attempted as it would have resulted in an unacceptable degree of tension on the aortic wall. The damaged section of the aortic wall was excised and a 14-mm interposition Dacron graft was placed with the distal anastomosis at the level of the aortic bifurcation (figure 2b). The back wall of the anastomoses were sutured in a running fashion and the anterior wall sutures were interrupted. Strong back bleeding was noted from the iliac vessels. Upon completion of the anastomoses there were strong femoral and pedal pulses noted bilaterally. The retroperitoneum was then closed after the bowel was reexamined, which appeared pink and no longer congested. The abdomen irrigated with antibiotic solution, and the abdomen was closed primarily. The patient was placed in a postoperative brace for
75 76 77
the Chance fracture repair the following day. His postoperative course was unremarkable. Through 48 months of follow-up, the patient had a stable pulse exam and transabdominal duplex ultrasound demonstrated a patent aortic graft.
78
Discussion:
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
BAAI is exceedingly rare with most pediatric aortic injuries occurring in the thoracic aorta. 4 A consistent triad of associated injuries has emerged in the literature, and was demonstrated in this case. Here, based on the presence of a “seat belt sign” a CT scan was performed and revealed the lumbar fracture and aortic injury. The small amount of free fluid in the abdomen was likely related to the mesenteric tears. Although he had not developed significant abdominal symptoms by the time that he was taken to surgery, his physical findings at that time were consistent with an underlying bowel injury and obstruction. A high index of suspicion for associated bowel injury should be present when treating a patient with aortic injury and Chance fracture. It has been reported that 6070% of Chance fractures are associated with visceral or mesenteric damage. 5 The range of pediatric AAI includes intimal injuries with or without aortic occlusion or aneurysm, rupture, contusion and various degrees of transection. Missed injuries may present with late 1aortic stenosis or pseudoaneurysm. A review of all recent relevant reports in the literature was performed .1,2,4,6-16 Given the rarity of these cases and the wide spectrum in degree of injury, it is not possible to make any conclusions as to the optimal treatment. Of the cases reviewed with available follow up, most involved limited intimal injury.1,2,4,12,14,15, Of these most were repaired primarily.1,4,15 Aortic transection was reported in 9 cases prior to this report 1,2,8,10,11,13 and was treated with resection and interposition graft placement in 4 patients 1,2,8,13, each with a different graft material or time interval to repair relative to bowel repair. The ultimate outcome of any method of treatment remains unknown. The potential benefit of an endovascular repair, may be appealing for the patient with an isolated injury of the aorta without associated mesenteric or bowel injury, however widespread application is challenging given the frequent concomitant intra-abdominal injuries that warrant urgent attention. There are no reported cases of infected aortic graft prostheses in children following repair with bowel repair, but a theoretic advantage to endovascular repair immediately followed by open abdominal exploration to avoid contamination of the retroperitoneum by intestinal repair exists, and further study is needed to evaluate this theory. Furthermore, the potential limitations of endovascular repair, including the need for long-term CT surveillance with associated radiation exposure, durability of the stent graft material over the lifespan of a child as well as issues of sizing an endograft appropriately to allow for appropriate future growth, are all relevant and need to be further elucidated. Despite greater experience with open repair of the aorta in children, no consensus exists as to the ideal method and material for repair. Conservative management of intimal injuries in this location is tempting, but sparse data exists to define which patients would be most suitably treated with repair versus observation.
111 112 113 114 115
Blunt injuries to the infrarenal aorta are rarely reported in children. At our institution, we follow a protocol that is admittedly based more on common sense and anecdotal experience than published outcomes. For injuries in which there is no disturbance of the contour of the outer wall of the aorta, we recommend repeat imaging in 24 to 48 hours. If there is any evidence of wall disruption, we generally proceed with operative repair, even without frank extravasation of blood.
