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Argyriou C, Varlami V, Kambouri K, Lazarides MK, Georgiadis GS. Characteristics and Validation of Pediatric Extremity Vascular Trauma in Dedicated Pediatric and Adult Trauma Centers: A Scoping Review Protocol. Ann Vasc Surg 2024; 105:189-200. [PMID: 38588951 DOI: 10.1016/j.avsg.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury. METHODS We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study. RESULTS The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall. CONCLUSIONS Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes.
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Affiliation(s)
- Christos Argyriou
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Thrace, Greece.
| | - Vasiliki Varlami
- Neonatal Intensive Care Unit, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Thrace, Greece
| | - Katerina Kambouri
- Department of Pediatric Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Thrace, Greece
| | - Miltos K Lazarides
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Thrace, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Thrace, Greece
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Moody N, Walter A, Daudu D, Wahlgren CM, Jongkind V. International Perspective on Extremity Vascular Trauma in Children: A Scoping Review. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00200-4. [PMID: 38428670 DOI: 10.1016/j.ejvs.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/17/2024] [Accepted: 02/26/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Extremity vascular trauma in children can result in significant morbidity and mortality. Most published studies have focused on supracondylar humeral fracture related injuries, with little focus on other injuries. This scoping review describes the current state of knowledge on paediatric vascular injuries in the upper and lower limbs, excluding injuries related to supracondylar humeral fractures. METHODS MEDLINE, PubMed, Web of Science, and Cochrane databases were searched for relevant studies evaluating the epidemiology, diagnosis, management, and outcomes of upper and lower limb vascular trauma in those aged under 18 years. Studies related to supracondylar humeral fractures were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews was used. RESULTS A total of 39 studies was included, all of which were retrospective, and 74% of which were based in North America or Europe. Extremity vascular trauma was reported to cause 0.6 - 4.4% of all paediatric trauma admissions, with penetrating mechanisms and upper limb injuries being the most common. Operative intervention was reported in 80 - 100% of children in the included studies. Primary repair was the most commonly reported operative intervention, followed by interposition graft and bypass graft. Synthetic graft use was less commonly reported (incidence range 0.5 - 33%). Lower limb fasciotomies and amputations were not commonly reported (incidence range 0 - 23% and 0 - 13%, respectively). The mortality rate appeared low, with 23 studies reporting no deaths (incidence range 0 - 4%). Complications were reported inconsistently, with no uniform outcome or follow up measures used. CONCLUSION The incidence of extremity vascular trauma appears low in children, with penetrating mechanisms and upper extremity injuries appearing to dominate. Most studies are from high income countries, with probable selection bias towards those treated by operative intervention. Prospective studies are required focusing on patterns of injury, rates of operative and endovascular intervention, and long term outcomes.
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Affiliation(s)
- N Moody
- Queen Elizabeth University Hospital, Glasgow, UK.
| | - A Walter
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Davina Daudu
- Department of Surgery, University of Western Australia, Perth, Australia
| | - Carl-Magnus Wahlgren
- Department of Vascular Surgery, Karolinska University Hospital/Karolinska Institute, Stockholm, Sweden
| | - Vincent Jongkind
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, the Netherlands; Microcirculation - Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Lozano-Corona R, Torres-Machorro A, Ortiz-Beitz R, Reyes-Monroy A, García-Lugo I, Ruben-Castillo C, Guerrero-Galindo LA. Review of surgical treatment of iatrogenic iliofemoral artery injury in the pediatric population after catheterization. Eur J Med Res 2023; 28:521. [PMID: 37968770 PMCID: PMC10652633 DOI: 10.1186/s40001-023-01510-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 11/05/2023] [Indexed: 11/17/2023] Open
Abstract
Trauma is the leading cause of death in the pediatric population. Although vascular trauma has an incidence of 6% in civilian population, iatrogenic injuries are the leading cause, and the most frequent injured vessel is the iliofemoral sector. However, little information is available and there are no guidelines about its treatment. Therefore, this review aimed to describe the information available concerning pediatric iatrogenic arterial trauma, focusing on the iliofemoral segment and present 3 cases. We described 11 articles with 171 patients, of whom 61% underwent surgery to treat iatrogenic trauma. Mean age was 3.28 years (standard deviation of 3.5 years), and 54% were female. Most iliofemoral injuries occurred after arterial catheterization for hemodynamic monitorization and therapeutic or diagnostic cardiac catheterization (due to congenital heart diseases, including septal defects, tetralogy of Fallot, aortic coarctation, and patent ductus arteriosus). For acute complications, arterial thrombosis was the leading injury, followed by pseudoaneurysm, hematoma, dissection, transection, avulsion, eversion, and combined lesions.
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Affiliation(s)
- Rodrigo Lozano-Corona
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Hospital Regional Licenciado Adolfo Lopez Mateos (Instituto de Seguridad y Servicios de Salud de los Trabajadores del Estado), Unuversidad Av 1321, Zip Code 01030, Mexico City, Mexico.
