The Needle Tip: Pediatric Vascular Injuries
John F. Bilello MD, FACS
Chief, Pediatric Trauma
Community Regional Medical Center
Traumatic vascular injuries in children are relatively uncommon, accounting for only 0.6–1.4 percent of all pediatric injuries.1 These injuries, however, still pose a significant problem, especially for Adult Trauma Centers Treating Injured Children (ATCTIC). Management of pediatric vascular injuries is based mostly on extrapolated data from adult vascular trauma patients. Vascular trauma in children involves smaller arteries, pronounced arterial vasospasm, and the impending demand of limb growth, which requires long-term patency.2-5
Many reported vascular injuries in children are iatrogenic.6 Iatrogenic femoral arterial trauma has become more common in the pediatric population as the use of interventional radiologic procedures and cardiac catheterizations has increased,7 and they are most common in the infant population.2,8 This includes invasive arterial blood pressure monitoring. Although routine interventional procedures are performed at dedicated pediatric centers, femoral arterial catheterization for invasive, intensive-care monitoring is commonly performed at ATCTICs. Arterial occlusion, dissection, hemorrhage, and pseudoaneurysm are recognized complications from procedures involving the femoral artery.7
In one of the largest epidemiologic reviews of pediatric vascular injuries— Wahlgren, et al.—reviewed 197 patients with traumatic (non-iatrogenic) vascular injury in children 15 years or younger from the National Vascular Surgery registry (Swedvasc).1 Blunt mechanism accounted for the majority of vascular injuries (66 percent) with penetrating and iatrogenic injuries following at 23 percent and 9 percent, respectively. Upper-extremity injuries were most common (60 percent), followed by lower-extremity (29 percent), and abdomen (7.2 percent) injuries. Upper-extremity vascular injuries were most common in children <10 years of age, whereas the majority of lower-extremity injuries were in children 11–15 years of age. Blunt brachial and popliteal arterial injuries resulted from sharp edges of fractured bone and/or dislocations. Interposition graft (24 percent), patch angioplasty (19 percent), and primary repair (12 percent) were the most common types of operative repair, with autologous vein being the most-used graft material. Endovascular technique (3.7 percent) was the least commonly used, but it is recommended when other life-threatening injuries preclude operative vascular repair. The most common post-operative complication is arterial occlusion/thrombosis.
The largest review of pediatric vascular trauma is by Bamparas, et al., and makes comparison to adult vascular trauma.9 Although a comparative analysis, the study reviewed 1,138 pediatric vascular-injury patients who were less than 16 years of age from the NTDB and, like Wahlgen, et al., they also found that upper-extremity vascular injury and blunt mechanism are the most predominant location and mechanism, respectively. However, torso-vascular injuries were the second most common type (37 percent), followed by lower-extremity injuries. Injuries of the thoracic aorta were rare. Amputation rates associated with upper- and lower-extremity vascular injuries did not differ between adults and children, and pediatric patients had an improved adjusted mortality rate when compared to adults. The thirty-day amputation rate appears to vary from 1.4 to 11 percent,1 and correlates with the presence of a mangled extremity rather than type of repair.
With regard to operative technique, reverse venous interposition graft or patch offers the best results if a tension-free primary anastomosis cannot be performed. PTFE grafts are more prone to infection, and smaller-diameter grafts are more prone to thrombosis. Use of interrupted sutures for anastomoses is recommended to anticipate for future growth.4,10
Nonoperative management of acute pediatric vascular injuries with anticoagulation and/or thrombolytic therapy (when appropriate) may be best in children less than 30 months of age with acutely ischemic, but nonthreatened, limbs 2,7,8,11,12 regardless of mechanism. The relatively small size of arteries in children less than 2.5 years of age makes angiogram and operative repair technically challenging, even for an experienced surgeon, but this age group has a remarkable ability to develop collateral circulation that can maintain extremity viability. Arteriography itself may be complicated by thrombosis in small children, and color-flow duplex ultrasound may be a better diagnostic option.12
The normal Ankle-Brachial Index (ABI) of neonates and infants is significantly lower when compared to that of older children and adults.15 This distinction should be recognized in the evaluation of neonates and infants less than 3 years of age, as an ABI of 0.8–0.9 may be a normal anatomic finding and not necessarily the result of obstruction or injury. Nonoperative management, when chosen appropriately in neonates and infants, allows elective arterial reconstruction at a later date—ideally before the adolescent growth spurt. A high index of suspicion for chronic arterial insufficiency should be entertained in a child with a limp, claudication, or an obvious discrepancy of muscle mass or foot size, and a history of remote femoral artery catheterization.10 However, limb-length discrepancy can occur any time before adolescence when the collateral circulation becomes insufficient at maintaining blood flow to the growing lower extremity.