116 117 118 119 120 121 122 123 124 125 126 127 128
Our operative approach is transabdominal. Any bowel injuries should be addressed first, followed by copious irrigation of the abdominal cavity. In decceleration injuries, the disruption is usually in the posterior wall of the aorta just proximal to the iliac bifurcation. Therefore control is obtained of the infrarenal aorta, inferior mesenteric artery, and both common iliac arteries. We begin with a transverse arteriotomy in the anterior surface of the aorta at the level of the injury. If a primary repair can be performed, this is accomplished with interrupted 3-0 prolene sutures. In most cases, however, an interposition graft is required. We prefer to use a woven polyester graft, diameter 2-3 mm greater than the native aorta. If there is frank spillage of bowel contents, autologous conduit can be considered. In our experience, this has never been necessary. Although the location of these injuries tends to be in the distal aorta, the iliac bifurcation can be salvaged in most cases, obviating the need for a bifurcated graft. We generally perform the posterior wall anastomosis with a running prolene and the anterior wall with interrupted sutures to allow for aortic growth. The retroperitoneum is tightly closed, especially in cases with concomitant bowel injury.
129 130 131
Follow up should be performed at least bi-annually for several years. We do not advocate routine CT surveillance in children. Outpatient ultrasound can be considered, but in most cases future therapy is dictated by clinical exam.
132 133
Our case demonstrates that durable long term results can be achieved with prosthetic repair of pediatric abdominal aortic transections, even when concomitant bowel injuries are present.
134
Conclusion:
135 136 137 138 139
Given the spectrum of injuries that can occur with BAAI there are several appropriate treatment options available today. No evidence-based recommendations for management of these injuries exist, especially in regard to graft material and surgical approach. Given their rarity, it may be that the answer lies in the future results of the Low Frequency Disease subgroup of the Vascular Quality Initiative (VQI).
140 141 142 143 144 145 146 147 148 149 150
151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192
References: 1. Sadaghianloo N, Jean-Baptiste E, Breaud J, Declemy J, Kurzenne J-Y, Hassen-Khoda R. Blunt abdominal aortic trauma in paediatric patients. Injury, Int. J. Care Injured 45 (2014) 183-191, which describes the mechanisms of injury, associated injuries, management, and outcomes of 40 children with blunt abdominal aortic injuries. 2. Choit RL, Tredwell SJ, Leblanc JG, Reilly CW, Mulpuri K. Abdominal aortic injuries associated with Chance fractures in pediatric patients. J Pediatr Surg. 2006;41:1184-90. 3. Dajee H, Richardson IW, Iype MO. Seat belt aorta: acute dissection and thrombosis of the abdominal aorta. Surgery 1979;85:263-267. 4. Lin PH, Barr V, Bush R, Velez D, Lumsden A, Ricketts J. Isolated abdominal aortic rupture in a child due to all-terrain vehicle accident. A case report. Vasc and Endovascular Surg. 2003;37:289-292. 5. Randhawa MPS, Menzoian JO. Seat belt aorta. Ann Vasc Surg. 1990;4:370-377. 6. Blanco FC, Powell DM, Guzzetta PC, Burd RS. Aortic bifurcation rupture after blunt abdominal trauma in a child: a case report. J Pediatr Surg. 2011;46:1452-54. 7. Swischuk LE, Siddharth JP, Chung DH. Aortic injury with chance fracture in a child. Emerg Radiol. 2008;15:285-87. 8. Muniz AE and Haynes JH. Delayed abdominal aortic rupture in a child with a seat-belt sign and review of the literature. J Trauma. 2004;56:194-97. 