ORIGINAL ARTICLE
Management of lower extremity vascular injuries in pediatric trauma patients: A single Level I trauma center experience Jason D. Sciarretta, MD, Francisco Igor B. Macedo, MD, Eunice Lee Chung, MD, Christian A. Otero, MD, Louis R. Pizano, MD, MBA, and Nicholas Namias, MD, MBA, Miami, Florida
Traumatic vascular injuries of the lower extremity in the pediatric population are rare but can result in significant morbidity. We aimed at describing our experience with such complex injuries, with associated patterns of injury, diagnostic and therapeutic challenges, and outcomes. METHODS: From January 2006 to December 2011, 2,844 pediatric trauma patients presented at the Ryder Trauma Center, an urban Level I trauma center in Miami, Florida. Among them, 18 patients (0.6%) were evaluated for lower extremity traumatic vascular injuries. Variables collected included age, sex, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: Mean (SD) age was T 14.7 (2.6) years (range, 6Y17 years), with 17 males (94.4%). Of the 18 traumatic pediatric patients, 32 vascular injuries were identified. All arterial injuries underwent definitive operative repair. Primary repair was performed in two patients (11.1%), six (33.3%) required saphenous vein interposition grafting as initial procedure, and eight (44.4%) underwent polytetrafluoroethylene grafting. Ligation was performed in major venous injuries and deep profunda branches. The overall survival in this series was 94.4%. CONCLUSION: Peripheral vascular injuries of the lower extremity in the pediatric population can result in acceptable outcomes if managed early and aggressively. Surgical principles of vascular surgery are similar to those applied to an adult. We recommend that these injuries should be managed in a tertiary specialized center with a multidisciplinary team of trauma surgeons, and pediatricians, which can potentially decrease morbidity and mortality. (J Trauma Acute Care Surg. 2014;76: 1386Y1389. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. KEY WORDS: Pediatric trauma; noniatrogenic vascular injury; pediatric vascular injury; peripheral vascular injury. BACKGROUND:
T
rauma remains the leading cause of death and disability for children older than 1 year in the United States.1,2 Vascular injury is a well-known cause of morbidity and mortality in adults, but it is encountered far less frequently in the pediatric population, even in Level 1 trauma centers, accounting for only 0.6% to 2% of all pediatric traumatic injuries.1,3 To date, most reports of vascular injury in children results from iatrogenic injuries after arterial or central venous catheterizations.1 In the trauma setting, management has traditionally been based on adult experience, but pediatric vascular injuries may differ from adults in that significant injuries are more difficult to detect because they are more commonly asymptomatic, are more associated with vasospasm, or have other more severe life-threatening injuries that take priority in the resuscitation process.4 The greatest concerns with vascular injuries in pediatric patients are restoration of sufficient circulation and future limb growth with vascular
Submitted: October 17, 2013, Revised: January 22, 2014, Accepted: January 22, 2014. From the Grand Strand Regional Medical Center (J.D.S.), Myrtle Beach, South Carolina; St John Hospital (F.I.B.M.), Southfield, Michigan; and Ryder Trauma Center (E.L.C., C.A.O., L.R.P., N.N.), Miami, Florida. Address for reprints: Jason Daniel Sciarretta, MD, 849 82nd Pkwy, Myrtle Bch, SC 29572 email: [email protected]. DOI: 10.1097/TA.0000000000000225
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repair. During the last decade, despite major advancements of angiography and contrast-enhanced studies, only a few series have reported clinical experience of such injuries.5,6 We aimed at demonstrating our experience with lower extremity traumatic vascular injury in the pediatric population, thereby focusing on initial management, surgical approach, associated complications, and outcomes.
PATIENTS AND METHODS Between January 1, 2006, and December 31, 2011, 2,844 pediatric trauma patients younger than 18 years presented to the Ryder Trauma Center, a Level I center in Miami, Florida. Among them, 18 (0.6%) were evaluated for lower extremity vascular injuries and were retrospectively included in this analysis. Institutional review board approval for this study was obtained, and the need for informed consent was waived. Data collected and analyzed included age, sex, type of injury, mechanism, clinical status on admission, diagnostic imaging, operative management, length of stay, and clinical outcome. All patients with iatrogenic injuries and/or 18 years or older were excluded from the study. Mean (SD) age was 14.7 (2.6) years (range, 6Y17 years), and the majority of patients were males (17 patients, 94.4%). Demographics and clinical data are summarized in Table 1. J Trauma Acute Care Surg Volume 76, Number 6
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J Trauma Acute Care Surg Volume 76, Number 6
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TABLE 1. Patient Demographics Number Age at presentation, mean (SD) [range], y Sex Male Female Mechanism Penetrating Gunshot injury Blunt Motor vehicle collision Motorcycle collision Auto-pedestrian collision Crush injury ISS at presentation, mean (SD) [range] GCS score at presentation, mean (SD) [range] ICU stay, mean (SD) [range], d Hospital stay, mean (SD) [range], d Preoperative procedures Resuscitative thoracotomy CT angiogram Fasciotomy (four compartment) Calf Thigh Temporary tourniquets
Percentage
14.7 (2.6) [6Y17] 17 1
94.4 5.6
14
77.8
1 1 1 1 16.5 (0.2) [4Y50] 12.9 (4.4) [3Y15]
5.6 5.6 5.6 5.6
3.2 (2.4) [0Y9] 13.3 (11.1) [1Y39] 1 5 6 1* 2
*One patient had both thigh and calf fasciotomies.
