Case Report
Endovascular Repair of Traumatic Aortic Pseudoaneurysm and Delayed Presentation of Pericardial Rupture with Cardiac Herniation in Pediatric Trauma
Daniel Hetherman1, Kimberly Malka2, Andres Schanzer2, E. Christine Wallace3, David Kane4,
Roger Breitbart5, Puja Banka5, Francis Fynn-Thompson6 and Michael Hirsh7*
1Department of Surgery, University of Massachusetts Medical School, USA
2Division of Vascular Surgery, University of Massachusetts Medical School, USA
3Department of Radiology, University of Massachusetts Medical School, USA
4Division of Pediatric Cardiology, University of Massachusetts Medical School, USA
5Division of Pediatric Cardiology, Boston Children’s Hospital, USA
6Division of Cardiac Surgery, Boston Children’s Hospital, Boston, USA
7Division of Pediatric Surgery, University of Massachusetts Medical School, USA
*Corresponding author: Michael Hirsh, Division of Pediatric Surgery, University of Massachusetts Medical School, USA
Published: 03 Aug, 2017
Cite this article as: Hetherman D, Malka K, Schanzer A,
Wallace EC, Kane D, Breitbart R, et
al. Endovascular Repair of Traumatic
Aortic Pseudoaneurysm and Delayed
Presentation of Pericardial Rupture with
Cardiac Herniation in Pediatric Trauma.
Clin Surg. 2017; 2: 1673.
Abstract
We present the case of a 14-year-old healthy boy who presented after being a restrained back seat passenger in a single motor vehicle accident. He was found to have a thoracic aortic pseudoaneurysm
which was managed with placement of an endovascular stent graft. Initially he recovered, then
experienced a syncopal episode, and on repeat imaging was found to have a pericardial rupture
with cardiac herniation. He underwent open repair of his pericardium and recovered uneventfully.
Thoracic aortic pseudoaneurysm and pericardial rupture with cardiac herniation, represent rare
potentially life threatening intrathoracic injuries that must be considered and appropriately treated
when evaluating pediatric thoracic trauma.
Keywords: Pediatric trauma; Cardiac herniation; Endovascular repair
Case Presentation
Our patient, a 14-year-old otherwise healthy boy, presented to University of Massachusetts
Medical Center as a transfer from an outside hospital after being the restrained backseat passenger
in a motor vehicle accident. His initial assessment showed a blood pressure of 102/60 mmHg, a
heart rate of 80 bmp, and an oxygen saturation of 100% on 2 liters of nasal cannula. He had a
Glasgow Coma Score of 15. His physical exam was notable for a right clavicle deformity, a seat belt
sign across his chest and abdomen, and moderate upper abdominal tenderness without peritonitis.
Focused Assessment with Sonography for Trauma was positive in the left upper quadrant which was
consistent with asplenic injury visualized on a CT scan obtained at the transferring hospital.
Chest X-ray during the initial assessment showed a right clavicle fracture and a left 9th
rib fracture. Given the degree of chest trauma, a CT chest with IV contrast was performed and
carried down through the upper abdomen for additional comparison to the prior CT scan of the
abdomen and pelvis. This demonstrated a grade 3 thoracic aortic pseudoaneurysm arising just
distal to the origin of the left subclavian artery (Figure 1) bilateral pulmonary contusions, and a
left pleural effusion. Additionally, the abdominal imaging uncovered a significant increase in the
size of a mesenteric hematoma, a grade 3 spleen laceration, and a grade 1 renal laceration. Vascular
Surgery was consulted and, in conjunction with Pediatric Surgery, the patient was taken emergently
to a hybrid operating room. Vascular surgery performed a right femoral cut-down, aortic arch
angiogram (Figure 2), and deployed a Cook™alpha thoracic endograft device measuring 20 mm x
105 mm. To exclude the pseudoaneurysm, the endograft was positioned just distal to the left carotid
artery, thereby intentionally covering the left subclavian artery. A completion arch angiogram was
performed (Figure 3) which demonstrated complete exclusion of the pseudoaneurysm. In addition,
anabdominal aortic angiogram was performed which demonstrated no active extravasation of
contrast. The patient remained stable but, given the increased size of this mesenteric hematoma on repeat imaging, a diagnostic laparoscopy was performed. A hematoma was noted in the transverse mesocolon, however, all examined bowel
was viable and there was no evidence of active bleeding from any
other abdominal source.