9. Diaz JA, Campbell BT, Moursi MM, Boneti C, Kokoska ER, Jackson RJ, Smith SD. Delayed manifestation of abdominal aortic stenosis in a child presenting 10 years after blunt abdominal trauma. J Vasc Surg. 2006;44:1104-06. 10. Sakran JV, Mukherjee D. Four-year follow-up of endograft repair of traumatic aortic transection in a 10-year-old. Vasc Endovascular Surg. 2009;43:597-98. 11. Aidinian G, Kamaze M, Russo EP, Mukherjee D. Endograft repair of traumatic aortic transection in a 10-year-old: a case report. Vasc Endovascular Surg. 2006;40:239-42. 12. Khanna PC, Rothenbach P, Guzzetta PC, Bulas DI. Lap-belt syndrome: management of aortic intimal dissection in a 7-year-old child with a constellation of injuries. Pediatr Radiol. 2007;37:87-90. 13. McCarthy MC, Price SW, Rundell WK, Lehner JT, Barney LM, Ekeh AP, Saxe JM, Woods RJ, Walusimbi MS. Pediatric blunt abdominal aortic injuries: case report and review of the literature. J Trauma. 2007;63:1383-87. 14. Burjonrappa S, Vinocur C, Smergel E, Chhabra A, Galiote J. Pediatric blunt abdominal aortic trauma. J Trauma. 2008;65:E10-12. 15. Yulevich A, Singer-Jordan J, Grozovsky Y, Zonis Z, Sweed Y. Traumatic abdominal aortic dissection in a child. J Trauma. 2007;62:1039-41. 16. Gauderer MWL, Wolkoff JS, Izant RJ. Traumatic aneurysm of the suprarenal abdominal aorta: surgical reconstruction in a 7-yr-old patient. J Pediatr Surg. 1982;17:940-43.
193 194 195
Legends: Figure 1a. CTA of abdominal aortic disruption with filling defect at the level of the aortic bifurcation
196 197 198
Figure 1b. CTA of the abdominal aorta demonstrates partial transection of the abdominal aorta. Note the filling defect across the posterolateral aorta.
199 200
Figure 2a. 50% transection of the posterolateral aortic wall just above the aortic bifurcation.
201 202 203 204 205 206 207
Figure 2b. 14 mm interposition Dacron graft in place between the inferior mesenteric artery and the aortic bifurcation. Note the diameter of the graft is slightly larger than the native aorta.
S0890-5096(20)30151-5
DOI:
https://doi.org/10.1016/j.avsg.2020.01.095
Reference:
AVSG 4897
To appear in:
Annals of Vascular Surgery
Received Date: 28 July 2019 Revised Date:
11 January 2020
Accepted Date: 13 January 2020
Please cite this article as: Patel S, McArthur Sheahan C, Fontenot DD, Sheahan MG, Aortic transection following blunt abdominal trauma in a child., Annals of Vascular Surgery (2020), doi: https:// doi.org/10.1016/j.avsg.2020.01.095. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
1
Title:
2
Aortic transection following blunt abdominal trauma in a child.
3 4
Authors:
5 6
Shivik Patel, MD Louisiana State University Health Sciences Center
7 8
Claudie McArthur Sheahan, MD Louisiana State University Health Sciences Center
9 10
Danielle D Fontenot, MD University of South Florida
11 12
Malachi Gerard Sheahan, MD Louisiana State University Health Sciences Center
13 14
Corresponding Author:
15 16 17 18 19
Claudie McArthur Sheahan, MD Louisiana State University Health Sciences Center 433 Bolivar Street New Orleans, LA 70112
20 21 22 23 24 25 26 27 28 29 30 31 32 33
34
Abstract:
35 36 37 38 39 40
Abdominal aortic injury secondary to blunt abdominal aortic trauma (BAAI) is a rare in children but frequently occurs in association with other injuries, including bowel injury and vertebral fracture. We present a case of a 14-year-old boy who sustained a partial transection of the infrarenal aorta with a lumbar chance fracture and small bowel injury following a motor vehicle accident. Repair was performed with bowel resection followed by Dacron graft interposition. We reviewed the literature on BAAI in children with a focus on the method of repair of these injuries.