| | - Adriana Torres-Machorro
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Cardiología "Ignacio Chávez", Mexico City, Mexico
| | | | - Aristeo Reyes-Monroy
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Hospital Regional Licenciado Adolfo Lopez Mateos (Instituto de Seguridad y Servicios de Salud de los Trabajadores del Estado), Unuversidad Av 1321, Zip Code 01030, Mexico City, Mexico
| | - Ignacio García-Lugo
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Hospital Regional Licenciado Adolfo Lopez Mateos (Instituto de Seguridad y Servicios de Salud de los Trabajadores del Estado), Unuversidad Av 1321, Zip Code 01030, Mexico City, Mexico
| | - Christopher Ruben-Castillo
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Luis Angel Guerrero-Galindo
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Hospital Regional Licenciado Adolfo Lopez Mateos (Instituto de Seguridad y Servicios de Salud de los Trabajadores del Estado), Unuversidad Av 1321, Zip Code 01030, Mexico City, Mexico
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Silverberg D, Hater H, Ismail O, Kenet G, Halak M. Acute Limb Ischemia in Pediatric Intensive Care Units. Ann Vasc Surg 2022; 92:65-70. [PMID: 36549473 DOI: 10.1016/j.avsg.2022.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND To determine the outcome of children treated for acute limb ischemia (ALI) in pediatric intensive care units (ICUs). METHODS A single-center, retrospective cohort study including all patients diagnosed with ALI between 2005 and 2022 in 2 different pediatric ICUs: respiratory and cardiac ICU. Data collected included patients demographics and comorbidities, location and cause of arterial occlusion, and type and duration of therapy. Primary end point was freedom from amputation. Secondary end point was all-cause mortality. RESULTS A total of 78 patients (58% male) with ALI were included in the study. Median age was 3.8 months (range 0.03-201). The lower extremity was involved in 55 (70%) patients. The limb ischemia was caused by arterial instrumentation in 94% of the patients. Anticoagulation was administered as the first-line therapy in all patients. Unfractionated heparin was administered for a median duration of 5 days (range 1-48). Low molecular weight heparin was continued for a median period of 28 days (range 4-420). Thrombolytic therapy was administered in 5 patients and 2 required surgical revascularization, all for failure of anticoagulation therapy. Mean follow-up was 21 months (range 1-188 months). None of the patients required major upper or lower extremity amputations during or after the index admission. Overall survival at 30 months was 68%. The causes of mortalities were unrelated to the limb ischemia. CONCLUSIONS This large, single-center study demonstrates that ALI in the pediatric ICU population can be treated conservatively and is associated with a low amputation rate following nonoperative management. The favorable outcome exists regardless of the etiology of the ALI and underlying diseases.
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Affiliation(s)
- Daniel Silverberg
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel.
| | - Haitam Hater
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Omar Ismail
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Gili Kenet
- The Institute of Thrombosis & Hemostasis, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Moshe Halak
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
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Isquemia arterial en población neonatal: dos casos clínicos y revisión de la literatura. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Amiti A, Abiramalatha T, Ayyappan MK, Rajendran UD. External iliac artery thrombosis: an unusual complication of femoral venous catheterisation in a neonate. BMJ Case Rep 2021; 14:14/4/e240099. [PMID: 33893124 PMCID: PMC8074542 DOI: 10.1136/bcr-2020-240099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a neonate who developed external iliac artery thrombosis after insertion of femoral venous catheter, without an apparent arterial puncture during the procedure. The baby developed acute limb ischaemia. As there was no improvement despite heparin infusion for 24 hours, thrombectomy was done. Following surgery, the limb perfusion improved gradually in 1 week. However, pulses did not reappear even after antithrombotic therapy for 3 months. There was residual Doppler abnormality in the form of severe narrowing at the origin of superficial femoral artery with reduced flow velocity in superficial femoral, popliteal and tibial arteries. The baby was kept under regular follow-up, with a plan for clinical assessment and Doppler every 6 months and to perform a vascular reconstructive surgery if he develops any clinical feature of chronic limb ischaemia. The baby is now 1 year of age. He is walking normally and there is no limb length discrepancy.
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Affiliation(s)
- Anvesh Amiti
- Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Thangaraj Abiramalatha
- Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | | | - Usha Devi Rajendran
- Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Pramanik S, Kumar M, Gupta A. Operative management and outcomes of peripheral vascular trauma in pediatric and adolescent population. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_140_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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Mousa A, Zakaria OM, Elkalla MA, Abdelsattar LA, Al-Game'a H. Reliability of the Mangled Extremity Severity Score in the Management of Peripheral Vascular Injuries in Children: A Retrospective Review. Int J Angiol 2020; 30:98-106. [PMID: 34054267 DOI: 10.1055/s-0040-1720970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
This study was aimed to evaluate different management modalities for peripheral vascular trauma in children, with the aid of the Mangled Extremity Severity Score (MESS). A single-center retrospective analysis took place between 2010 and 2017 at University Hospitals, having emergencies and critical care centers. Different types of vascular repair were adopted by skillful vascular experts and highly trained pediatric surgeons. Patients were divided into three different age groups. Group I included those children between 5 and 10 years; group II involved pediatrics between 11 and 15 years; while children between 16 and 21 years participated in group III. We recruited 183 children with peripheral vascular injuries. They were 87% males and 13% females, with the mean age of 14.72 ± 04. Arteriorrhaphy was performed in 32%; end-to-end anastomosis and natural vein graft were adopted in 18% and 29% respectively. On the other hand, 20% underwent bypass surgery. The age groups I and II are highly susceptible to penetrating trauma ( p = 0.001), while patients with an extreme age (i.e., group III) are more susceptible to blunt injury ( p = 0.001). The MESS has a significant correlation to both age groups I and II ( p = 0.001). Vein patch angioplasty and end-to-end primary repair should be adopted as the main treatment options for the repair of extremity vascular injuries in children. Moreover, other treatment modalities, such as repair with autologous vein graft/bypass surgery, may be adopted whenever possible. They are cost-effective, reliable, and simple techniques with fewer postoperative complication, especially in poor/limited resources.