Severe injury was categorically defined as an Injury Severity Score (ISS) of greater than 15. The results of specific diagnostic studies, including duplex ultrasonography, computed tomography (CT), and arteriography, were collected and correlated with physical examination. Classic ‘‘hard signs’’ of vascular compromise included pulsatile bleeding, absent or diminished pulses, expanding or pulsatile hematoma, presence of a bruit or palpable thrill, or signs of distal ischemia as demonstrated by the presence of pain, pallor, paresthesia, paralysis, and poikilothermia. Standard diagnostic studies, including radiographs of the lower extremity, were routinely performed when indicated to assess for bony fractures. Vascular injuries of the lower extremity consisted of vessels below the inguinal ligament and below the knee including arterial, venous, and/or combined injuries. Although injuries to the deep femoral vessels are typically not limb threatening, most of these injuries were accompanied with another vascular injury and were included in this study.
RESULTS The majority of the mechanisms of injury were secondary to penetrating injury (14 patients, 77.8%), all resulting from gunshot wounds. The remaining injuries (4 patients, 22.2%) were the result of blunt trauma, including a motor vehicle crash, a pedestrian hit by a moving vehicle, a motorcycle crash, and a crush injury. Regardless of the mechanism, 32 vessels had traumatic vascular injury. The mean (SD) ISS
was 16.5 (10.2) (range, 4Y50), and the mean (SD) Glasgow Coma Scale (GCS) score on admission was 12.9 (4.4) (range, 3Y15), with three patients having a GCS score of less than 8. On arrival, mean (SD) systolic blood pressure was 124.1 (40.3) mm Hg (range, 0Y190 mm Hg), mean (SD) blood pH was 7.36 (0.11) (range, 7.00Y7.43), mean (SD) base deficit on presentation was j4.8 (3.3) (range, 0 to j12), and mean (SD) hematocrit was 32.1 (4.3) (range, 29Y41). Classic signs of vascular compromise were present in 94.4% of the cases at presentation. The most common signs were absent or diminished distal pulses (17 patients, 94.4%), distal limb ischemia (11 patients, 61.1%), and hematoma formation (5 patients, 27.8%). Two patients presented with hemorrhagic shock, and one patient had a bruit and thrill in the lower extremity. Only one patient had an unremarkable physical examination result. Nine patients required blood transfusion during initial resuscitation, with a mean (SD) packed red blood cells given at 10.5 (9.5) U (range, 1Y28 U). Associated orthopedic injuries occurred in six patients (33.3%), including three distal femoral fractures (16%), two knee dislocations (11.1%), and one iliac apophyseal avulsion fracture (5.5%). In 13 cases (72.2%), physical examination alone based on the classical hard signs of vascular injury favored immediate surgical intervention, and no further diagnostic studies were performed. Preoperative CT angiogram was performed in five patients (27.8%). Indications included loss of pulses after orthopedic fixation, diminished distal pulses from admission, and expanding hematoma suggestive of infectious pseudoaneurysm on postoperative Day 40 after initial operation. The lower extremity vessels injured are listed in Table 2. The superficial femoral artery and vein were the most commonly injured vessels, followed by the popliteal and deep femoral vessels. Combined arterial and venous injuries occurred in seven patients (38.8%). Surgical interventions are summarized in Table 2. All arterial injuries underwent definitive operative repair. Primary repair was performed in two patients (11.1%) with partial transection of the common femoral artery and popliteal vein. Six patients (33.3%) required saphenous interposition grafting as initial procedure, and eight patients (44.4%) patients underwent polytetrafluoroethylene (PTFE) grafting. One patient developed PTFE graft infection and underwent revision with autogenous reverse saphenous vein graft from the common femoral to superficial femoral artery. Ligation was performed in major venous injuries and deep profunda branches (Table 2). Profunda artery and vein were ligated in five patients (27.8%), and the superficial and common femoral veins were ligated in three cases (16.7%) and two cases (11.1%), respectively. Emergent tourniquets and temporary intravascular shunts were used in two cases (11.1%) and one case (5.5%), respectively. Intraoperative heparin and arteriogram were used in 12 and 4 patients, respectively. Catheter thromboembolectomy was performed in seven patients with satisfactory results. Fasciotomy was required in six patients (33.3%), with one case of extensive fasciotomy including the thigh and calf. Nonoperative management was not performed in any of the vascular injured patients included in this analysis. Postoperative complications included deep vein thrombosis in two patients (11.1%), graft infection (1, 5.6%), and wound
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TABLE 2.