41
Introduction:
42 43 44 45 46
Pediatric BAAI is a rare and frequently fatal event with few surgical cases available for comparison in the literature. 1 When BAAI does occur, it is usually associated with other injuries.2 Trauma to the aorta associated with seat belt use was first described by Dajee et al3, and a triad of injuries including lumbar Chance fractures, bowel injury, and aortic injury associated with seat belt use in children has been described.2 Informed consent to publish this case was obtained from the patient’s father.
47
Case Report:
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74
A 14-year-old boy was brought to the emergency department of an outside hospital following a high-speed motor vehicle accident. The child was a rear passenger restrained in a two-point lap-belt. At the time of presentation physical examination revealed a transverse line of ecchymosis consistent with a “seatbelt sign”. A contrast-enhanced CT of the abdomen was obtained which showed a Chance fracture at the L3 level and a filling defect at the aortic bifurcation extending into the right common iliac artery (figure 1a, 1b). A small amount of fluid was noted in the pelvis without contrast extravasation. No free-air was noted. The patient was hemodynamically stable with normal pulses and was subsequently transferred to our facility for further management. On evaluation the patient reported mild abdominal discomfort with suprapubic tenderness and mild abdominal distension. He remained hemodynamically stable and neurologically intact. He was taken to the OR for a concern for bowel injury as well as planned repair of the aorta. At laparotomy, several mesenteric injuries were repaired and an internal hernia was reduced. This segment of bowel appeared congested. There was a serosal tear of a nearby segment of small bowel. An 8 cm of involved small bowel was resected and reanastomosed primarily with an EEA-stapler without spillage of bowel contents. The abdomen was irrigated with antibiotic solution and we focused our attention on the aorta. The retroperitoneum appeared free of hematoma initially, and the aorta was dissected from the inferior mesenteric artery to the iliac bifurcation bilaterally. A longitudinal arteriotomy revealed a transection of approximately 50% of the circumference of the aorta along the posterolateral wall. The transection was through both intima and media (figure 2a). Primary repair was not attempted as it would have resulted in an unacceptable degree of tension on the aortic wall. The damaged section of the aortic wall was excised and a 14-mm interposition Dacron graft was placed with the distal anastomosis at the level of the aortic bifurcation (figure 2b). The back wall of the anastomoses were sutured in a running fashion and the anterior wall sutures were interrupted. Strong back bleeding was noted from the iliac vessels. Upon completion of the anastomoses there were strong femoral and pedal pulses noted bilaterally. The retroperitoneum was then closed after the bowel was reexamined, which appeared pink and no longer congested. The abdomen irrigated with antibiotic solution, and the abdomen was closed primarily. The patient was placed in a postoperative brace for
75 76 77
the Chance fracture repair the following day. His postoperative course was unremarkable. Through 48 months of follow-up, the patient had a stable pulse exam and transabdominal duplex ultrasound demonstrated a patent aortic graft.