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Affiliation(s)
- Ahmed Mousa
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Darrasa, Cairo, Egypt.,Division of Vascular Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Ossama M Zakaria
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.,Division of Pediatric Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mai A Elkalla
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Lotfy A Abdelsattar
- Department of General Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Darrasa, Cairo, Egypt
| | - Hamad Al-Game'a
- College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
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9
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D'Oria M, Mani K, Rodriguez Lorenzo A. Microsurgical Salvage of Acute Lower Limb Ischemia after Iatrogenic Femoral Injury during Orthopedic Surgery in a Pediatric Patient. Ann Vasc Surg 2020; 69:452.e5-452.e11. [PMID: 32634560 DOI: 10.1016/j.avsg.2020.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/04/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
Acute lower limb ischemia (ALLI) in the pediatric population is rare but may lead to limb loss and life-long complications. We report the technique and outcomes of microsurgical salvage of ALLI in a preterm newborn after open reduction of congenital hip dysplasia. A 2-month-old girl was born premature at week 36 with congenital bilateral hip dysplasia. The initial management attempted was conservative and entailed placement of bilateral Von Rosen splints. The treatment was successful on the left side, but the patient had recurrent unstable hip dislocation on the right side. Subsequently, 2 attempts at close reduction under general anesthesia were done and both were unsuccessful in maintaining the right hip in the acetabulum. Therefore, an open reduction of the right hip was planned through a medial/obturator approach. During the surgical procedure, the neurovascular femoral bundle (including the superficial femoral artery [SFA], femoral vein [FV], and femoral nerve) was accidently transected with subsequent development of ALLI. Therefore, the FV was harvested distally to the injury site and a 4-cm long healthy segment was obtained. It was reversed, flushed with heparin, spatulated at both extremities, and interposed to the SFA in end-to-end fashion using two 9/0 polypropylene interrupted sutures under microscope. Reperfusion of the limb was noted immediately after releasing the vascular clamps. The final ischemia time at completion of the surgical procedure was 6 hr. Thereby, prophylactic 4-compartment fasciotomies were performed in the right leg. The patient tolerated the procedure well and the postoperative clinical course was free from adverse events. Duplex ultrasound examination at 6 weeks after the intervention confirmed sustained clinical success and showed no signs of venous thromboembolism. At the same time, X-ray examination of the right hip confirmed adequate and stable reduction of the joint in the acetabulum. ALLI due to accidental arterial injury during orthopedic surgical procedures for congenital defects in newborns is a rare but potentially devastating complication. Microsurgical salvage is a safe, feasible, and effective option to restore limb flow. Multidisciplinary expertise and meticulous technique are mandatory in order to achieve satisfactory and durable outcomes.
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Affiliation(s)
- Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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10
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Ramirez JL, Kuhrau CR, Wu B, Zarkowsky DS, Conte MS, Oskowitz AZ, Nijagal A, Vartanian SM. Natural history of acute pediatric iliofemoral artery thrombosis treated with anticoagulation. J Vasc Surg 2020; 72:2027-2034. [PMID: 32276025 DOI: 10.1016/j.jvs.2020.02.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/11/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Acute iliofemoral artery thrombosis (IFAT) can occur in critically ill neonates and infants who require indwelling arterial cannulas for monitoring or as a consequence of cardiac catheterization. Guidelines suggest treatment with anticoagulation, but evidence supporting the optimal duration of therapy and the role of surveillance ultrasound is limited. The objectives of this study were to characterize the kinetics of thrombus resolution and to define an appropriate duration of anticoagulation and interval for surveillance ultrasound. METHODS This was a single-center retrospective cohort study of pediatric patients with acute IFAT from 2011 to 2019. Medical records and vascular laboratory studies were reviewed. Patients with one or more surveillance ultrasound examinations were included. Thrombus resolution was defined as multiphasic flow throughout the index limb without evidence of echogenic intraluminal material by ultrasound. Time to resolution of thrombus was assessed using Kaplan-Meier analysis. RESULTS Fifty-four limbs in 50 patients were identified with acute IFAT. The median age was 9.9 weeks (interquartile range, 3.1-21.7 weeks), with a median weight of 4.2 kg (interquartile range, 3.3-5.5 kg). The majority of limbs (65%) with acute IFAT presented with a diminished pedal Doppler signal, commonly after cardiac catheterization (55%). Forty-eight (89%) limbs had complete arterial occlusion on index ultrasound, and flow could not be detected below the ankle in 48%. The median number of ultrasound examinations per limb was three (range, two to seven), and 61% of limbs had a surveillance ultrasound within 7 days of diagnosis. At 14 and 30 days, 33% and 64% of patients, respectively, treated with anticoagulation had an estimated complete resolution of thrombus. Nine (17%) patients did not receive anticoagulation, and only two of these patients experienced IFAT resolution. At the time of diagnosis, one patient underwent open thrombectomy because of a contraindication to anticoagulation, and one patient was treated with thrombolysis. There were no instances of tissue loss or amputation CONCLUSIONS: Management of IFAT with anticoagulation resulted in successful short-term outcomes. Based on the observed rate of resolution, management should start with anticoagulation, followed by surveillance ultrasound at 2-week intervals. With treatment by anticoagulation, resolution can be expected to occur in one-third of patients every 2 weeks.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Christina R Kuhrau
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Bian Wu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Devin S Zarkowsky
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Adam Z Oskowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Amar Nijagal
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Shant M Vartanian
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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11
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Maithel S, Fujitani RM, Grigorian A, Kabutey NK, Gambhir S, Sheehan BM, Nahmias J. Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma. Ann Vasc Surg 2020; 66:242-249. [PMID: 31978483 DOI: 10.1016/j.avsg.2020.01.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.
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Affiliation(s)
- Shelley Maithel
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA.
| | - Roy M Fujitani
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
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12
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Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 218] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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13
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Boyd S, Shah V, Belik J. A novel role for milrinone in neonatal acute limb ischaemia: successful conservative treatment of thrombotic arterial occlusion without thrombolysis. BMJ Case Rep 2019; 12:12/12/e232440. [DOI: 10.1136/bcr-2019-232440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Acute neonatal limb ischaemia (NLI) is most frequently an iatrogenic complication, however, may also occur in utero due to thromboembolism. There is no widely accepted protocol for treatment of NLI and limited evidence to guide management. Thrombolysis and surgical management have been attempted, though both are associated with significant morbidities. Milrinone is a phosphodiesterase-3 inhibitor used for its vasodilatory effects on the systemic and pulmonary vasculature. There is also emerging evidence for benefit of milrinone in ameliorating ischaemia-reperfusion injury. The authors present a case report of a term infant with spontaneous perinatal acute limb ischaemia secondary to near-completely occlusive thrombosis of the right subclavian artery. The infant was successfully managed conservatively with milrinone without requirement for thrombolysis or surgical intervention. Milrinone represents a novel treatment option for neonates with acute limb ischaemia and consideration of a trial of milrinone prior to higher risk treatment options is warranted in this patient group.
