REVIEW ARTICLE
Venous injuries in pediatric trauma: Systematic review of injuries and management Simon Peter Rowland, MRCS (Eng), Brahman Dharmarajah, MRCS (Eng), Hayley M. Moore, MRCS (Eng), Katie Dharmarajah, MRCPCH, and Alun H. Davies, FRCS, London, United Kingdom
Diagnosis of vascular injury in pediatric trauma is challenging as clinical signs may be masked by physiologic compensation. We aimed to (1) investigate the prevalence of noniatrogenic pediatric venous injuries, (2) discuss options in management of traumatic venous injury, and (3) investigate mortality from venous injury in pediatric trauma. Our objective was to provide the practicing clinician with a summary of the published literature and to develop an evidence-based guide to the diagnosis and management of traumatic venous injuries in children. METHODS: A systematic review of published literature (PubMed) describing noniatrogenic traumatic venous injury in the pediatric population (G17 years) was performed according to PRISMA [Preferred Reporting Items for Systematic Reviews and MetaAnalyses] guidelines. Data were retrieved systematically under the following headings: Study Design, Population Demographics (dates of recruitment, mean age, mechanism of injury), Diagnostic Approach, Vessel Injured, Management (operative technique), and Mortality. RESULTS: Thirteen articles were included in this systematic review. In total, 508 noniatrogenic traumatic venous injuries were reported in children between the year 1957 and present day. Mechanisms of injury included blunt trauma from seat beltYrelated injury and fall from height or penetrating trauma from gunshot and foreign object. Injury to the inferior vena cava was most frequently reported, followed by femoral vein and internal jugular injuries. Primary repair was the most frequently reported technique for surgical repair (38%), followed by ligation (25%) and end-to-end anastomosis (15%). Mortality in pediatric trauma patients who had venous injury was reported as 0% to 67% in published series, highest in the series in which the most frequently reported injury was of the inferior vena cava. CONCLUSION: Traumatic venous injury in the pediatric population is uncommon but may be associated with significant morbidity and mortality. Intra-abdominal venous injuries are associated with high mortality from exsanguination. Early diagnosis and intervention are therefore essential in such cases. (J Trauma Acute Care Surg. 2014;77: 356Y363. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Systematic review, level IV. KEY WORDS: Pediatric trauma; venous injury; IVC injury. BACKGROUND:
T
rauma is the leading cause of childhood death in the developed world.1 Early recognition of injuries is essential to avoid significant morbidity and mortality.2 However, diagnosis can be challenging in pediatric trauma as symptoms and signs of internal injury may be masked by physiologic compensation. Clinicians must therefore have a high index of suspicion for associated injuries. Knowledge of likely patterns of injury and management options is essential. Vascular injury in pediatric trauma may be associated with significant morbidity and mortality from acute or delayed ischemia secondary to acute blood loss, arterial dissection,3 pseudoaneurysm,4,5 aneurysm,6 thrombosis,7,8 or fistula formation.9,10 There are a number of published series describing arterial injuries;11Y17 however, little is known about the distribution and Submitted: December 7, 2013, Revised: April 15, 2014, Accepted: April 18, 2014. From the Academic Section of Vascular Surgery (S.P.R., B.D., H.M.M., A.H.D.), Imperial College London (S.P.R.); and Department of Paediatrics (K.D.), Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom. This study was presented at the XVII World Meeting of the International Union of Phlebology, September 8Y13, 2013, Boston, Massachusetts. Address for reprints: Alun H. Davies, FRCS, Academic Section of Vascular Surgery, Imperial College London, 4 North, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK; email: [email protected]. DOI: 10.1097/TA.0000000000000312
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management of venous injuries in pediatric trauma. As a consequence, management of such injuries is rarely evidence based. We aimed to (1) investigate the prevalence of noniatrogenic pediatric venous injuries, (2) discuss options in management of traumatic venous injury, and (3) investigate mortality from venous injury in pediatric trauma. Our objective was to provide the practicing clinician with a summary of the published literature for these aims and to develop an evidencebased guide to the diagnosis and management of traumatic venous injuries in children.
PATIENTS AND METHODS A systematic review of the literature was conducted according to the PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] guidelines. We searched PubMed up until July 2013 with four search terms: paediatric venous trauma, pediatric venous trauma, paediatric vascular trauma, and pediatric vascular trauma. Two investigators independently assessed search results according to an agreed list of eligibility criteria. Reference lists were reviewed to identify additional articles. Articles were eligible for inclusion within the review if they described a case series of noniatrogenic extracranial venous injuries in individuals aged 1 year to 17 years written in English. We included all available case J Trauma Acute Care Surg Volume 77, Number 2
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series regardless of geographic location or injury setting. We excluded case reports, commentaries, and editorial articles. Case series describing iatrogenic injuries and trauma in infants (aged G 1 year) were also excluded, as were articles written in a language other than English. Digital venous injuries were excluded from analysis. Data were retrieved systematically under the following headings: Study Design, Population Demographics (dates of recruitment, mean age, mechanism of injury), Diagnostic Investigations, Vessel Injured, Management (operative technique), and Mortality. Two investigators assessed the methodological quality of each study using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool.18 The QUADAS-2 tool is recommended for use in systematic reviews to evaluate the risk of bias and applicability of primary diagnostic accuracy studies. Review-specific guidelines were developed locally for applicability of this tool, as recommended by published QUADAS-2 guidance notes. Because of the nature of the research question and the studies included within this review, the QUADAS-2 domain titled ‘‘Reference Standard’’ was omitted from our assessment process.