Postoperatively, our patient’s initial recovery was uncomplicated
and his diet was advanced with return of bowel function. During that
initial recovery, a troponin was sent to evaluate for cardiac injury and
was increased (0.57 ng/mL). This prompted echocardiography that
showed a large left pleural effusion and mild biventricular systolic
dysfunction from a presumed cardiac contusion. There was no
pericardial effusion was noted and the troponin leak resolved over a
few days and he was discharged on post trauma day seven.
One week after his discharge, the patient experienced a syncopal
event prompting additional workup. A CT angiogram of the chest
abdomen and pelvis revealed a well positioned thoracic endograft
with no evidence of leak or rupture and no new abdominal pathology.
However, the heart was now oriented more posteriorly and leftward,
with “ghosting” artifacts present in the descending aorta secondary
to transmitted left ventricle contractions (Figure 4). This finding was
felt to represent cardiac displacement and was similar in appearance
to congenital absence of the pericardium. This change in cardiac
position and orientation raised the possibility of a pericardial rupture
with cardiac herniation. The patient was referred to a high volume
cardiac surgical center for further diagnostics and consideration.
Video-assisted thoracoscopy was performed and confirmed rupture
of the pericardium and cardiac displacement into the left pleural
space (Figure 5).
Although there was no evidence of strangulation of the great
vessels, pulmonary venous obstruction or compression of the
coronary arteries at the time of the thoracoscopy; the uncertainty
about these risks developing in the future led to the decision for
operative repair. A left thoracotomy was performed with the patient
placed in the right decubitus position. The pericardial rupture was
in a vertical plane and spared the phrenic nerve. The edges of the
pericardium were mobilized and repaired with the use of a bovine pericardial patch. Once the pericardial space was closed, the heart
was returned to its normal anatomic position. Six months after his
trauma, he is doing well and has returned to his baseline function and
sports participation.
Figure 1
Figure 1
Admission CT Scan showing aortic pseudoaneurysm distal to the
take off of the left subclavian artery.
Figure 2
Figure 3
Figure 4
Figure 4
Admission CT scan (top) showing the normal position of the
apex of the heart (white arrow). Follow up CT scan on the (below) showing
displacement of the heart apex into the left chest consistent with pericardial
rupture (white arrow).
Figure 5
Figure 5
Cardiac subluxation through the pericardium. Edge of pericardium
is demonstrated with the white arrows.
Discussion
Trauma continues to be a leading cause of morbidity and
mortality in the pediatric population. The patient presented in this
case report highlights two rare intrathoracic injuries, both of which
can lead to devastating outcomes. Blunt thoracic aortic injury occurs
in approximately 0.1% of traumas and carries with it a mortality
rate of more than 40% [1]. Similarly, blunt pericardial rupture is
primarily a postmortem finding, and was found in only 17 patients
in a retrospective review of 20,000 trauma patients [2]. Both these
injuries are rare, often fatal, and each has their own diagnostic an1d
therapeutic considerations in the pediatric trauma population.
Thoracic aortic injuries typically result from rapid deceleration;
however, there is no evidence to suggest that seat belt use increases
the incidence of thoracic aortic injury [3]. Blunt thoracic aortic
injuries are graded based on the severity of injury: grade 1 injuries
are intimal tears and hematomas; grade 2 injuries are intimal injury
with periaortic hematoma; grade 3 injuries are transections with
pseudoaneurysm formation, and grade 4 injuries include free aortic
rupture. Management of adult aortic injuries has shifted toward
endovascular repair in patients who are stable enough to obtain
imaging and have a grade 3 or 4 injury. Operative repair is also
indicated in those lower grade injuries with associated traumatic
brain injury thus precluding non-operative management due to the
need for increased cerebral perfusion [4]. Traditionally, more severe
gradeblunt aortic injuries in children have been repaired in an open
fashion, with or without the assistance of cardiopulmonary bypass.