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Markovic MD, Cvetkovic SD, Koncar IB, Dragas MV, Markovic DM, Kukic BP, Kuzmanovic IB, Dimic AD, Sladojevic MM, Davidovic LB. Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center. INT ANGIOL 2019; 38:250-255. [PMID: 30994319 DOI: 10.23736/s0392-9590.19.04124-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity. METHODS Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas. RESULTS There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency. CONCLUSIONS Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.
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Affiliation(s)
- Miroslav D Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia - .,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia -
| | - Slobodan D Cvetkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Igor B Koncar
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Marko V Dragas
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Dragan M Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Biljana P Kukic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Ilija B Kuzmanovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Andreja D Dimic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Milos M Sladojevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Lazar B Davidovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
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15
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Mousa A, Zakaria OM, Hanbal I, Sultan TA, El-Gibaly AM, Zakaria MY, Nasr MA, Bosat BE, Sharabi A, Neinaa M, El-Hamid MA, Daoud MY, Amin MM, Odeh AM, Alhaieg OM, Farhan MA, Bubshait M, Al-Mulhim ARS. Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting. Asian J Surg 2018; 42:761-767. [PMID: 30396715 DOI: 10.1016/j.asjsur.2018.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/17/2018] [Accepted: 09/27/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting. METHODS A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported. RESULTS During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25 ± 4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases. CONCLUSION Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.
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Affiliation(s)
- Ahmed Mousa
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt; Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia.
| | - Ossama M Zakaria
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia; Divisions of Pediatric Surgery, Emergency Surgery, Department of General and Emergency Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ibrahim Hanbal
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Tamer A Sultan
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Amr M El-Gibaly
- Department of General, Visceral, Thoracic and Vascular Surgery, Hanse Klinikum Stralsund, University Medicine of Greifswald, Germany
| | - Mohamed Y Zakaria
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohammed A Nasr
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Al-Azhar University, Assiut Branch, Assiut, Egypt
| | - Bosat E Bosat
- Department of General Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Alaa Sharabi
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohamed Neinaa
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mohamed Abd El-Hamid
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohamed Y Daoud
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mahsoub M Amin
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Ahmed M Odeh
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Omer M Alhaieg
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohamed A Farhan
- Divisions of Pediatric Surgery, Emergency Surgery, Department of General and Emergency Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mohamed Bubshait
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Abdul Rahman S Al-Mulhim
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
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16
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Wang SK, Drucker NA, Raymond JL, Rouse TM, Fajardo A, Lemmon GW, Dalsing MC, Gray BW. Long-term outcomes after pediatric peripheral revascularization secondary to trauma at an urban level I center. J Vasc Surg 2018; 69:857-862. [PMID: 30292605 DOI: 10.1016/j.jvs.2018.07.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The purpose of this investigation was to determine our limb-related contemporary pediatric revascularization perioperative and follow-up outcomes after major blunt and penetrating trauma. METHODS A retrospective review was performed of a prospectively maintained pediatric trauma database spanning January 2010 to December 2017 to capture all level I trauma activations that resulted in a peripheral arterial revascularization procedure. All preoperative, intraoperative, and postoperative continuous variables are reported as a mean ± standard deviation; categorical variables are reported as a percentage of the population of interest. RESULTS During the study period, 1399 level I trauma activations occurred at a large-volume, urban children's hospital. The vascular surgery service was consulted in 2.6% (n = 36) of these cases for suspected vascular injury based on imaging or physical examination. Our study population included only patients who received an arterial revascularization, which was performed in 23 of the 36 consultations (1.6% of total traumas; median age, 11 years). These injuries were localized to the upper extremity in 60.9% (n = 14), lower extremity in 30.4% (n = 7), and neck in 8.7% (n = 2). The mean Injury Severity Score in the revascularized cohort was 14.0 (±7.6). Bone fractures were associated with 39.1% of the vascular injuries (90% of blunt injuries). Restoration of in-line flow was achieved by an endovascular solution in one patient and open surgery in the remainder, consisting of arterial bypass in 59.1% and direct repair in 40.9%. Within 30 days of the operation, we observed no deaths, no infections of the arterial reconstruction, and no major amputations. One patient required perioperative reintervention by the vascular team secondary to the development of a superficial seroma without evidence of graft involvement. Mean follow-up in our cohort was 43.3 (±35.4) months. During this phase, no additional deaths, amputations, chronic wounds, or limb length discrepancies were observed. All vascular repairs were patent, and all but one patient reported normal function of the affected limb at the latest clinic visit. CONCLUSIONS Traumatic peripheral vascular injury is rare in the pediatric population but is often observed secondary to a penetrating force or after long bone fracture. However, contemporary perioperative and long-term outcomes after surgical revascularization are excellent as demonstrated in this institutional case series.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind.
| | - Natalie A Drucker
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Jodi L Raymond
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Thomas M Rouse
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Gary W Lemmon
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Brian W Gray
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
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17
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Lim S, Javorski MJ, Halandras PM, Kuo PC, Aulivola B, Crisostomo P. Epidemiology, treatment, and outcomes of acute limb ischemia in the pediatric population. J Vasc Surg 2018; 68:182-188. [DOI: 10.1016/j.jvs.2017.11.064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 11/05/2017] [Indexed: 10/17/2022]
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18
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Wang SK, Lemmon GW, Drucker NA, Motaganahalli RL, Dalsing MC, Gutwein AR, Gray BW, Murphy MP. Results of nonoperative management of acute limb ischemia in infants. J Vasc Surg 2018; 67:1480-1483. [DOI: 10.1016/j.jvs.2017.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
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19
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Adamson KA, Braza ME, LoGiudice JA, Dzwierzynski WW. Microsurgical repair of neonatal iliac artery injuries with saphenous vein grafts. J Neonatal Perinatal Med 2018; 11:105-108. [PMID: 29689742 DOI: 10.3233/npm-181724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Two neonates with congenital heart disease, one and thirty-one days old respectively, suffered inadvertent arterial injury from cardiac catheterization. Both insults resulted in unrecognized avulsion of the external iliac artery from its origin. The patients quickly decompensated, with their right lower extremities becoming critically ischemic. In both cases, segments of reversed greater saphenous vein were used as interposition grafts from the common iliac artery to the common femoral artery. Reperfusion of the right foot was immediate for the one-day-old. She is now three years old and able to run, but is followed for a mild limb length discrepancy. The 31-day-old had restoration of flow to the right limb; however, the foot remained ischemic and eventually required transmetatarsal amputation. She is now 16 months old and able to crawl; she also is followed for limb length discrepancy. Without vein grafting, both infants would likely have lost their affected limbs, and possibly lost their lives. These cases advocate for microsurgical repair of arterial injuries in even the youngest patients, and promote the use of vein grafts when direct anastomosis is not feasible.
