Trends and Outcomes in Management of Pediatric Thoracic Aortic Injury using Age Stratified Data from the National Trauma Data Bank
Stephen J Raulli, Andrew B Schneider, Jared Gallaher, Fernando Motta, Ezequiel Parodi, Mark A Farber, Luigi Pascarella
University of North Carolina, Chapel Hill, NC
Background: 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 thoracic aortic injury. 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). We compared patient characteristics, injury mechanism and severity, and treatment type between the three groups using bivariate analysis (Chi-squared and ANOVA). ICD-9 and -10 procedural codes were used to identify patients who underwent TEVAR, open repair, or both. We then performed a modified Poisson regression with risk ratios (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 mean injury severity scores (34.1) than the adolescent (38.0) or mature population (36.1) (p=0.001). 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 (6.0% children, 10.1% adolescent, 12.5% mature) (p<0.001). TAI management also differed significantly between pediatric age groups. Mature patients had significantly higher rates of TEVAR (3.0% children, 25.2% adolescent, 29.2% mature) and children were most likely to be treated with medical management (94.0% children, 67.9% adolescent, 64.8% mature) (p<0.001). Upon modified Poisson regression analysis, patient age was not associated with an increased risk of in-hospital mortality. Intervention with TEVAR (RR 0.23, 95% CI 0.13-0.39, p<0.001) and open aortic repair (RR 0.49, 95% CI 0.27-0.88, p=0.017) were associated with a lower risk of mortality than medical management. Conclusions: TAI is less prevalent in children compared to adults. TEVAR for TAI is associated with lower risk of in-hospital mortality compared to both medical management and open repair without differences between pediatric subgroups. Further studies should be completed to determine the most appropriate management guidelines.
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