78
Discussion:
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
BAAI is exceedingly rare with most pediatric aortic injuries occurring in the thoracic aorta. 4 A consistent triad of associated injuries has emerged in the literature, and was demonstrated in this case. Here, based on the presence of a “seat belt sign” a CT scan was performed and revealed the lumbar fracture and aortic injury. The small amount of free fluid in the abdomen was likely related to the mesenteric tears. Although he had not developed significant abdominal symptoms by the time that he was taken to surgery, his physical findings at that time were consistent with an underlying bowel injury and obstruction. A high index of suspicion for associated bowel injury should be present when treating a patient with aortic injury and Chance fracture. It has been reported that 6070% of Chance fractures are associated with visceral or mesenteric damage. 5 The range of pediatric AAI includes intimal injuries with or without aortic occlusion or aneurysm, rupture, contusion and various degrees of transection. Missed injuries may present with late 1aortic stenosis or pseudoaneurysm. A review of all recent relevant reports in the literature was performed .1,2,4,6-16 Given the rarity of these cases and the wide spectrum in degree of injury, it is not possible to make any conclusions as to the optimal treatment. Of the cases reviewed with available follow up, most involved limited intimal injury.1,2,4,12,14,15, Of these most were repaired primarily.1,4,15 Aortic transection was reported in 9 cases prior to this report 1,2,8,10,11,13 and was treated with resection and interposition graft placement in 4 patients 1,2,8,13, each with a different graft material or time interval to repair relative to bowel repair. The ultimate outcome of any method of treatment remains unknown. The potential benefit of an endovascular repair, may be appealing for the patient with an isolated injury of the aorta without associated mesenteric or bowel injury, however widespread application is challenging given the frequent concomitant intra-abdominal injuries that warrant urgent attention. There are no reported cases of infected aortic graft prostheses in children following repair with bowel repair, but a theoretic advantage to endovascular repair immediately followed by open abdominal exploration to avoid contamination of the retroperitoneum by intestinal repair exists, and further study is needed to evaluate this theory. Furthermore, the potential limitations of endovascular repair, including the need for long-term CT surveillance with associated radiation exposure, durability of the stent graft material over the lifespan of a child as well as issues of sizing an endograft appropriately to allow for appropriate future growth, are all relevant and need to be further elucidated. Despite greater experience with open repair of the aorta in children, no consensus exists as to the ideal method and material for repair. Conservative management of intimal injuries in this location is tempting, but sparse data exists to define which patients would be most suitably treated with repair versus observation.
111 112 113 114 115
Blunt injuries to the infrarenal aorta are rarely reported in children. At our institution, we follow a protocol that is admittedly based more on common sense and anecdotal experience than published outcomes. For injuries in which there is no disturbance of the contour of the outer wall of the aorta, we recommend repeat imaging in 24 to 48 hours. If there is any evidence of wall disruption, we generally proceed with operative repair, even without frank extravasation of blood.
116 117 118 119 120 121 122 123 124 125 126 127 128
Our operative approach is transabdominal. Any bowel injuries should be addressed first, followed by copious irrigation of the abdominal cavity. In decceleration injuries, the disruption is usually in the posterior wall of the aorta just proximal to the iliac bifurcation. Therefore control is obtained of the infrarenal aorta, inferior mesenteric artery, and both common iliac arteries. We begin with a transverse arteriotomy in the anterior surface of the aorta at the level of the injury. If a primary repair can be performed, this is accomplished with interrupted 3-0 prolene sutures. In most cases, however, an interposition graft is required. We prefer to use a woven polyester graft, diameter 2-3 mm greater than the native aorta. If there is frank spillage of bowel contents, autologous conduit can be considered. In our experience, this has never been necessary. Although the location of these injuries tends to be in the distal aorta, the iliac bifurcation can be salvaged in most cases, obviating the need for a bifurcated graft. We generally perform the posterior wall anastomosis with a running prolene and the anterior wall with interrupted sutures to allow for aortic growth. The retroperitoneum is tightly closed, especially in cases with concomitant bowel injury.
129 130 131
Follow up should be performed at least bi-annually for several years. We do not advocate routine CT surveillance in children. Outpatient ultrasound can be considered, but in most cases future therapy is dictated by clinical exam.
132 133
Our case demonstrates that durable long term results can be achieved with prosthetic repair of pediatric abdominal aortic transections, even when concomitant bowel injuries are present.
134
Conclusion:
135 136 137 138 139
Given the spectrum of injuries that can occur with BAAI there are several appropriate treatment options available today. No evidence-based recommendations for management of these injuries exist, especially in regard to graft material and surgical approach. Given their rarity, it may be that the answer lies in the future results of the Low Frequency Disease subgroup of the Vascular Quality Initiative (VQI).