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Affiliation(s)
- Karri A Adamson
- Department of Plastic Surgery, The Medical College of Wisconsin, WI, USA
| | - Matthew E Braza
- Department of Plastic Surgery, The Medical College of Wisconsin, WI, USA
| | - John A LoGiudice
- Department of Plastic Surgery, The Medical College of Wisconsin, WI, USA
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20
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The spectrum and management of noniatrogenic vascular trauma in the pediatric population. J Pediatr Surg 2018; 53:771-774. [PMID: 28506479 DOI: 10.1016/j.jpedsurg.2017.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 04/22/2017] [Accepted: 04/22/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND To describe the spectrum of noniatrogenic pediatric vascular injuries and their outcomes at a large tertiary pediatric hospital. METHODS Retrospective review of a prospectively-maintained trauma database, identifying children with noniatrogenic vascular injuries managed between 1994 and 2014. RESULTS A total of 198 patients were identified. Those patients with a digital or intracerebral vascular injury (92/198) were excluded from further analysis. The remaining 106 patients represented 1.2% of all traumas managed at our institution during the 21-year study period. The majority were male (75%), and between 1 and 12years of age (71% of all patients). Median time from trauma scene to any hospital was 48min (range 0-132), and most patients were transferred from another hospital (64%). Three patients were declared dead upon arrival (3%). Penetrating injuries accounted for most injuries (72%), while blunt injuries accounted for the remainder. Ulnar, radial, or brachial artery trauma accounted for 47% of injuries. Most vessels were treated operatively, by primary repair (49%), vessel ligation (15%), or interposition graft (12%). Fourteen patients (13%) were managed nonoperatively and most patients (74%) experienced no complications in hospital or during follow-up. CONCLUSION Noniatrogenic pediatric vascular injuries are rare and represent a highly heterogeneous population. Most children recover well, with minimal perioperative complications. LEVEL OF EVIDENCE IV (case series with no comparison group).
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21
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Deindl P, Waldhör T, Unterasinger L, Berger A, Keck M. Arterial catheterisation in neonates can result in severe ischaemic complications but does not impair long-term extremity function. Acta Paediatr 2018; 107:240-248. [PMID: 28960442 DOI: 10.1111/apa.14100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/19/2017] [Accepted: 09/25/2017] [Indexed: 11/27/2022]
Abstract
AIM We evaluated the incidence of arterial catheterisation and analysed the risk factors and the extent and outcome of ischaemic complications in neonates. METHODS This was a retrospective cohort study of 1506 neonates admitted to two, ten-bed neonatal intensive care units (NICUs) at the Medical University of Vienna, Austria, between 1 January 2011 and 31 December 2014. Medical charts, daily reports and photo documentation were reviewed for arterial catheterisation and ischaemic complications. Patients with severe ischaemic complications were followed up to evaluate extremity function, scaring and cosmetic results. RESULTS There were 542 arterial catheterisations in 485 patients, including 275 born below 28 weeks, which resulted in severe complications in 19 of 485 (4%) patients. Three died before follow-up. Patients with complications had a significantly lower birthweight, lower postmenstrual age and higher rates of intracranial haemorrhage, retinopathy of prematurity and necrotising enterocolitis. They had also undergone multiple arterial catheterisations more often, needed longer inotropic support and had longer NICU stays than patients without complications. Extremity function was unimpaired in ten of 16 patients with severe ischaemic complications. CONCLUSION Severe ischaemic complications in neonates following arterial catheterisation were rare events, but could cause devastating damage. Most patients didn't show impaired extremity function at follow-up.
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Affiliation(s)
- Philipp Deindl
- Department of Neonatology and Pediatric Intensive Care Medicine; University Children's Hospital; University Medical Center Hamburg Eppendorf; Hamburg Germany
- Department of Pediatrics and Adolescent Medicine; Division of Neonatology; Pediatric Intensive Care and Neuropediatrics; Medical University of Vienna; Vienna Austria
| | - Thomas Waldhör
- Department of Epidemiology; Center for Public Health; Medical University of Vienna; Vienna Austria
| | - Lukas Unterasinger
- Department of Pediatrics and Adolescent Medicine; Division of Neonatology; Pediatric Intensive Care and Neuropediatrics; Medical University of Vienna; Vienna Austria
| | - Angelika Berger
- Department of Pediatrics and Adolescent Medicine; Division of Neonatology; Pediatric Intensive Care and Neuropediatrics; Medical University of Vienna; Vienna Austria
| | - Maike Keck
- Department of Plastic and Reconstructive Surgery; Medical University of Vienna; Vienna Austria
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22
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Arterial reconstructions for chronic lower extremity ischemia in preadolescent and adolescent children. J Vasc Surg 2017; 67:1207-1216. [PMID: 29162367 DOI: 10.1016/j.jvs.2017.08.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/23/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Chronic lower extremity ischemia in pediatric patients is uncommon. The intent of this study was to better define the arterial reconstructive options and their long-term durability in preadolescent and adolescent children having clinically relevant arterial occlusions affecting the lower extremity. METHODS The medical records of 33 consecutive pediatric patients who underwent lower extremity revascularization for chronic ischemia at the University of Michigan from 1974 to 2016 were reviewed. Patients were categorized by age, clinical manifestation, surgical intervention undertaken, and outcomes. RESULTS Operative treatments involved 26 preadolescent children (mean age, 6.1 years; range, 3-9 years) and 7 adolescent children (mean age, 13.9 years; range, 10-17 years). Occlusions were due to earlier injury related to catheter (14), cannula (2), or both catheter and cannula (14); penetrating trauma (2); and vasculitis (1). Preoperative manifestations included symptomatic extremity ischemia (25), growth retardation manifested by documented limb length discrepancies (21), and scoliosis (5). Primary arterial reconstructions were delayed after the precipitating vascular event an average of 5.3 and 11.2 years in the preadolescent and adolescent