Lower Extremity Vascular Injuries and Surgical Repair
Injuries Common femoral artery With common femoral vein Superficial femoral artery With superficial femoral vein Deep femoral artery With deep femoral vein Popliteal Artery Vein Anterior tibial artery Posterior tibial artery Peroneal artery Types Partial transection Complete transection Contusion with thrombosis Pseudoaneurysm Intimal disruption Surgical procedures Lateral primary repair Autogenous saphenous grafting PTFE grafting Ligation Intraoperative arteriogram Temporary intravascular shunt Catheter embolectomy
Number
Percentage
1 2 5 3 2 2
3.1 6.2 15.6 9.3 6.2 6.2
4 2 1 1 1
12.5 6.2 3.1 3.1 3.1
12 16 2 1 1
37.5 50 6.3 3.1 3.1
Artery 1 7 8* 8 4 1 7
Vein 1 0 0 7 12.5 3.1 21.9
*One patient required revision with autogenous graft.
seroma (1, 5.5%). In 13 patients (72.2%), no postoperative complications were observed. Both cases of deep vein thrombosis were successfully treated with anticoagulation, and there were no cases of pulmonary embolism in this series. Long-term complications included neurologic deficits from nerve injury (3 patients, 16.7%) and soft tissue defects requiring muscle flap coverage (2 patients, 11.1%). Amputation was required in only one patient (5.5%) who presented after motorcycle crash with a distal tibial fracture and complete transection of the anterior tibial, posterior tibial, and peroneal arteries. This patient developed stump infection that required further operative revision. One patient underwent decompressive laparotomy for suspected intra-abdominal compartment syndrome on postoperative Day 3, and no ischemic findings were identified. The mean (SD) length of hospital and intensive care unit (ICU) stays were 13.3 (11.1) days (range, 1Y39 days) and 3.2 (2.4) days (range, 0Y9 days), respectively. The overall survival in this series was 94.4%; the only one patient who died presented after multiple gunshot wounds, with an ISS of 50, and underwent resuscitative thoracotomy in the emergency department with return of vital signs. He underwent exploratory laparotomy and PTFE grafting of the right common femoral artery with end-to-end anastomosis and, subsequently, died on postoperative Day 1. Cardiac arrest also occurred in one other patient 1388
in the operating room, but he survived and was discharged home without sequelae. Outpatient follow-up was available for 12 of the 17 surviving patients. The data available on length of follow-up available ranged from 35 days to 1,062 days after injury. Six patients returned to their normal function without sequelae, although three of them had diminished pulse examination results. Three patients had documented neurologic dysfunction including numbness or conduction abnormality on electromyogram. One patient developed a leg length discrepancy requiring orthopedic intervention. All 12 patients who were seen after discharge were eventually able to walk, including the patient who had received a below-the-knee amputation. Although there was one patient who required vascular revision for a late presentation of an infected pseudoaneurysm, there were no cases that required operative revision for arterial ischemia.
DISCUSSION Pediatric lower extremity vascular injuries are usually iatrogenic following catheterization or invasive monitoring.7 Pediatric peripheral vascular trauma is far less frequent, and there is a scarcity of reported experience for the management of such injuries. In this series, we encountered 32 vascular injuries in the lower extremity in 18 pediatric trauma patients with an incidence of 0.6%, which is consistent with previous studies.3 This series also confirmed higher likelihood of penetrating trauma as a cause of peripheral vascular injury in the pediatric population as compared with blunt trauma (77.8% vs. 22.2%, respectively).8 The initial and surgical managements are performed similarly to that of the adult population. Any bony fracture with diminished pulses prompted immediate reduction and vascular reassessment. The use of arteriography has been reported in the management of pediatric vascular injuries in few retrospective series.9 Although it is a relatively safe and infrequent procedure, angiography has been appropriate when indicated in the pediatric trauma population as demonstrated by previous reports.9,10 In this series, the majority of patients (94.4%) presented with obvious hard signs of vascular injury, which require immediate operation, and therefore, further diagnostic studies were limited. Additional diagnostic imaging was performed only for those patients with persistent pulse discrepancies and hemodynamic stability. CT angiograms were preferred in our institution compared with conventional angiography in the pediatric population as a noninvasive and readily available diagnostic tool.11 The role of therapeutic angiography in the pediatric population is yet unknown. The principles of vascular repair in adults are the same for pediatrics. If minimal vascular injury is present (define it), primary repair should include debridement of the devitalized. When primary repair is not feasible, the choice of conduit for reconstruction is of particular importance. Autologous grafts, such as reversed saphenous vein, are preferred and have demonstrated the best results.12 Synthetic conduits, such as PTFE graft, can also be successfully used; however, small diameter grafts have higher thrombosis rates with poor long-term patency.13 In our series, both synthetic and autologous grafts were used more commonly compared with primary repair (46.8% and * 2014 Lippincott Williams & Wilkins
