Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 66-68

Operative management and outcomes of peripheral vascular trauma in pediatric and adolescent population


Department of Cardiothoracic and Vascular Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission16-Oct-2020
Date of Decision16-Nov-2020
Date of Acceptance07-Dec-2020
Date of Web Publication30-Aug-2021

Correspondence Address:
Subrata Pramanik
Department of Cardiothoracic and Vascular Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_140_20

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  Abstract 


Introduction: Unique characteristics of vascular injuries in children such as pronounced vascular spasm and lack of tissue support over small, thin-walled vessel make vascular repair challenging. This retrospective study was done to evaluate the management and outcome of pediatric and adolescent peripheral vascular trauma. Methodology: Fifteen patients with peripheral vascular trauma who met the inclusion criteria during the study period (August 2019-July 2020) were included. Data were analyzed retrospectively. Results: Majority, 12( 80%) of patients suffered blunt trauma. Primary repair in 13(86.66%) patients was the most common surgical technique employed. All the patients had associated long bone fracture dealt with internal fixation. Four (26.66%) cases had median nerve injury which was amenable to direct repair. Associated venous injury in 5 (33.33%) was also repaired. No mortality, re-operations, or amputation was noted. Conclusion: Excellent limb salvage rate was achieved. Initial revascularization without delay should be the norm. Associated neurological involvement determines postoperative functional outcome. Clinical evaluation with Doppler assessment saves time and crucial in vascular injuries prone to spasm.

Keywords: Functional outcome, limb salvage, pediatric vascular injury, vascular trauma


How to cite this article:
Kumar M, Pramanik S, Gupta A. Operative management and outcomes of peripheral vascular trauma in pediatric and adolescent population. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:66-8

How to cite this URL:
Kumar M, Pramanik S, Gupta A. Operative management and outcomes of peripheral vascular trauma in pediatric and adolescent population. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Nov 28];8, Suppl S1:66-8. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/66/324933




  Introduction Top


Vascular trauma in the pediatric population is uncommon, accounting for 0.6%–1.4% of all pediatric injuries.[1],[2] Extremity vascular trauma (EVT) can cause limb loss, disability, and even death.[3] Mechanism can be blunt or penetrating trauma, and EVT can present in isolation or as a part of complex multisystem trauma.[4] Arterial injury in children poses special challenge to a surgeon as they usually affect atherosclerosis-free, spasm-prone, and smaller vessels.

Although children enjoy distinct advantage of a rich-collateral circulation, the arterial repair needs to be more than just patency-preserving flow for adequate limb growth.[5],[6],[7] Varied patterns of arterial injury may result in some disorders, taking into account the extremities blood supply and tissue ischemia.[8],[9] Most EVTs are suitable for direct simple suturing or primary end-to-end anastomosis.

This retrospective study was done to evaluate the management and outcome of pediatric and adolescent peripheral vascular trauma.


  Methodology Top


The retrospective study was conducted in the department of cardiothoracic and vascular surgery after institutional ethical approval.

The data of all the patients less than 18 years of age with noniatrogenic peripheral vascular injury during study period (August 2019 to July 2020) were retrieved from medical records department. Patients with nonsalvageable traumatic limb loss at the time of injury, iatrogenic vascular injury, severe vascular injury associated with massive orthopedic neuromuscular injury (i.e., crush injury) and injury to neck, chest, abdomen, or any pseudoaneurysm were excluded. The demographic details, clinical status in the emergency department and the types and mechanisms of injury, site of injury (anatomical location), the time lag between the occurrence of injury and the repair, the type of repair, any associated procedure such as vein ligation, fasciotomy, preoperative and postoperative Doppler ultrasonography of the affected part as well as anticoagulation, and the length of hospital stay were recorded and analyzed.

All patients had undergone Doppler ultrasonography pre- and postoperatively. Systemic heparinization was administered. On exploration, proximal and distal ends of the artery were identified. Fogarty catheter was introduced both distally and proximally of the transacted artery to remove any thrombus. Primary repair (lateral/end-to-end anastomosis) or interposition reverse saphenous vein graft from contralateral limb was used depending on the injury. All patients with fracture underwent reduction and internal fixation. At our institute, intravenous unfractionated heparin infusion was administered intraoperatively and postoperatively for 48 h.

Primary outcomes of this study were limb salvage rates, functional outcomes, and mortality. Secondary outcomes were vascular complications such as graft failure, re-explorations, and fasciotomy rates.

Good functional outcome was defined as no neurological disorder and extremity finger movement. Satisfactory functional outcome was recorded as slight paresthesia and reduced finger movement. Poor function was noted with significant paresthesia and no finger movement.