children, respectively. Primary procedures involved revascularizations of 36 extremities (in preadolescents and adolescents) including autologous vein (26/5), polyethylene terephthalate (Dacron; 1/0), and expanded polytetrafluoroethylene (0/3) bypasses and vein patch angioplasty (0/1). Vein grafts traversing the abdominal cavity (15) were wrapped with a synthetic mesh. Excluding one early graft occlusion, there were no major early postoperative complications after the primary procedures. Secondary operations followed 31% of the primary operations, being performed an average of 8.8 and 6.7 years later (in 8 preadolescent and 3 adolescent children, respectively) for late graft occlusions (6), graft stenoses (3), aneurysmal vein grafts (2), and anastomotic pseudoaneurysm (1). The unassisted primary graft patency rate was 69%, and the assisted secondary graft patency rate was 94%. Symptomatic ischemia resolved in all but two children. Mean postoperative ankle-brachial indices improved to 1.08 from 0.76 preoperatively. Among children having postoperative documentation of limb lengths, the limb length discrepancies became less (11), were unchanged (1), or progressed (3). Follow-up averaged 8.0 years. There was no operative mortality in this experience. CONCLUSIONS Primary lower extremity arterial reconstructions in children with chronic lower extremity ischemia can be successfully undertaken with excellent results. Nevertheless, the potential for late primary graft failures, evident in nearly a third of this experience, mandates careful long-term follow-up and may necessitate secondary interventions to maintain satisfactory outcomes.
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23
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Andraska EA, Jackson T, Chen H, Gallagher KA, Eliason JL, Coleman DM. Natural History of Iatrogenic Pediatric Femoral Artery Injury. Ann Vasc Surg 2017; 42:205-213. [PMID: 28341498 DOI: 10.1016/j.avsg.2016.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Iatrogenic femoral artery trauma complicates the course of critically ill neonates and children. Complications from persistent arterial occlusion may include claudication and limb length discrepancies. Data supporting risk factors for such and need for revascularization are lacking. METHODS Review of a prospectively maintained database at a tertiary institution of iatrogenic pediatric femoral artery injuries incurred between 2013 and 2014 was performed. Additional injuries were identified by review of pediatric arterial duplex performed between 2008 and 2013. Demographics, risk factors, and outcomes were queried. Data analysis utilized Fischer's exact t-test and logistic regression. RESULTS Seventy-six patients were identified of which 68 presented with acute limb ischemia (ALI) and 8 with chronic iliofemoral arterial occlusion resulting in claudication (n = 6) or limb length discrepancy (n = 2). Mean weight at injury was 6.3 kg; mean age at injury was 49 weeks (50% aged <3 months). Mean follow-up was 14 months (out to 11 years). Six patients required surgery for ALI, and 6 required delayed operation for limb length discrepancy (n = 4) or for persistent external iliac artery (EIA) occlusion. Mean age at delayed revascularization was 6 years (range: 2-13 years). Vasopressor use, mechanism/location of injury, and concomitant venous thrombosis were not significantly correlated with need for operation; trends suggested that cardiac catheterization and EIA thrombosis may correlate with chronic disease. Increased age at injury was associated with need for operation. CONCLUSIONS Although a majority of children with ALI may be successfully treated medically, 9% will require operation for ALI and 16% ultimately required revascularization during follow-up. Persistent iliofemoral arterial thrombosis is a likely risk factor for limb length discrepancy with growth; identifying risk factors for this and improved methods for surveillance requires ongoing investigation.
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Affiliation(s)
- Elizabeth A Andraska
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Tatum Jackson
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Huiting Chen
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Katherine A Gallagher
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Jonathan L Eliason
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Dawn M Coleman
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
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24
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Outcomes of arterial vascular extremity trauma in pediatric patients. J Pediatr Surg 2016; 51:1885-1890. [PMID: 27497495 DOI: 10.1016/j.jpedsurg.2016.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/26/2016] [Accepted: 07/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vascular trauma in children, although rare, carries significant risk for repair. Here we report outcomes from a single trauma center for children with extremity vascular trauma, proximal to the digits. METHODS Retrospective chart review of patients less than age 18years with an acute, non-iatrogenic traumatic arterial vascular injury of the upper and/or lower extremity between January 2008 and December 2013. Abstracted patient demographics, injury characteristics, surgical management, and disposition were summarized and compared with nonparametric methods. RESULTS 23 children comprised the study cohort: median age of 8years (IQR: 4.6-12), 61% (n=14) males, 100% survival. Penetrating injuries were the predominate mechanism (n=17, 74%). The median time to presentation was 154min (IQR: 65-330). Acute operations for revascularization included a primary repair (n=15, 65%) or reversed vein graft (n=7, 30%). Fasciotomies were done for 3 (13%) patients. Three amputations were done for failed revascularization. Upper extremity vascular injury (n=15, 65%) was more common. The rate of associated extremity fracture was similar between upper (21%) and lower (33%) extremities (p=0.643). Eight (35%) patients required additional surgery most commonly for debridement, washouts and dressing changes. Three patients' hospital stays were complicated by infection. Impaired function was the most common short- and long-term complication (60%, 75%). CONCLUSION Pediatric vascular injuries are commonly associated with penetrating injuries and male gender and occurred more frequently in the upper extremities. Overall patency rates after repair were 87%. Fasciotomies were done in 13% of patients, and the overall surgical amputation rate was 13%. There was no mortality in this cohort; however, multiple operations are commonly required, including the return to OR for washouts, debridements and dressing changes. The most common short- and long-term complication was impaired function. Overall good results are achievable in pediatric vascular trauma treated with revascularization.
