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J Thorac Cardiovasc Surg 2006;132:731-732
© 2006 The American Association for Thoracic Surgery
Letter to the Editor |
a Department of Cardiothoracic Surgery, Sydney Children's hospital, High Street, Randwick, NSW 2031, Australia
b Department of Children's Intensive Care, Sydney Children's hospital, High Street, Randwick, NSW 2031, Australia
(Email: peter.grant{at}SESIAHS.HEALTH.NSW.GOV.AU).
We read with interest the article entitled "The effect of changing presentation and management on the outcome of blunt rupture of the thoracic aorta."1
We commend the authors for their work. We agree with them that the nature and the management of traumatic rupture of the aorta (TRA) is changing. The authors stated that "Currently, we consider all patients to be candidates for endograft approaches if the anatomy is suitable" and concluded by stating that "As newer devices are studied, the endovascular stent grafts might very well ultimately become the primary treatment of choice at all centers." This is where we would like to sound a word of caution with regard to TRA in children. We agree with the proposed guidelines by Kouchoukos and colleagues.2 A new technique involves uncertainty and risk. The pressure for rapid adoption can lead to deviations from the fundamental principles of surgery, which might compromise the quality and safety of patients.2 As the technology evolves, there is a danger of subjecting younger patients to stent grafting.
The incidence of TRA in children ranges from 0.1% to 1% of all children with major chest injuries, and their management is a challenge. The experience of most centers is limited to a few case reports. Pediatric patients differ from adult patients in that significant intrathoracic injury can occur in the absence of rib fracture because of the increased compliance and elasticity of the chest wall. The key to management is to maintain a high index of suspicion in cases of high-speed collisions.
There have been case reports of endovascular aortic stent grafts being used in younger patients.3 The known complications of stents include occlusion of the left main stem bronchus, erosions, perigraft leak, graft migration, limb ischemia, arch perforation, entrapment, infection, pseudoaneurysm, distal embolization, and femoral artery complications. The fate of the stent is unknown, and there are no long-term results.3
We recently treated a 10-year-old boy with TRA. Aortography revealed an aneurysm just distal to the left subclavian artery indicative of an acute aortic transection (Figure 1). The possibility of using an aortic stent graft was raised because there was a successful outcome in a 17-year-old boy previously. In view of this child's age and the potential uncertainties of stenting in a growing child, we decided on the operative option.
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We propose that TRA in children be repaired whenever feasible and that stents be reserved only as a salvage procedure. We recommend the use of left heart bypass to maintain cerebral perfusion and to minimize spinal injury. If heparin is contraindicated, a clamp-and-sew technique might be a reasonable alternative, as suggested by Trachiolis and associates.4 In a selected group initial nonoperative management and stabilization with ß-blockers while other comorbidities are addressed, followed by elective repair, might be a reasonable option.
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