Shah, et al.3 recommended a more aggressive operative approach with liberal use of on-table intraoperative angiograms and arterial exploration (when other trauma-related procedures were being performed under anesthesia) to confirm or refute the presence of arterial injury. The average age for this study group was 9 years old, and 26 percent of the patients were found to have only significant vasospasm that required no further intervention. Sciarretta, et al.6,13 also propose early identification and prompt surgical intervention of lower extremity vascular injuries in children over the age of 2.5 years with referral to tertiary pediatric care centers with multidisciplinary capabilities. The study by Corneille, et al.4 involved no pediatric surgeons, but the average age of the patients was almost 11 years old. Klinkner, et al.14 also advocate referral to a tertiary care center with pediatric surgeons and/or “extremity specialists.”
Penetrating neck trauma in children is extremely rare (0.3 percent), and evaluation parallels that of adults, with physical exam and CT scan replacing mandatory neck exploration in appropriately selected patients.16 (An excellent review of blunt cerebrovascular injury [BCVI] in pediatric trauma patients by James W. “Trey” Eubanks, MD, has been previously published in the Cutting Edge: Needle Tip, July/August 2017.)
In conclusion, traumatic vascular injury can be managed with acceptable results when the surgical principles applied to adults are used. Children under the age of 2.5 years may benefit from nonoperative management and anticoagulation when an ischemic, but nonthreatened, limb is encountered since this age group is prone to pronounced arterial vasospasm and tends to form adequate collaterals. The ABI of neonates and infants is normally less than that of their older counterparts. Referral to a pediatric tertiary care center offers the advantage and expertise of multiple disciplines for appropriate patients, but should not deter initial emergent intervention to save life or limb.
- Wahlgren C, Kragsterman B. Management and outcome of pediatric vascular injuries. J Trauma Acute Care Surg. 2015; 79: 563–567.
- Nehler MR, Taylor LM, Porter JM. Iatrogenic vascular trauma. Sem Vasc Surg. 1998; 11: 283–293.
- Shah SR, Wearden PD, Gaines BA. Pediatric peripheral vascular injuries: a review of our experience. J Surg Res. 2009; 153: 162–166.
- Corneille MG, Gallup TM, Villa C, Richa JM, Wolf SE, Myers JG, et al. Pediatric vascular injuries: acute management and early outcomes. J Trauma. 2011; 70: 823–828.
- De Virgilio C, Mercado PD, Arnell T, Donayre C, Bongard F, White R. Noniatrogenic pediatric vascular trauma: a ten year experience at a level I trauma center. Amer Surg. 1997; 63: 781–784.
- Sciarretta JD, Macedo FI, Chung EL, Otero CA, Pizano LR, Namias N. Management of lower extremity vascular injuries in pediatric trauma patients: a single level I trauma center experience. J Trauma Acute Care Surg. 2014; 76: 1386–1389.
- Lin PH, Dodson TF, Bush RL, Weiss VJ, Conklin BS, Chen C, et al. Surgical intervention for complications caused by femoral artery catheterization in pediatric patients. J Vasc Surg. 2001; 33: 1071–1078.
- Matos JM, Fajardo A, Dalsing MC, Motaganahalli R, Akingba GA, Murphy MP. Evidence for nonoperative management of acute limb ischemia in infants. J Vasc Surg. 2012; 55: 1156–1159.
- Barmparas G, Inaba K, Talving P, David J, Lam L, Plurad D, et al. Pediatric vs. adult vascular trauma: a National Trauma Data Bank review. J Ped Surg. 2010; 45: 1404–1412.
- Eliason JL, Coleman DM, Gumushian A, Stanley JC. Arterial reconstructions for chronic lower extremity ischemia in preadolescent and adolescent children. J Vasc Surg. 2017; Vol: 1–10.
- Kayssi A, Shaikh F, Roche-Nagle G, Brandao LR, Williams SA, Rubin BB. Management of acute limb ischemia in the pediatric population. J Vasc Surg. 2014; 60: 106–110.
- Lazarides MK, Georgiadis GS, Papas TT, Gardikis S, Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities. J Vasc Surg. 2006; 43: 72–76.
- Macedo FI, Sciarretta JD, Namias N. Regarding “Management of acute limb ischemia in the pediatric population” (Letters to the Editor). J Vasc Surg. 2014; 60: 1122–1123.
- Klinkner DB, Arca MJ, Lewis BD, Oldham KT, Sato TT. Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Ped Surg. 2007; 42: 178–183.
- Katz S, Globerman A, Avitzour M, Dolfin T. The ankle-brachial index in normal neonates and infants is significantly lower than in older children and adults. J Ped Surg. 1997; 34: 269–271.
- Stone ME, Farber BA, Olorufemi O, Kalata S, Meltzer JA, Chao E, et al. Penetrating neck trauma in children: an uncommon entity described using the National Trauma Data Bank. J Trauma Acute Care Surg. 2016; 80: 604–609.