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25
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Linnaus ME, Langlais CS, Kirkilas M, Muenzer JT, Zoldos J, Graziano K, Notrica DM. Outcomes of digital artery revascularization in pediatric trauma. J Pediatr Surg 2016; 51:1543-7. [PMID: 27156104 DOI: 10.1016/j.jpedsurg.2016.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 04/13/2016] [Accepted: 04/14/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Digit amputation is rare in pediatric trauma but can lead to functional morbidity. The true incidence of digital arterial injury is lacking in the literature, and revascularization techniques are not well-described. METHODS Retrospective review of a pediatric trauma registry identified patients with a digital artery injury between July 2008 and December 2013. Isolated vein injuries and arterial injuries proximal to the digits were excluded. Descriptive statistics were used. RESULTS Twenty-five subjects met inclusion. Most were male (n=16; 64%) and the median age was 6.8 (IQR: 2.8, 11.1) years. The most common blunt (n=12) trauma was struck/crushed by object (n=4; 33%) and the most common penetrating (n=13) trauma was because of glass (n=9; 69%). All subjects were managed operatively. Initial operations for arterial repair were primary arterial repair (15; 20%), vein graft (7; 28%), thrombectomy (1; 4%), and amputation (1; 4%). Twelve patients (48%) had reported complications at initial follow-up, but only two (8%) had long-term (>24weeks) sequelae. CONCLUSION Digital artery injury is rare among pediatric traumas. Functional outcomes after digital artery revascularization are favorable. Primary repair can successfully manage these injuries and vein grafting appears to be a suitable alternative when primary repair is not feasible.
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Affiliation(s)
- Maria E Linnaus
- Department of Surgery and Level I Pediatric Trauma Center, Phoenix Children's Hospital, 1919 E Thomas Ave, Phoenix, AZ, USA, 85016; Department of Surgery, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, USA, 85054
| | - Crystal S Langlais
- Department of Surgery and Level I Pediatric Trauma Center, Phoenix Children's Hospital, 1919 E Thomas Ave, Phoenix, AZ, USA, 85016
| | - Mary Kirkilas
- Department of Pediatric Emergency Medicine, Phoenix Children's Hospital, 1919 E Thomas Ave, Phoenix, AZ, USA, 85016
| | - Jared T Muenzer
- Department of Pediatric Emergency Medicine, Phoenix Children's Hospital, 1919 E Thomas Ave, Phoenix, AZ, USA, 85016; Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E Van Buren St, Phoenix, AZ, USA, 85004
| | - Jozef Zoldos
- Arizona Center for Hand Surgery, 370 E Virginia Ave, Suite 100, Phoenix, AZ, USA, 85004
| | - Kathleen Graziano
- Department of Surgery and Level I Pediatric Trauma Center, Phoenix Children's Hospital, 1919 E Thomas Ave, Phoenix, AZ, USA, 85016; Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E Van Buren St, Phoenix, AZ, USA, 85004
| | - David M Notrica
- Department of Surgery and Level I Pediatric Trauma Center, Phoenix Children's Hospital, 1919 E Thomas Ave, Phoenix, AZ, USA, 85016; Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E Van Buren St, Phoenix, AZ, USA, 85004; Department of Surgery, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, USA, 85054.
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Affiliation(s)
- Ahmed AR. Ammar
- Department of Cardiovascular Surgery, Ibn Al-Bitar Center for Cardiac Surgery, Baghdad, Iraq
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The early management of gunshot wounds Part II: the abdomen, extremities and special situations. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408607084151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.
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Sadat U, Hayes PD, Varty K. Acute Limb Ischemia in Pediatric Population Secondary to Peripheral Vascular Cannulation. Vasc Endovascular Surg 2015; 49:142-7. [DOI: 10.1177/1538574415604059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: In this article, we discuss published literature on the management of pediatric patients with acute limb ischemia and also present our center’s experience. Results: Literature review suggests that in the absence of imminent risk of limb loss, noninterventional management with anticoagulants and systemic thrombolysis is preferable and associated with better clinical outcomes than surgery such as reduced per operative morbidity and mortality. In selected more severe cases, surgery may be required. We propose an algorithm for improved clinical outcomes based on the published literature and the American College of Chest Physicians’ recommendations for antithrombotic management in the pediatric population. Conclusion: Literature review suggests an inverse relationship between age and surgical success, particularly in preschool pediatric population. Conservative management as a preliminary strategy seems most beneficial. It is hoped that the proposed intercalated algorithm of medical and surgical management of these patients can further improve clinical outcomes.
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Affiliation(s)
- Umar Sadat
- Cambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge University hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul D. Hayes
- Cambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge University hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Kevin Varty
- Cambridge Vascular Unit, Addenbrooke’s Hospital, Cambridge University hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Macedo FIB, Sciarretta JD, Namias N. Regarding "Management of acute limb ischemia in the pediatric population". J Vasc Surg 2014; 60:1122-3. [PMID: 25260482 DOI: 10.1016/j.jvs.2014.06.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/11/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Francisco Igor B Macedo
- Ryder Trauma Center/Jackson Memorial Hospital and Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Jason D Sciarretta
- Ryder Trauma Center/Jackson Memorial Hospital and Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Nicholas Namias
- Ryder Trauma Center/Jackson Memorial Hospital and Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
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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; 60:106-10. [DOI: 10.1016/j.jvs.2014.01.051] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 01/13/2014] [Accepted: 01/20/2014] [Indexed: 11/28/2022]
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Akingbola O, Singh D, Steiner R, Frieberg E, Petrescu M. High-dose tissue plasminogen activator, topical nitroglycerin, and heparin for severe ischemic injury in a neonate. Clin Pediatr (Phila) 2012; 51:1095-8. [PMID: 21997143 DOI: 10.1177/0009922811423312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Olugbenga Akingbola
- Department of Pediatrics, Tulane Hospital for Children, New Orleans, LA 70112, USA.