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6.2%, respectively). Venous injuries were commonly ligated (21.9%) in those presenting with signs of shock, those with significant blood loss, those with combined vessel injury, or those not amendable to primary repair. This is partially caused by the unfortunate high incidence of high-powered weapons in neighboring communities, resulting in extensive vessel and tissue destruction, allowing primary repair as a less feasible option. Similar results were encountered in recent military data at a US combat support hospital with 75% incidence of penetrating injuries.14 No primary arterial repair was attempted, and 20% of the patients underwent venous ligation.14 Blunt mechanisms create more shear and traction-type injuries with injury to a greater length of the vessel, making it unsuitable for primary repair.15 We recommend repair of concomitant venous injuries whenever time permits and is particularly important for injuries to the common femoral vein and popliteal vein. Early amputation occurred more frequently in this military setting compared with our civilian cohort (16% vs. 5.5%, respectively), which also compares favorably between other civilian Level I trauma centers with 10.7% amputation rates.6 Interestingly, fasciotomy was more liberally undertaken in our series compared with the military cohort (38% vs. 28%, respectively).14 Factors contributing to delayed amputations may include delayed presentation, extensive injury, and failed revascularization of the extremity.15Y17 In contrast to the adult population, repair of all injured vessels is essential because there is a considerable risk for potentially skeletal growth retardation in pediatric trauma patients. Inadequate circulation may compromise the normal growth of the affected bones, leading to limb length discrepancies and long-term disability.18 Vascular anastomosis should be performed with interrupted sutures to accommodate growth patterns in children.18,19 Continuous suture repair may lead to arterial narrowing with progressive limb growth. Other differences include more frequent arterial spasms and potential for early thrombosis in the pediatric vascular trauma patient, and the use of intra-arterial vasodilators, such as papaverine or nitroglycerin, may be helpful.2 We acknowledge that our study has several important limitations. In addition to the retrospective design and relatively small number of patients, we were unable to analyze long-term outcomes, including mortality and limb-salvage survival. Further studies are needed to establish the long-term impact on lower extremity salvage in the pediatric trauma population. Functional long-term outcomes are needed to determine if the presence of arterial repair and concomitant vein ligation as short-term treatment shows increased morbidity. In conclusion, peripheral vascular injuries of the lower extremity in the pediatric population are rare but can result in significant morbidity. The management of such injury requires early identification and prompt surgical intervention and can result in acceptable early outcomes. Clinical management and vascular surgical principles applied to an adult should also be applied in children. Such complex lesions should be managed in tertiary specialized care centers with a multidisciplinary team involving trauma and pediatric surgeons as well as pediatricians, which can potentially decrease morbidity and mortality associated
Sciarretta et al.
with lower extremity vascular injuries in the pediatric trauma population. AUTHORSHIP J.D.S., F.I.B.M., C.A.O., L.R.P., and N.N. contributed to the creation of the manuscript and data/statistical analysis E.C. provided follow up research, tables.
DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Myers SI, Reed MK, Black CT, Burkhalter, Lowry PA. Noniatrogenic pediatric vascular trauma. J Vasc Trauma. 1989;10:258Y265. 2. de Virgilio C, Mercado PD, Arnell T, Donayre C, Bongard F, White R. Noniatrogenic pediatric vascular trauma: a ten-year experience at a Level I trauma center. Am Surg. 1997;63:781Y784. 3. Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, Green D, Demetriades D. Pediatric versus adult vascular trauma: a National Trauma Databank review. J Pediatr Surg. 2010;45:1404Y1412. 4. Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma. 2003;55:814Y824. 5. Shah SR, Wearden PD, Gaines BA. Pediatric peripheral vascular injuries: a review of our experience. J Surg Res. 2009;153:162Y166. 6. Klinkner DB, Arca MJ, Lewis BD, Oldham KT, Sato TT. Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Pediatr Surg. 2007;42: 178Y183. 7. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Guzzetta PC, Anderson KD, Garcia VF, Randolph JG, Bowman LM. Patterns of injury in children. J Pediatr Surg. 1990;25:85Y91. 8. Milas ZM, Dodson TF, Ricketts RR. Pediatric blunt trauma resulting in major arterial injuries. Am Surg. 2004;70:443Y447. 9. Reichard KW, Hall JR, Meller JL, Spigos D, Reyes HM. Arteriography in the evaluation of penetrating pediatric extremity injuries. J Pediatr Surg. 1994;29:19Y22. 10. Puapong D, Brown CV, Katz M, Kasotakis G, Applebaum H, Salim A, Rhee P, Demetriades D. Angiography and the pediatric trauma patient: a 10-year review. J Pediatr Surg. 2006;41:1859Y1863. 