Statistical analysis

The data were entered in MS Excel spreadsheet and analysis was performed using Statistical Package for the Social Sciences (SPSS) version 21.0 (International Business Machines Corporation (IBM), Chicago, USA).

Categorical variables were presented in number and percentage (%) while continuous variables were presented as mean ± standard deviation and median.


  Results Top


Among 15 patients studied, the mean age at the time of presentation was 8.63 + 4.86 (range, 1.5–16) years. Majority were male 10 (66.66%) with male-to-female ratio of 2:1. The study variables evaluated are shown in [Table 1]. In the study population, 10 fell from height and five suffered road traffic accident. Intraoperatively, 13 (86.66%) patients had complete transection of the artery. Of these, 11 (84.61%) had primary repair in the form of end-to-end anastomosis and 2 (15.38%) underwent reverse interposition vein grafting using vein from contralateral limb. Graft was required in one case each of right superficial femoral artery (SFA) and left popliteal artery (PA) injury. Two patients with partial laceration of the brachial artery underwent primary (lateral) repair. All brachial artery injuries were associated with supracondylar fracture of humerus and fracture of right femur and left tibia in case of right SFA and left PA injuries, respectively. All associated venous injuries were repaired. Four cases underwent end-to-end repair of median nerve. In 3 (20%) patients, major soft tissue loss was sequelae to upper limb blunt trauma. No mortality or re-explorations were noted in the study population. Majority, 11(73.33%) had good functional outcome and 4 (26.66%) had satisfactory functional results. Limb salvage was universal.
Table 1: Variables evaluated in the study population

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  Discussion Top


In the present study, limb salvage rate of 100% was achieved. Multiple authors had reported similar outcomes.[10],[11] Concomitant neurological injury dictates functional outcome. Majority (65%) of patients with isolated vascular injury showed complete recovery as compared to 8% cases with associated neurological injury.[12] However, the scenario was opposite in children with complete and faster recuperation from peripheral neurological injuries than adults.[13] Although isolated EVT injuries were associated with good functional results, patients with associated median nerve repair had satisfactory outcome. Harris et al. identified two-third patients with combined injury resuming normal activities.[14] Although arteriography remains gold standard to diagnose or even exclude vascular injury in children,[15],[16] arterial spasm and iatrogenic injury during manipulation is more common in pediatric population than adults. Duplex scan with color mapping of arteries and veins of the affected limb was performed. Bergstein et al. described 99% specificity, 50% sensitivity, and 66% and 7% negative and positive predictive values, respectively.[17] As compared to conventional arteriography and exploration, Fry et al. reported 100% specificity with color Doppler.[18] All the patients underwent arterial repair in accordance to Sciarretta et al.,[19] although some authors advocate its ligation.[20] Delayed repair in view to improve collateral circulation can prove to be detrimental as their development to maintain tissue viability can hamper growth of extremity.[21],[22] Revascularization of all arterial injuries was uncomplicated in this study. All the patients had associated long bone fracture, managed with internal fixation. Lower muscle mass and tone predisposes children to musculoskeletal injuries. Technique of arterial repair was described elsewhere.[23] At our institute, interrupted small monofilament sutures were used to facilitate future growth, similar to reports from other authors.[14],[24] The mean age of presentation in this study was 8.63 ± 4.86 years, with blunt trauma as the most common mechanism of injury. Similar results were evident in a study of 222 children with vascular injury.[2] However, according to many authors, penetrating trauma was dominant mechanism.[11],[25]

Limitation

  • Retrospective study design and shortfall of long-term limb salvage and functional outcomes.



  Conclusion Top


Limb salvage was universal with overall good immediate functional outcome. Associated neurological injury dictates the functional recovery. Assessment of extremity vascular injuries in association with fracture by clinical and Doppler examination saves time. Early revascularization without delay is essential. Blunt trauma was the prime mechanism of injury.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, et al. Pediatric vs adult vascular trauma: A National Trauma Databank Review. J Pediatr Surg 2010;45:1404-12.  Back to cited text no. 1
    
2.
Wahlgren CM, Kragsterman B. Management and outcome of pediatric vascular injuries. J Trauma Acute Care Surg 2015;79:563-7.  Back to cited text no. 2
    
3.
Siddique MK, Bhatti AM. A two-year experience of treating vascular trauma in the extremities in a military hospital. J Pak Med Assoc 2013;63:327-30.  Back to cited text no. 3
    
