Renal Artery Angiography in Pediatric Trauma Using a National Data Set
Angelena Edwards, M.D., Catherine Chen, M.D., Niccolo Passoni, M.D., Bruce Schlomer, M.D., Micah Jacobs, M.D., MPH.
UT Southwestern, Dallas, TX, USA.
Background: With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking. This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery or major abdominal vessel angiography. We hypothesized that patients requiring renal artery angiography for renal trauma need minimal additional surgical interventions. Renal artery angiography with the potential for intravascular intervention serves as a minimally invasive approach for the management of renal injury and allows for renal preservation in this setting.
Methods: All children ≤ 18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. Those with AISS codes of renal injury not otherwise specified were excluded. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement. Fisher's exact test was used to compare prepubertal (age <14) and pubertal (age ≥ 14) groups.
Results: 536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4,506 renal injury cases that could be converted from AIS scores to AAST grade. A total of 87 patients, which included 62 males and 25 females, median age 16 years (IQR 13-18 years), had renal artery angiography (ICD-9 88.45). Mechanism of injury included 87% (n=76) blunt trauma, 9% (n= 8) penetrating trauma, and 3% (n=3) unspecified. Six grade 1 injuries, ten grade 2 injuries, twenty-four grade 3 injuries, thirty-seven grade 4 injuries and ten grade 5 injuries. Only 10% (n=9) of patients who received renal artery angiography required an additional urological intervention (i.e. nephrostomy, ureteral stenting, partial nephrectomy or nephrectomy) Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements. In a subset analysis, there was no statistical difference between prepubertal and pubertal groups.
Conclusion: Renal artery angiography in children remains a rare procedure, 87/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography. Further studies are needed to create pediatric specific trauma management algorithms.
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