11. Lineen EB, Faresi M, Ferrari M, Neville HL, Thompson WR, Sola JE. Computed tomography angiography in pediatric blunt traumatic vascular injury. J Pediatr Surg. 2008;43:549Y554. 12. Whitehouse WM, Coran AG, Stanley JC, Kuhns LR, Weintraub WH, Fry WJ. Pediatric vascular trauma. Arch Surg. 1976;111:1269Y1275. 13. Meagher DP, Defore WW, Mattox KL, Harberg FJ. Vascular trauma in infants and children. J Trauma. 1979;19:532Y536. 14. Dua A, Via KC, Kreishman P, Kragh JF Jr, Spinella PC, Patel B, Gillespie DL, Mahoney P, Fox CJ. Early management of pediatric vascular injuries through humanitarian surgical care during U.S. military operations. J Vasc Surg 2013;58:695Y700. 15. Corneille MG, Gallup TM, Villa C, Richa JM, Wolf SE, Myers JG, Dent DL, Stewart RM. Pediatric vascular injuries: acute management and early outcomes. J Trauma. 2011;70(4):823Y828. 16. Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg. 2001;33(6):1212Y1219. 17. Reichard KW, Reyes HM. Vascular trauma and reconstructive approaches. Semin Pediatr Surg. 1994;3:124Y122. 18. Harris LM, Hordines J. Major vascular injuries in the pediatric population. Ann Vasc Surg. 2003;17:266Y269. 19. Eren N, Ozgen G, Ener BK, Solak H, Furtun K. Peripheral vascular injuries in children. J Pediatr Surg. 1991;26:1164Y1168.
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Management of lower extremity vascular injuries in pediatric trauma patients: A single Level I trauma center experience Jason D. Sciarretta, MD, Francisco Igor B. Macedo, MD, Eunice Lee Chung, MD, Christian A. Otero, MD, Louis R. Pizano, MD, MBA, and Nicholas Namias, MD, MBA, Miami, Florida
Traumatic vascular injuries of the lower extremity in the pediatric population are rare but can result in significant morbidity. We aimed at describing our experience with such complex injuries, with associated patterns of injury, diagnostic and therapeutic challenges, and outcomes. METHODS: From January 2006 to December 2011, 2,844 pediatric trauma patients presented at the Ryder Trauma Center, an urban Level I trauma center in Miami, Florida. Among them, 18 patients (0.6%) were evaluated for lower extremity traumatic vascular injuries. Variables collected included age, sex, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: Mean (SD) age was T 14.7 (2.6) years (range, 6Y17 years), with 17 males (94.4%). Of the 18 traumatic pediatric patients, 32 vascular injuries were identified. All arterial injuries underwent definitive operative repair. Primary repair was performed in two patients (11.1%), six (33.3%) required saphenous vein interposition grafting as initial procedure, and eight (44.4%) underwent polytetrafluoroethylene grafting. Ligation was performed in major venous injuries and deep profunda branches. The overall survival in this series was 94.4%. CONCLUSION: Peripheral vascular injuries of the lower extremity in the pediatric population can result in acceptable outcomes if managed early and aggressively. Surgical principles of vascular surgery are similar to those applied to an adult. We recommend that these injuries should be managed in a tertiary specialized center with a multidisciplinary team of trauma surgeons, and pediatricians, which can potentially decrease morbidity and mortality. (J Trauma Acute Care Surg. 2014;76: 1386Y1389. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. KEY WORDS: Pediatric trauma; noniatrogenic vascular injury; pediatric vascular injury; peripheral vascular injury. BACKGROUND:
T
rauma remains the leading cause of death and disability for children older than 1 year in the United States.1,2 Vascular injury is a well-known cause of morbidity and mortality in adults, but it is encountered far less frequently in the pediatric population, even in Level 1 trauma centers, accounting for only 0.6% to 2% of all pediatric traumatic injuries.1,3 To date, most reports of vascular injury in children results from iatrogenic injuries after arterial or central venous catheterizations.1 In the trauma setting, management has traditionally been based on adult experience, but pediatric vascular injuries may differ from adults in that significant injuries are more difficult to detect because they are more commonly asymptomatic, are more associated with vasospasm, or have other more severe life-threatening injuries that take priority in the resuscitation process.4 The greatest concerns with vascular injuries in pediatric patients are restoration of sufficient circulation and future limb growth with vascular
Submitted: October 17, 2013, Revised: January 22, 2014, Accepted: January 22, 2014. From the Grand Strand Regional Medical Center (J.D.S.), Myrtle Beach, South Carolina; St John Hospital (F.I.B.M.), Southfield, Michigan; and Ryder Trauma Center (E.L.C., C.A.O., L.R.P., N.N.), Miami, Florida. Address for reprints: Jason Daniel Sciarretta, MD, 849 82nd Pkwy, Myrtle Bch, SC 29572 email: [email protected]. DOI: 10.1097/TA.0000000000000225
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repair. During the last decade, despite major advancements of angiography and contrast-enhanced studies, only a few series have reported clinical experience of such injuries.5,6 We aimed at demonstrating our experience with lower extremity traumatic vascular injury in the pediatric population, thereby focusing on initial management, surgical approach, associated complications, and outcomes.