4.
Stovall RT, Pieracci FM, Johnson JL. Perioperative management of peripheral vascular trauma. Semin Cardiothorac Vasc Anesth 2012;16:133-41.  Back to cited text no. 4
    
5.
Tshifularo N, Moore SW. Surgical intervention in vascular trauma in children. Pediatr Surg Int 2012;28:375-8.  Back to cited text no. 5
    
6.
Ammar AR. Peripheral arterial injuries in pediatric age group. J Trauma Injury 2016;29:37e42.9.  Back to cited text no. 6
    
7.
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;43:72-6.  Back to cited text no. 7
    
8.
Inaba K, Branco BC, Reddy S, Park JJ, Green D, Plurad D, et al. Prospective evaluation of multidetector computed tomography for extremity vascular trauma. J Trauma 2011;70:808-15.  Back to cited text no. 8
    
9.
Saunders BE, Adams ZW. Epidemiology of traumatic experiences in childhood. Child Adolesc Psychiatr Clin N Am 2014;23:167-84, vii.  Back to cited text no. 9
    
10.
Morão S, Ferreira RS, Camacho N, Vital VP, Pascoal J, Ferreira ME, et al. Vascular trauma in children-Review from a major paediatric center. Ann Vasc Surg 2018;49:229-33.  Back to cited text no. 10
    
11.
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;70:823-8.  Back to cited text no. 11
    
12.
Brown KR, Jean-Claude J, Seabrook GR, Towne JB, Cambria RA. Determinates of functional disability after complex upper extremity trauma. Ann Vasc Surg 2001;15:43-8.  Back to cited text no. 12
    
13.
Iconomou TG, Zuker RM, Michelow BJ. Management of major penetrating glass injuries to the upper extremities in children and adolescents. Microsurgery 1993;14:91-6.  Back to cited text no. 13
    
14.
Harris LM, Hordines J. Major vascular injuries in the pediatric population. Ann Vasc Surg 2003;17:266-9.  Back to cited text no. 14
    
15.
Meagher DP Jr., Defore WW, Mattox KL, Harberg FJ. Vascular trauma in infants and children. J Trauma 1979;19:532-6.  Back to cited text no. 15
    
16.
Richardson JD, Fallat M, Nagaraj HS, Groff DB, Flint LM. Arterial injuries in children. Arch Surg 1981;116:685-90.  Back to cited text no. 16
    
17.
Bergstein JM, Blair JF, Edwards J, Towne JB, Wittmann DH, Aprahamian C, et al. Pitfalls in the use of color-flow duplex ultrasound for screening of suspected arterial injuries in penetrated extremities. J Trauma 1992;33:395-402.  Back to cited text no. 17
    
18.
Fry WR, Smith RS, Sayers DV, Henderson VJ, Morabito DJ, Tsoi EK, et al. The success of duplex ultrasonographic scanning in diagnosis of extremity vascular proximity trauma. Arch Surg 1993;128:1368-72.  Back to cited text no. 18
    
19.
Sciarretta JD, Macedo FI, Chung EL, Otero CA, Pizano LR, Namias N, et al. Management of lower extremity vascular injuries in pediatric trauma patients: A single level I trauma center experience. J Trauma Acute Care Surg 2014;76:1386-9  Back to cited text no. 19
    
20.
Lally KP, Foster CE 3rd, Chwals WJ, Brennan LP, Atkinson JB. Long-term follow-up of brachial artery ligation in children. Ann Surg 1990;212:194-6.  Back to cited text no. 20
    
21.
Whitehouse WM, Coran AG, Stanley JC, Kuhns LR, Weintraub WH, Fry WJ, et al. Pediatric vascular trauma. Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment. Arch Surg 1976;111:1269-75.  Back to cited text no. 21
    
22.
White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE, et al. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 2011;253:1184-9.  Back to cited text no. 22
    
23.
Guzetta PC. Vascular trauma. In: Eichelberger MR, editor. Pediatric trauma: prevention, acute care, rehabilitation. St. Louis: Mosby-Year Book; 1993. p. 326-31.  Back to cited text no. 23
    
24.
Eren N, Ozgen G, Ener BK, Solak H, Furtun K. Peripheral vascular injuries in children. J Pediatr Surg 1991;26:1164-8.  Back to cited text no. 24
    
25.
Kirkilas M, Notrica DM, Langlais CS, Muenzer JT, Zoldos J, Graziano K, et al. Outcomes of arterial vascular extremity trauma in pediatric patients. J Pediatr Surg 2016;51:1885-90.  Back to cited text no. 25
    



 
 
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