140 141 142 143 144 145 146 147 148 149 150
151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192
References: 1. Sadaghianloo N, Jean-Baptiste E, Breaud J, Declemy J, Kurzenne J-Y, Hassen-Khoda R. Blunt abdominal aortic trauma in paediatric patients. Injury, Int. J. Care Injured 45 (2014) 183-191, which describes the mechanisms of injury, associated injuries, management, and outcomes of 40 children with blunt abdominal aortic injuries. 2. Choit RL, Tredwell SJ, Leblanc JG, Reilly CW, Mulpuri K. Abdominal aortic injuries associated with Chance fractures in pediatric patients. J Pediatr Surg. 2006;41:1184-90. 3. Dajee H, Richardson IW, Iype MO. Seat belt aorta: acute dissection and thrombosis of the abdominal aorta. Surgery 1979;85:263-267. 4. Lin PH, Barr V, Bush R, Velez D, Lumsden A, Ricketts J. Isolated abdominal aortic rupture in a child due to all-terrain vehicle accident. A case report. Vasc and Endovascular Surg. 2003;37:289-292. 5. Randhawa MPS, Menzoian JO. Seat belt aorta. Ann Vasc Surg. 1990;4:370-377. 6. Blanco FC, Powell DM, Guzzetta PC, Burd RS. Aortic bifurcation rupture after blunt abdominal trauma in a child: a case report. J Pediatr Surg. 2011;46:1452-54. 7. Swischuk LE, Siddharth JP, Chung DH. Aortic injury with chance fracture in a child. Emerg Radiol. 2008;15:285-87. 8. Muniz AE and Haynes JH. Delayed abdominal aortic rupture in a child with a seat-belt sign and review of the literature. J Trauma. 2004;56:194-97. 9. Diaz JA, Campbell BT, Moursi MM, Boneti C, Kokoska ER, Jackson RJ, Smith SD. Delayed manifestation of abdominal aortic stenosis in a child presenting 10 years after blunt abdominal trauma. J Vasc Surg. 2006;44:1104-06. 10. Sakran JV, Mukherjee D. Four-year follow-up of endograft repair of traumatic aortic transection in a 10-year-old. Vasc Endovascular Surg. 2009;43:597-98. 11. Aidinian G, Kamaze M, Russo EP, Mukherjee D. Endograft repair of traumatic aortic transection in a 10-year-old: a case report. Vasc Endovascular Surg. 2006;40:239-42. 12. Khanna PC, Rothenbach P, Guzzetta PC, Bulas DI. Lap-belt syndrome: management of aortic intimal dissection in a 7-year-old child with a constellation of injuries. Pediatr Radiol. 2007;37:87-90. 13. McCarthy MC, Price SW, Rundell WK, Lehner JT, Barney LM, Ekeh AP, Saxe JM, Woods RJ, Walusimbi MS. Pediatric blunt abdominal aortic injuries: case report and review of the literature. J Trauma. 2007;63:1383-87. 14. Burjonrappa S, Vinocur C, Smergel E, Chhabra A, Galiote J. Pediatric blunt abdominal aortic trauma. J Trauma. 2008;65:E10-12. 15. Yulevich A, Singer-Jordan J, Grozovsky Y, Zonis Z, Sweed Y. Traumatic abdominal aortic dissection in a child. J Trauma. 2007;62:1039-41. 16. Gauderer MWL, Wolkoff JS, Izant RJ. Traumatic aneurysm of the suprarenal abdominal aorta: surgical reconstruction in a 7-yr-old patient. J Pediatr Surg. 1982;17:940-43.
193 194 195
Legends: Figure 1a. CTA of abdominal aortic disruption with filling defect at the level of the aortic bifurcation
196 197 198
Figure 1b. CTA of the abdominal aorta demonstrates partial transection of the abdominal aorta. Note the filling defect across the posterolateral aorta.
199 200
Figure 2a. 50% transection of the posterolateral aortic wall just above the aortic bifurcation.
201 202 203 204 205 206 207
Figure 2b. 14 mm interposition Dacron graft in place between the inferior mesenteric artery and the aortic bifurcation. Note the diameter of the graft is slightly larger than the native aorta.