Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 229-235

A single-center 5-year experience of iatrogenic vascular injuries and their outcomes


1 Department of Surgery (Vascular Division) Command Hospital Air Force Bangalore, Karnataka; Department of Surgery (Vascular Division) Command Hospital Udhampur, J&K, India
2 Department of Surgery (Trauma Division) Command Hospital Udhampur, J&K, India
3 Department of Medicine (Medical Division) Command Hospital Udhampur, J&K, India
4 Department of Medicine St John's Hospital, Bengaluru, Karnataka, India
5 Department of Medicine (Cardiology Division) Command Hospital Air Force Bangalore, Karnataka; Department of Cardiology Army Hospital R&R, Delhi Cantt, India
6 Department of Cardiology, Manipal Hospital, Bengaluru, Karnataka, India

Date of Submission25-Mar-2022
Date of Acceptance26-Apr-2022
Date of Web Publication21-Aug-2022

Correspondence Address:
Ajay Kumar Dabas
Department of Surgery (Vascular Division) Command Hospital Air Force Bangalore, Karnataka; Department of Surgery (Vascular Division) Command Hospital Udhampur, J&K
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_20_22

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  Abstract 


Introduction: Diagnostic and therapeutic interventions can lead to iatrogenic vascular injuries (IVIs). The spectrum of IVIs, their management, and outcomes is presented. Materials and Methods: This prospective observational study from January 2016 to December 2020, included all successive IVIs managed by the vascular surgery department. IVI was defined as vascular injury manifesting as hemorrhage/vessel occlusion/and/or retained foreign body in vasculature. Those due to trauma and/or <30 days follow-up were excluded. Reasons for IVI, presentation, vessels involved, and outcomes were analyzed. Results: Thirty-eight IVIs were analyzed. Age ranged from 3 days to 77 years. Sixteen were due to cardiology, seven due to orthopedics, four cases in end-stage kidney patients, 4 cases due to invasive arterial monitoring, and two following cardiac surgery. One case each was following laparoscopy, spine surgery, thrombectomy, endovascular aneurysm repair, and umbilical catheterization. Manifestations were limb ischemia (lower limb-13, upper limb-6), pseudoaneurysms-10, retained foreign body-4 (superior vena cava and/or right atrium-3; external iliac artery-1), hemorrhage-2, arterio-venous fistula-2, and compartment syndrome-1. Common femoral artery (with/without superficial femoral artery) was affected in 13, forearm arteries in 8, popliteal artery and crural arteries in three each, and one case, each of profunda femoris, carotid artery, external iliac artery branch, and thoracic aorta. IVIs were managed by thrombectomy in 13, arterial repair in 11, endovascular procedures in 5, bypass in 4, conservative in 3, and by laparotomy and open retrieval of a balloon in one case each. Four developed surgical site infections, three died, three suffered amputations, three had motor deficits, and two developed acute kidney injury. Conclusion: IVIs have heterogeneous presentation. Both open and endovascular skill sets are required for management. IVIs carry high morbidity and mortality.

Keywords: Iatrogenic vascular injury, retained foreign bodies in vasculature, vascular injury


How to cite this article:
Dabas AK, Katiyar A, Srivastava S, Chadha AS, Janardhanapillai RK, Bhat KG, Chadha DS. A single-center 5-year experience of iatrogenic vascular injuries and their outcomes. Indian J Vasc Endovasc Surg 2022;9:229-35

How to cite this URL:
Dabas AK, Katiyar A, Srivastava S, Chadha AS, Janardhanapillai RK, Bhat KG, Chadha DS. A single-center 5-year experience of iatrogenic vascular injuries and their outcomes. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Sep 24];9:229-35. Available from: https://www.indjvascsurg.org/text.asp?2022/9/3/229/354072




  Introduction Top


Iatrogenic vascular injuries (IVI) are a bane for both patients and clinicians alike. There is a rising trend in IVIs.[1],[2],[3] Presented in this study is the spectrum and management of IVIs at a tertiary care hospital over 5 years.


  Materials and Methods Top


It is a prospective observational study at a tertiary care center from January 2016 to December 2020. Data were collected prospectively and analyzed.