PATIENTS AND METHODS Between January 1, 2006, and December 31, 2011, 2,844 pediatric trauma patients younger than 18 years presented to the Ryder Trauma Center, a Level I center in Miami, Florida. Among them, 18 (0.6%) were evaluated for lower extremity vascular injuries and were retrospectively included in this analysis. Institutional review board approval for this study was obtained, and the need for informed consent was waived. Data collected and analyzed included age, sex, type of injury, mechanism, clinical status on admission, diagnostic imaging, operative management, length of stay, and clinical outcome. All patients with iatrogenic injuries and/or 18 years or older were excluded from the study. Mean (SD) age was 14.7 (2.6) years (range, 6Y17 years), and the majority of patients were males (17 patients, 94.4%). Demographics and clinical data are summarized in Table 1. J Trauma Acute Care Surg Volume 76, Number 6
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J Trauma Acute Care Surg Volume 76, Number 6
Sciarretta et al.
TABLE 1. Patient Demographics Number Age at presentation, mean (SD) [range], y Sex Male Female Mechanism Penetrating Gunshot injury Blunt Motor vehicle collision Motorcycle collision Auto-pedestrian collision Crush injury ISS at presentation, mean (SD) [range] GCS score at presentation, mean (SD) [range] ICU stay, mean (SD) [range], d Hospital stay, mean (SD) [range], d Preoperative procedures Resuscitative thoracotomy CT angiogram Fasciotomy (four compartment) Calf Thigh Temporary tourniquets
Percentage
14.7 (2.6) [6Y17] 17 1
94.4 5.6
14
77.8
1 1 1 1 16.5 (0.2) [4Y50] 12.9 (4.4) [3Y15]
5.6 5.6 5.6 5.6
3.2 (2.4) [0Y9] 13.3 (11.1) [1Y39] 1 5 6 1* 2
*One patient had both thigh and calf fasciotomies.
Severe injury was categorically defined as an Injury Severity Score (ISS) of greater than 15. The results of specific diagnostic studies, including duplex ultrasonography, computed tomography (CT), and arteriography, were collected and correlated with physical examination. Classic ‘‘hard signs’’ of vascular compromise included pulsatile bleeding, absent or diminished pulses, expanding or pulsatile hematoma, presence of a bruit or palpable thrill, or signs of distal ischemia as demonstrated by the presence of pain, pallor, paresthesia, paralysis, and poikilothermia. Standard diagnostic studies, including radiographs of the lower extremity, were routinely performed when indicated to assess for bony fractures. Vascular injuries of the lower extremity consisted of vessels below the inguinal ligament and below the knee including arterial, venous, and/or combined injuries. Although injuries to the deep femoral vessels are typically not limb threatening, most of these injuries were accompanied with another vascular injury and were included in this study.
RESULTS The majority of the mechanisms of injury were secondary to penetrating injury (14 patients, 77.8%), all resulting from gunshot wounds. The remaining injuries (4 patients, 22.2%) were the result of blunt trauma, including a motor vehicle crash, a pedestrian hit by a moving vehicle, a motorcycle crash, and a crush injury. Regardless of the mechanism, 32 vessels had traumatic vascular injury. The mean (SD) ISS
was 16.5 (10.2) (range, 4Y50), and the mean (SD) Glasgow Coma Scale (GCS) score on admission was 12.9 (4.4) (range, 3Y15), with three patients having a GCS score of less than 8. On arrival, mean (SD) systolic blood pressure was 124.1 (40.3) mm Hg (range, 0Y190 mm Hg), mean (SD) blood pH was 7.36 (0.11) (range, 7.00Y7.43), mean (SD) base deficit on presentation was j4.8 (3.3) (range, 0 to j12), and mean (SD) hematocrit was 32.1 (4.3) (range, 29Y41). Classic signs of vascular compromise were present in 94.4% of the cases at presentation. The most common signs were absent or diminished distal pulses (17 patients, 94.4%), distal limb ischemia (11 patients, 61.1%), and hematoma formation (5 patients, 27.8%). Two patients presented with hemorrhagic shock, and one patient had a bruit and thrill in the lower extremity. Only one patient had an unremarkable physical examination result. Nine patients required blood transfusion during initial resuscitation, with a mean (SD) packed red blood cells given at 10.5 (9.5) U (range, 1Y28 U). Associated orthopedic injuries occurred in six patients (33.3%), including three distal femoral fractures (16%), two knee dislocations (11.1%), and one iliac apophyseal avulsion fracture (5.5%). In 13 cases (72.2%), physical examination alone based on the classical hard signs of vascular injury favored immediate surgical intervention, and no further diagnostic studies were performed. Preoperative CT angiogram was performed in five patients (27.8%). Indications included loss of pulses after orthopedic fixation, diminished distal pulses from admission, and expanding hematoma suggestive of infectious pseudoaneurysm on postoperative Day 40 after initial operation. The lower extremity vessels injured are