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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; 55:1156-9; discussion 1158-9. [DOI: 10.1016/j.jvs.2011.09.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 09/15/2011] [Accepted: 09/26/2011] [Indexed: 10/14/2022]
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Long-term Follow-up of Vascular Reconstructions after Supracondylar Humerus Fracture with Vascular Lesion in Childhood. Eur J Vasc Endovasc Surg 2011; 42:684-8. [DOI: 10.1016/j.ejvs.2011.06.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 06/15/2011] [Indexed: 11/23/2022]
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Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, Green D, Demetriades D. Pediatric vs adult vascular trauma: a National Trauma Databank review. J Pediatr Surg 2010; 45:1404-12. [PMID: 20638516 DOI: 10.1016/j.jpedsurg.2009.09.017] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 09/17/2009] [Accepted: 09/19/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The purpose of this study was to examine nationwide data on vascular injuries in children and to compare pediatric and adult patients with respect to the incidence, injury mechanisms, and outcomes. METHODS This is a National Trauma Databank analysis based on dataset version 7.0 (spanning a 5-year period ending December 2006). Pediatric patients under the age of 16 with at least one reported diagnosis of a vascular injury were compared to the adult cohort aged 16 and greater with a vascular injury. RESULTS During the study period, of 251,787 injured patients younger than 16 years, 1138 (0.6%) had a vascular injury. The incidence in patients 16 years or older was significantly higher, at 1.6% (P < .01). Compared to the adult vascular patients, pediatric patients had a significantly lower Injury Severity Score (16.8 +/- 14.9 vs 26.3 +/- 16.7, P < .001) and encountered less frequently penetrating injuries (41.8% vs 51.2%, P < .001). The most commonly injured vessels in the pediatric population were vessels of the upper extremity (424 patients or 37.9%). The overall incidence of thoracic aortic injuries in children was seven-fold lower compared to the incidence in adults (0.03% vs 0.21%). After adjusting for confounding factors, pediatric patients demonstrated improved survival following vascular injuries (adjusted odds ratio, 0.60; 95% CI, 0.45-0.79; P < .001). No significant difference was identified in the rate of amputation between pediatric and adult patients who had sustained upper or lower extremity vascular injuries. CONCLUSION Vascular trauma in the pediatric population is uncommon, occurring in only 0.6% of all pediatric trauma patients. Although less frequent than adults, a significant proportion was due to penetrating injury. Vessels of the upper extremity were the most commonly injured and were associated with low mortality. Injuries of the thoracic aorta are rare. Overall, pediatric patients had an improved adjusted mortality when compared to adults.
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Affiliation(s)
- Galinos Barmparas
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, Los Angeles, CA 90033, USA
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Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, Krettek C, Probst C. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res 2010; 5:25. [PMID: 20398337 PMCID: PMC2873547 DOI: 10.1186/1749-799x-5-25] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 04/15/2010] [Indexed: 11/10/2022] Open
Abstract
Background Traumatic paediatric arterial injuries are a great challenge due to low incidence and specific characteristics of paediatric anatomy and physiology. The aim of the present study was to investigate their epidemiology, diagnostic and therapeutic options and complications. Furthermore, the prognostic value of the Mangled Extremity Severity Score (MESS) was evaluated. Methods In a retrospective clinical study 44 children aged 9.0 ± 3.2 years treated for traumatic extremity arterial lesions in our Level I trauma center between 1971 and 2006 were enrolled. Exclusion criteria were age > 14, venous and iatrogenic vascular injury. Demographic data, mechanism of injury, severity of arterial lesions (by Vollmar and MESS), diagnostic and therapeutic management, complications and outcome were evaluated. Results The most commonly injured vessel was the femoral artery (25%) followed by the brachial artery (22.7%). The mechanism of injury was penetrating (31.8%), isolated severe blunt extremity trauma (29.6%), multiple trauma (25%) and humeral supracondylar fractures (13.6%). In 63.6% no specific vascular diagnostic procedure was performed in favour of emergency surgery. Surgical reconstructive strategies were preferred (68.2%). A MESS < 7 was associated with initial (p < 0.05) and definite limb salvage (p < 0.001) of the lower extremity. Conclusions Traumatic paediatric vascular injuries are very rare. The most common situations of vascular lesions in childhood were penetrating injuries and fractures of the extremities either as isolated injuries or in multiply injured patients. In paediatric patients, the MESS could serve as a basis for decision making for limb salvage or amputation.
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Affiliation(s)
- Philipp Mommsen
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany.
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Georgiadis GS, Lazarides MK. Comment on "Management of limb ischaemia in the neonate and infant" (Eur J Vasc Endovasc Surg 2009;38:61-65). A proposed algorithm for optimal results. Eur J Vasc Endovasc Surg 2009; 38:531-2. [PMID: 19608441 DOI: 10.1016/j.ejvs.2009.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Accepted: 06/01/2009] [Indexed: 10/20/2022]
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Goz M, Cakir O, Eren N. Peripheral vascular injuries due to firearms in children. Eur J Vasc Endovasc Surg 2006; 32:690-5. [PMID: 16872850 DOI: 10.1016/j.ejvs.2006.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Accepted: 06/14/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vascular injuries caused by firearms are rare among children. In this paper we discuss the surgical methods of treating peripheral vascular injuries due to firearms in children. MATERIALS AND METHODS Forty-four patients with peripheral vascular injuries due to firearms were included in this retrospective study. The patients were under the age of 14 and treated in our clinic between January 1985 and December 2004. RESULTS Vascular injuries due to firearms in children made up 4.9% of all cases of vascular trauma in our clinic. The male to female ratio was 38:6, and the age range was 3-14. The survival rate was 98% and the rate of limb salvage was 91%. For arterial and venous injuries, a saphenous vein interposition graft and interrupted sutures were often preferred surgically. CONCLUSION Peripheral vascular injuries due to firearms in children and other accompanying traumas can be easily identified and treated, and have low morbidity and mortality with an acceptable limb salvage rate if a rapid and effective approach is used.
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Affiliation(s)
- M Goz
- Dicle University School of Medicine, Cardiovascular Surgery, Diyarbakir, Turkey.
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