Inclusion criteria

All successive patients referred to the vascular surgery department for vascular injury and/or retained foreign body in vessels, arising out of any intervention/surgery were included. This included cases where interventions/surgeries leading to IVI were carried out at other hospitals, and the patients were subsequently referred.

Exclusion criteria

Vascular injuries caused by trauma were excluded. Also excluded were the cases where the follow-up was <30 days. The medical records were scrutinized for the primary procedure/intervention causing IVI, the time delay in recognizing IVI, therapy instituted to treat IVIs, and the outcomes.

An effort was made to determine the likely reason for the IVI and the delay in recognition. The delay period for the study was considered as the time lapsed between the occurrence of IVI and the recognition of IVI.

Hospital Ethical Committee Approval was obtained for the study.

Statistical analysis

Data from the study are presented in a descriptive statistical format.


  Results Top


Seventy-seven patients were treated for vascular injuries between January 2016 and December 2020. Thirty-two were due to trauma and 45 were iatrogenic. Out of forty-five cases of IVI, seven were excluded due to follow-up of <30 days. Thirty-eight patients were analyzed. Age, gender, procedures leading to IVI, presentation, management, and outcomes are depicted in [Table 1].
Table 1: Age, gender, interventions leading to iatrogenic vascular injuries, the vessel affected, management, and adverse events

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There were 25 males and 13 females. Age ranged from 3 days to 77 years. The median follow-up was 8. 5 months (range 2–41 months). The most common cause of IVIs was the cardiology interventions resulting in 16 cases of IVI. This was followed by orthopedic interventions (7 cases), interventions in end-stage kidney patients (ESKD) (4 cases), four cases due to arterial monitoring for intensive care, and two cases following cardiac surgery. One case each was following laparoscopic surgery, spine surgery, thrombectomy, endovascular aneurysm repair, and umbilical catheterization.

The most common presentation was acute limb ischemia (ALI). Thirteen had lower limb ischemia and six had upper limb ALI. Five cases of lower limb ALI required bypass (three using saphenous vein and two with polytetrafluoroethylene [PTFE]). Fluoro-guided thrombectomy alone was required in four cases of lower limb ALI and thrombectomy with vein patch repair in two cases. Additional fasciotomy was necessary in one case of lower limb ALI. Only sheath/catheter removal sufficed in two pediatric cases. One was a 3-day-old male, neonate who developed bilateral lower limb ischemia following umbilical catheterization after 12 h of catheterization. It manifested as blanching and cyanosis in the right lower limb and blanching in the left lower limb and with absent femoral pulses. The catheter was removed, and heparin was started. The child improved over the next 72 h. At 12 months, the child had normal milestones and limb length, but color Doppler showed poor flow in the right CFA. Another case was a 3-month child with femoral arterial sheath following cardiac surgery. The child improved with the removal of the sheath with no limb length deficit at 14 months follow-up.

Those with upper limb ischemia required thrombectomy with vein patch repair in all cases, with additional forearm fasciotomy in one case.

With ten cases, pseudoaneurysm was the third-most common presentation. All required open repair. This was due to failed attempt at ultrasound-guided (USG) compression in four, overlying skin of questionable viability in four cases [Figure 1], and the large size (5.5 and 6.5 cm) in two cases. There was a median delay of 5 days (range 1–12 days) in recognition by the treating physician.
Figure 1: Pseuodoaneurysm left common femoral artery with compromised skin vascularity

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There were four cases of retained foreign bodies in this series. Two were pieces of the tunneled catheter for hemodialysis in ESKD patients and were snared out via femoral vein. One child had retained a piece of balloon in the external iliac artery, which was surgically removed after the failure of the endovascular attempt. In the fourth case, a stent migrated into the right atrium. The patient was on a tunneled catheter through the right internal jugular vein (IJV) for 14 months after multiple arteriovenous fistula (AVF) failures. The catheter got occluded and the patient developed superior vena cava (SVC) syndrome. A stent was placed in SVC, as shown in [Figure 2]. However, the stent got dislodged into the right atrium while replacing the occluded tunneled catheter. Cardiac surgeon's consultation was taken; however, the patient refused any surgery.
Figure 2: A case of SVC syndrome. Migration of stent in right atrium. SVC: Superior vena cava

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Two cases presented with iatrogenic AVF. One AVF was between the posterior tibial artery and the posterior tibial vein following an external fixator application in the leg. This was recognized after 5 months when the patient presented with features of venous hypertension. The other was AVF between the right common carotid artery (CCA) and IJV after a failed attempt at neck catheter placement for dialysis. This was detected after 6 months of delay. This was managed by placing a covered stent in CCA.