listed in Table 2. The superficial femoral artery and vein were the most commonly injured vessels, followed by the popliteal and deep femoral vessels. Combined arterial and venous injuries occurred in seven patients (38.8%). Surgical interventions are summarized in Table 2. All arterial injuries underwent definitive operative repair. Primary repair was performed in two patients (11.1%) with partial transection of the common femoral artery and popliteal vein. Six patients (33.3%) required saphenous interposition grafting as initial procedure, and eight patients (44.4%) patients underwent polytetrafluoroethylene (PTFE) grafting. One patient developed PTFE graft infection and underwent revision with autogenous reverse saphenous vein graft from the common femoral to superficial femoral artery. Ligation was performed in major venous injuries and deep profunda branches (Table 2). Profunda artery and vein were ligated in five patients (27.8%), and the superficial and common femoral veins were ligated in three cases (16.7%) and two cases (11.1%), respectively. Emergent tourniquets and temporary intravascular shunts were used in two cases (11.1%) and one case (5.5%), respectively. Intraoperative heparin and arteriogram were used in 12 and 4 patients, respectively. Catheter thromboembolectomy was performed in seven patients with satisfactory results. Fasciotomy was required in six patients (33.3%), with one case of extensive fasciotomy including the thigh and calf. Nonoperative management was not performed in any of the vascular injured patients included in this analysis. Postoperative complications included deep vein thrombosis in two patients (11.1%), graft infection (1, 5.6%), and wound
* 2014 Lippincott Williams & Wilkins
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TABLE 2.
Lower Extremity Vascular Injuries and Surgical Repair
Injuries Common femoral artery With common femoral vein Superficial femoral artery With superficial femoral vein Deep femoral artery With deep femoral vein Popliteal Artery Vein Anterior tibial artery Posterior tibial artery Peroneal artery Types Partial transection Complete transection Contusion with thrombosis Pseudoaneurysm Intimal disruption Surgical procedures Lateral primary repair Autogenous saphenous grafting PTFE grafting Ligation Intraoperative arteriogram Temporary intravascular shunt Catheter embolectomy
Number
Percentage
1 2 5 3 2 2
3.1 6.2 15.6 9.3 6.2 6.2
4 2 1 1 1
12.5 6.2 3.1 3.1 3.1
12 16 2 1 1
37.5 50 6.3 3.1 3.1
Artery 1 7 8* 8 4 1 7
Vein 1 0 0 7 12.5 3.1 21.9
*One patient required revision with autogenous graft.
seroma (1, 5.5%). In 13 patients (72.2%), no postoperative complications were observed. Both cases of deep vein thrombosis were successfully treated with anticoagulation, and there were no cases of pulmonary embolism in this series. Long-term complications included neurologic deficits from nerve injury (3 patients, 16.7%) and soft tissue defects requiring muscle flap coverage (2 patients, 11.1%). Amputation was required in only one patient (5.5%) who presented after motorcycle crash with a distal tibial fracture and complete transection of the anterior tibial, posterior tibial, and peroneal arteries. This patient developed stump infection that required further operative revision. One patient underwent decompressive laparotomy for suspected intra-abdominal compartment syndrome on postoperative Day 3, and no ischemic findings were identified. The mean (SD) length of hospital and intensive care unit (ICU) stays were 13.3 (11.1) days (range, 1Y39 days) and 3.2 (2.4) days (range, 0Y9 days), respectively. The overall survival in this series was 94.4%; the only one patient who died presented after multiple gunshot wounds, with an ISS of 50, and underwent resuscitative thoracotomy in the emergency department with return of vital signs. He underwent exploratory laparotomy and PTFE grafting of the right common femoral artery with end-to-end anastomosis and, subsequently, died on postoperative Day 1. Cardiac arrest also occurred in one other patient 1388
in the operating room, but he survived and was discharged home without sequelae. Outpatient follow-up was available for 12 of the 17 surviving patients. The data available on length of follow-up available ranged from 35 days to 1,062 days after injury. Six patients returned to their normal function without sequelae, although three of them had diminished pulse examination results. Three patients had documented neurologic dysfunction including numbness or conduction abnormality on electromyogram. One patient developed a leg length discrepancy requiring orthopedic intervention. All 12 patients who were seen after discharge were eventually able to walk, including the patient who had received a below-the-knee amputation. Although there was one patient who required vascular revision for a late presentation of an infected pseudoaneurysm, there were no cases that required operative revision for arterial ischemia.
