National Trends of Thoracic Endovascular Aortic Repair (TEVAR) Versus Open Thoracic Aortic Repair (OTAR) in Pediatric Blunt Thoracic Aortic Injury.

INTRODUCTION: Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment modality in adult patients with BTAI but its use in pediatrics is currently not supported by device manufacturers and lacks United States Food and Drug Administration approval. We hypothesized that there would also be an increased use of TEVAR in the pediatric population, thus conferring a lower risk of mortality compared to open thoracic aortic repair (OTAR).

METHODS: The National Trauma Data Bank (2007-2015) was queried for patients <17-years-old with BTAI. The primary outcomes were the incidences of TEVAR and OTAR. Secondary outcome was risk of mortality in those undergoing intervention. A multivariable logistic regression model was used to determine risk of mortality in OTAR vs. TEVAR.

RESULTS: We identified 650 pediatric BTAI patients with 159 (24.5%) undergoing intervention. Of these, 124 underwent TEVAR (78.0%) and 35 (22.0%) underwent OTAR. The rate of TEVAR steadily increased from 2007 to 2015 (15.4% vs. 27.1%, p<0.001). Patients receiving OTAR and TEVAR had a similar injury severity score and rate of hypotension on admission (p>0.05). Compared to OTAR, TEVAR patients had a higher rate of any traumatic brain injury (TBI) (63.7% vs. 37.1%, p=0.005) and shorter hospital and ICU length of stay (LOS) (16.4 vs. 21.4 days, p=0.02; 10.1 vs. 12.2 days, p=0.01). TEVAR and OTAR, even when stratified by <14-years-old and 15-17-years old, had no difference in risk for mortality (OR 1.20, CI 0.29-5.01, p=0.80).

CONCLUSION: The rate of TEVAR in pediatric BTAI nearly doubled from 2007 to 2015. Compared to OTAR, TEVAR was associated with a shorter hospital LOS despite a higher rate of TBI. There was no difference in risk for mortality between TEVAR and OTAR. Longitudinal studies to determine the long-term efficacy and complication rates, including re-intervention, development of endoleak, and/or need for further operations is needed as this technology is being rapidly adopted for pediatric trauma patients.