Two cases presented with hemorrhagic shock in postoperative period. One developed hemothorax following spine surgery for fracture spine due to impingement of pedicle screw over descending thoracic aorta. This was managed by deploying a stent graft and withdrawing of the screws. There was a delay of 6 h in recognition. Second developed hemoperitoneum and shock following laparoscopic appendicectomy. Laparotomy revealed ongoing bleed from a branch of the external iliac artery, which was ligated. There was a delay of 8 h.

One case presented with right forearm compartment syndrome following percutaneous coronary intervention through the radial route. This was due to rent in the radial artery in the forearm. This was managed by fasciotomy, hematoma evacuation, and vein patch repair of the radial artery.

Outcomes

There were three deaths. Two were in the coronary interventions group. One following repair of pseudoaneurysm and the second after the bypass surgery for ALI of the lower limb. The third was a case of stent migration in the right atrium in the ESKD group.

There was one above-knee amputation in a patient who sustained popliteal artery injury during total knee replacement surgery (TKR). There was a complete transection of the popliteal artery behind the knee. Distal SFA to below-knee popliteal artery bypass using PTFE graft was done after completion of TKR. However, bypass failed intra-operatively, and fasciotomy revealed nonviable muscles. Above-knee amputation was required later.

Two patients with upper limb ischemia due to arterial monitoring had partial loss of digits [Figure 3]. Three cases had surgical site infection in the groin after pseudoaneurysm repair, which required multiple sittings of wound debridement. All three patients (one lower limb and two upper limbs) who required fasciotomy had a residual weakness. Two patients developed acute kidney injury requiring dialysis; however, they recovered after 3 and 4 weeks.
Figure 3: Partial loss of digits in a patient following right radial arterial cannulation for invasive blood pressure monitoring

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  Discussion Top


Presentation of IVIs is varied, depending on the primary procedure and the vessel injured.[3],[4],[5] Managing IVIs requires both open and endovascular procedures. IVI leads to significant morbidity and mortality.[6]

Interventions in cardiology can cause IVI.[3],[7],[8] This is attributed to the sheer number of procedures performed and the increasing complexities of the procedures.[3] Pseudoaneurysm was the most common presentation in the current series. Although USG guided compression is the first line of management, all cases required open repair because of large size, failed USG guided compression, or due to compromised viability of the skin.

ALI after the cardiac intervention is uncommon.[9] Dissection, underlying peripheral vascular disease, and larger sheaths predispose to ALI. Dissection and underlying plaques were the likely cause of ALI in the current series. Landmark-guided femoral/radial access is the current prevalent approach. USG guidance is promulgated to reduce adverse events.[10],[11]

Compartment syndrome of the forearm following cardiac interventions through the radial artery is uncommon.[12] This occurred in one case due to hematoma and was managed with fasciotomy and radial artery repair.

Retained segments of devices/balloons are another uncommon documented occurrence.[13],[14] Endovascular retrieval is the preferred modality. However, in the current series, a segment of a balloon got entrapped in EIA, in one case, which had to be retrieved by open surgery after endovascular attempts failed.

Orthopedic surgery (including spine surgery) has consistently remained a cause of IVI.[1],[2],[3],[15],[16] ALI was the most common presentation due to orthopedic procedures. There was one above-knee amputation following popliteal artery injury post-TKR. Popliteal artery injury during TKR varies between 0.003% and 0.23%.[17],[18],[19] Pal et al. reported two amputations out of nine cases of popliteal artery injury during TKR.[17] An amputation rate of 9% following major vascular injury in TKR has been reported.[19] In the current series, amputation was required despite a bypass being performed immediately after the TKR. Probably the absolute ischemia caused by the tourniquet for two and half hours led to a no-reflow phenomenon. Releasing the tourniquet during TKR and placing a shunt during TKR completion could have had a different outcome.