DISCUSSION Pediatric lower extremity vascular injuries are usually iatrogenic following catheterization or invasive monitoring.7 Pediatric peripheral vascular trauma is far less frequent, and there is a scarcity of reported experience for the management of such injuries. In this series, we encountered 32 vascular injuries in the lower extremity in 18 pediatric trauma patients with an incidence of 0.6%, which is consistent with previous studies.3 This series also confirmed higher likelihood of penetrating trauma as a cause of peripheral vascular injury in the pediatric population as compared with blunt trauma (77.8% vs. 22.2%, respectively).8 The initial and surgical managements are performed similarly to that of the adult population. Any bony fracture with diminished pulses prompted immediate reduction and vascular reassessment. The use of arteriography has been reported in the management of pediatric vascular injuries in few retrospective series.9 Although it is a relatively safe and infrequent procedure, angiography has been appropriate when indicated in the pediatric trauma population as demonstrated by previous reports.9,10 In this series, the majority of patients (94.4%) presented with obvious hard signs of vascular injury, which require immediate operation, and therefore, further diagnostic studies were limited. Additional diagnostic imaging was performed only for those patients with persistent pulse discrepancies and hemodynamic stability. CT angiograms were preferred in our institution compared with conventional angiography in the pediatric population as a noninvasive and readily available diagnostic tool.11 The role of therapeutic angiography in the pediatric population is yet unknown. The principles of vascular repair in adults are the same for pediatrics. If minimal vascular injury is present (define it), primary repair should include debridement of the devitalized. When primary repair is not feasible, the choice of conduit for reconstruction is of particular importance. Autologous grafts, such as reversed saphenous vein, are preferred and have demonstrated the best results.12 Synthetic conduits, such as PTFE graft, can also be successfully used; however, small diameter grafts have higher thrombosis rates with poor long-term patency.13 In our series, both synthetic and autologous grafts were used more commonly compared with primary repair (46.8% and * 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 76, Number 6
6.2%, respectively). Venous injuries were commonly ligated (21.9%) in those presenting with signs of shock, those with significant blood loss, those with combined vessel injury, or those not amendable to primary repair. This is partially caused by the unfortunate high incidence of high-powered weapons in neighboring communities, resulting in extensive vessel and tissue destruction, allowing primary repair as a less feasible option. Similar results were encountered in recent military data at a US combat support hospital with 75% incidence of penetrating injuries.14 No primary arterial repair was attempted, and 20% of the patients underwent venous ligation.14 Blunt mechanisms create more shear and traction-type injuries with injury to a greater length of the vessel, making it unsuitable for primary repair.15 We recommend repair of concomitant venous injuries whenever time permits and is particularly important for injuries to the common femoral vein and popliteal vein. Early amputation occurred more frequently in this military setting compared with our civilian cohort (16% vs. 5.5%, respectively), which also compares favorably between other civilian Level I trauma centers with 10.7% amputation rates.6 Interestingly, fasciotomy was more liberally undertaken in our series compared with the military cohort (38% vs. 28%, respectively).14 Factors contributing to delayed amputations may include delayed presentation, extensive injury, and failed revascularization of the extremity.15Y17 In contrast to the adult population, repair of all injured vessels is essential because there is a considerable risk for potentially skeletal growth retardation in pediatric trauma patients. Inadequate circulation may compromise the normal growth of the affected bones, leading to limb length discrepancies and long-term disability.18 Vascular anastomosis should be performed with interrupted sutures to accommodate growth patterns in children.18,19 Continuous suture repair may lead to arterial narrowing with progressive limb growth. Other differences include more frequent arterial spasms and potential for early thrombosis in the pediatric vascular trauma patient, and the use of intra-arterial vasodilators, such as papaverine or nitroglycerin, may be helpful.2 We acknowledge that our study has several important limitations. In addition to the retrospective design and relatively small number of patients, we were unable to analyze long-term outcomes, including mortality and limb-salvage survival. Further studies are needed to establish the long-term impact on lower extremity salvage in the pediatric trauma population. Functional long-term outcomes are needed to determine if the presence of arterial repair and concomitant vein ligation as short-term treatment shows increased morbidity. In conclusion, peripheral vascular injuries of the lower extremity in the pediatric population are rare but can result in significant morbidity. The management of such injury requires early identification and prompt surgical intervention and can result in acceptable early outcomes. Clinical management and vascular surgical principles applied to an adult should also be applied in children. Such complex lesions should be managed in tertiary specialized care centers with a multidisciplinary team involving trauma and pediatric surgeons as well as pediatricians, which can potentially decrease morbidity and mortality associated
Sciarretta et al.
with lower extremity vascular injuries in the pediatric trauma population. AUTHORSHIP J.D.S., F.I.B.M., C.A.O., L.R.P., and N.N. contributed to the creation of the manuscript and data/statistical analysis E.C. provided follow up research, tables.
DISCLOSURE The authors declare no conflicts of interest.
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