These repairs have had variable degrees of success with mortality
rates ranging from 0% - 40% in various series, with complications
including paralysis, pulmonary embolism, renal failure and recurrent
laryngeal nerve injury [5,6].
However, since the early 2000s, there have been an increased
number of endovascular repairs reported in children. [5-9].
Endovascular repair offers a minimally invasive approach but is
not without significant considerations in the pediatric population.
The growing patient and vessel may predispose to endovascular
leaks as a patient continues to grow and may necessitate additional
re-interventions, although we are not aware of any reports of reinterventions
to date. Additionally, the need for long term surveillance
imaging with CT scans does pose a significant radiation exposure
over the lifetime of a pediatric patient. Despite these challenges,
endovascular repair is becoming the more common approach and has
been used in children as young as 16 months old [7]. Endovascular
repair appears to carry less risk of morbidity than open repair,
however limited data exist. Treatment algorithms for adolescents
with blunt aortic injury have been proposed with endovascular repair
suggested for grades 3 and 4 injuries [5]. We feel that endovascular
repair should become the first line treatment in children due to the
decreased rates of significant surgical complications. However, we do
recognize the need for more long term follow up data to fully evaluate
the impact of these repairs in both children and adolescents.
While endovascular repair of blunt aortic injury is becoming more
common in the pediatric trauma population, delayed presentation
of blunt pericardial rupture with cardiac herniation has not, to our
knowledge, been reported in the pediatric trauma literature. Blunt
pericardial rupture is a rare injury in adult trauma patients, with
only 17 cases of isolated pericardial rupture found over 10 years in a
review of 20,000 adult patients. Based on this review, approximately
64% of pericardial ruptures were into the left pleural cavity, with 18%
being through the diaphragm, 9% into the right pleural cavity, and 9%
involving the superior mediastinum. This series described just 6 cases
of associated herniation of the heart through the pericardium, with 5
being into the left pleural cavity. When cardiac herniation is found,
death can occur due to torsion or incarceration of the great vessels
with ensuing loss of cardiac output [2].
The diagnosis of pericardial rupture remains challenging. Chest
x-ray showing displacement of the heart or pneumopericardium can
be used to help diagnosis pericardial rupture, but the diagnosis still
requires a high degree of suspicion. While the wide use of CT scan
imaging can significantly increase the detection of pericardial injuries,
not all patients with pericardial injuries have findings on initial
imaging, as is the case with our patient. Physical exam may reveal a
“bruit de moulin” or waterwheel splashing murmur, although that is
clinically difficult to detect and was not noted in our patient. [2,10-
14]. Late presentations are rare but have been reported [12]. In these
reports and in this case, echocardiography can be non-diagnostic.
The change in cardiac orientation that occurs with subluxation may
not manifest until a patient becomes ambulatory and the heart is
more influenced by gravitational effects. This diagnosis should be
considered strongly in a pediatric patient with blunt trauma severe
enough to result in aortic injury.
Treatment for pericardial rupture with cardiac herniation is
surgical in most cases due to the high mortality rates [2]. In cases
with cardiac herniation, surgical repair should be undertaken
expeditiously to prevent torsion of the great vessels as well as coronary
artery compression. This has been approached both thoracoscopically
or with an open approach in various reports. The principals of the
operations are that the heart should be returned to the mediastinum
and the pericardium repaired when feasible. When pericardial
injuries are found that are too small to allow cardiac herniation, these
injuries could be left un repaired as the surgical risk for pericardial or
myocardial injury may be greater than the benefit of closure [2,10-
17].
Conclusion
This case highlights two rare intrathoracic injuries that must be considered in the evaluation of the pediatric trauma patient. In the setting of blunt aortic trauma, we are in the midst of a paradigm shift where most of these injuries can be treated with a minimally invasive endovascular approach. Early data suggest that an endovascular strategy is associated with a significant reduction in morbidity and mortality compared to open repair. Pericardial injuries with cardiac herniation occur much less frequently, but when recognized, must be fixed expeditiously given the potential devastating outcome if great vessel incarceration or coronary artery compression occurs. While it is possible that the seat belt restraint played a role in the etiology of our patient's injuries, it is important to note that it did likely prevent any associated severe head injury from this high velocity motor vehicle injury event.
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