Aortic injury during spine surgery can be disastrous.[15] In this series, pedicle screw pierced the aorta, causing hemothorax and shock, as shown in [Figure 4]. This was managed with a covered stent graft, followed by withdrawal of the screw.
Figure 4: A pedicle screw piercing the thoracic aorta managed by throcaic endovascular aneurysm repair

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Arterial access for hemodynamic monitoring in intensive caring units is known to cause IVIs.[20],[21],[22] Hypotension, size of cannulae, malignancy, and vasoactive drugs predispose to hand ischemia. In the current series, the cannula was 20 G and three patients were on vasoactive drugs. Some cases can be observed after removal of the cannula, and in some thrombectomy would be required.[20],[21] All four cases required thrombectomy as there was thrombus in the affected vessels. Two patients lost digits. Loss of digits has been documented in other series too.[22]

ALI is reported following cardiac surgery with an incidence of 1.4%.[23] The most common procedures done to salvage limbs are thrombectomy and fasciotomy.[23] In the current series, this was required in one case.

Two cases of lower limb ischemia occurred in children, one after cardiac surgery and the other in a neonate (3 days old) following umbilical artery catheterization. Umbilical catheterization can cause limb ischemia due to spasms and/or thrombosis.[24] Majority of children in these settings can be observed and have a good prognosis but require follow-up.[25] Both improved with conservative measures.

Thrombus can dislodge proximally during transfemoral thrombectomy of the iliac artery and can embolize to the opposite iliac/femoral artery.[26] This occurred in one case, which required contralateral transfemoral embolectomy.

Thrombosis and/or hemorrhage from the brachial artery, when it is used for access during endovascular interventions, are reported to be at 10.6%.[27] The left brachial artery got thrombosed following endovascular aneurysm repair in one case. This was dealt with thrombectomy and vein patch repair, with the return of normal pulse.

Vascular injury can occur during laparoscopy.[28],[29] One patient developed hemoperitoneum due to external iliac artery branch injury following laparoscopic appendicectomy.

Central venous stenosis/occlusion occurs if the dialysis catheter is left for long.[30],[31] One patient was treated with venoplasty and stenting for SVC syndrome. However, the stent migrated into the right atrium during the replacement of the occluded tunneled catheter. Management of foreign bodies in the right atrium depends on symptoms and chronicity and should be individualized.[32],[33] Patient refused any surgical intervention. Another stent had to be placed as she developed a recurrence of SVC syndrome. She died after 10 days at home, likely due to arrhythmia/pulmonary embolism.

IVI causes significant morbidity and mortality.[2],[3],[16] There were three deaths, two patients suffered AKI, five developed surgical site infections, and three suffered amputations. There was partial loss of limb function in three patients.

Delayed recognition

Hemorrhage and ischemic events have obvious adverse outcomes if there is a delay in recognition. Even in pseudoaneurysms, late presentation led to vascular compromise of the overlying skin, increased inflammation, and wound complications.

Lack of single all-encompassing definition of iatrogenic vascular injuries

Authors are of the view that there is a lack of a single acceptable “all-encompassing definition” of IVI. This has led to heterogeneous reporting of IVIs under various categories. This, we believe, leads to less than a true reflection of the incidence of IVI.

Limitations of the study

This series included patients who were referred to the vascular surgery department. Patients with pseudoaneurysms who got referred for USG-guided compression could not be accounted for. Furthermore, the incidence of IVI cannot be commented upon. The number of IVI is more than those due to trauma during this period. Whether it is a true reflection of a changing pattern cannot be commented upon, as many traumatic vascular injuries might not reach the tertiary care hospital due to logistics and time constraints. However, five years is a reasonable period to observe a trend.


  Conclusion Top


IVIs present with varied patterns and affect all age groups. IVIs cause high morbidity and mortality. Early recognition would result in amelioration of morbidity. There is a need for a comprehensive definition of IVIs.

Acknowledgment

We acknowledge valuable contributions of Dr. Rajeshwari, MD, Dr. Saranga Bharati, MCh and Mr. RPS Gambhir MS, DNB, FRCSEd, FFSTEd, FRCS, FACS, FEBS Consultant Vascular Surgeon and Honorary Clinical Senior Lecturer, King's College Hospital London, in preparing this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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