RESULTS Our search returned a total of 1,242 records (Fig. 1), which were reduced to 962 articles after removal of duplicates.
Following screening of titles and abstracts, there were 24 articles eligible for full-text review. After application of exclusion criteria, 13 studies were included for analysis (Table 1). Results of quality assessment using the QUADAS-2 tool are summarized in Figure 2. A quantitative summary analysis of the data extracted was not performed because of the significant heterogeneity of the articles included within this review.
Diagnosis of Venous Injuries in Pediatric Trauma Approaches to the diagnosis of venous injury in children differed according to the clinical picture at presentation. Hemodynamically unstable patients were highly likely to undergo early operative intervention without the use of other diagnostic modalities.20,21 Diagnosis was therefore made at laparotomy. In hemodynamically stable individuals, including those with clinical signs of arterial injury, there was variation in approach to diagnosis. Meagher et al.21 reported the earliest series of venous injuries included within this review. In this series, diagnosis was clinical, and there was a low threshold for surgical intervention. Preoperative angiography was rarely used. A similar approach was seen in a series reported by Goz et al.,30 in which only 6.8% underwent angiography; however, traditional angiography has been used to investigate suspected vascular injury in as many as 36% of cases in some series.26 In modern series, there has been a shift toward the use of radiologic investigations in hemodynamically stable individuals with suspected vascular injury. Hamner et al.20 reported that, of patients with confirmed vascular injury after blunt abdominal trauma, 70.1% had undergone preoperative imaging using computed tomography (CT), 25.4% had undergone CT and diagnostic peritoneal lavage, 3% had undergone only diagnostic peritoneal lavage, and ultrasound had been used in one patient. In a recent series, CT angiography (CTA) was the preferred diagnostic modality.28 Ultrasound and duplex investigations have been used to identify suspected vascular injury for individual patients;20,26 however, further imaging was subsequently required for definitive diagnosis.
Distribution of Venous Injuries in Pediatric Trauma
Figure 1. PRISMA literature review results.
In a review of vascular injuries recorded with the American College of Surgeons National Trauma Data Bank (NTDB) between the years 2002 and 2006, Barmparas et al.19 reported a total of 260 traumatic pediatric venous injuries. There were slightly more penetrating injuries (55.4%) compared with blunt injuries (44.6%). The inferior vena cava (IVC) was the most commonly injured vessel, making up 25% of all venous injuries. Most IVC injuries occurred in the 11-year to 16-year age group. There were 54 (20.8%) internal jugular, 40 (15.4%) femoral vein, and 22 (8.5%) hepatic vein injuries reported. Less frequently injured were the mesenteric veins (5.8%), the superior vena cava (5.8%), the saphenous vein (5.4%), the popliteal vein (5.4%), the portal vein (5.0%), and the splenic vein (1.9%). In a separate review of the NTDB, Hamner et al.20 summarized traumatic blunt abdominal injuries between the years 2000 and 2004. Venous injury was present in 13.6% of patients with concurrent arterial injury. There were 16 venous injuries in 14 patients, with the portal vein (56.3% of all injuries) most frequently injured. IVC injury occurred in 3 cases
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American College of Surgeons NTDB American College of Surgeons NTDB Retrospective cohort, Texas, US Retrospective cohort
Article Description
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Retrospective cohort Retrospective cohort study truncal injuries Retrospective cohort Retrospective cohort Retrospective cohort
NS, not specified.
Klinkner et al.31
Goz et al.30
Cox et al.29
Allison et al.28
Eren et al.27
32
1957Y1977
27 15
1995Y2008
1984Y1994
1993Y2005
1985Y2004
1986Y1996
1997Y2006
21
25
21
11
39
24
1976Y1993
1978Y1988
11
1988Y1989
6
16
2000Y2004
1985Y1988
260
2002Y2006
NS
NS
NS
NS
NS
NS
NS
NS
14.3
14
NS
8.6
NS
NS
0%
NS
NS
NS
NS
NS
100%
0%
0%
NS
NS
44.62%
NS
0%
NS
NS
NS
NS
NS
0%
0%
33.30%
NS
NS
55.38%
NS
100.00%
NS
NS
NS
NS
NS
0%
100.00%
66.60%
NS
NS
NS
Mean Age of Venous Injury Venous Injury Venous Injury Patient No. Venous Patients With Mechanism: Mechanism: Mechanism: Recruitment Injuries Venous Injuries, y Blunt Penetrating Gunshot
Demographics, Injuries, and Management of Traumatic Pediatric Venous Injuries
Schnitzer and Retrospective cohort Fitzgerald23 lower limb plastic bullet injuries Fayiga et al.24 Retrospective cohort Corneille Retrospective et al.25 cohort de Virgilio Retrospective et al.26 cohort
Myers et al.22
Meagher et al.21
Hamner et al.20
Barmparas et al.19
Author
TABLE 1.
End-to-end anastomosis (48.7%) NS
Primary repair (53.3%)
Primary repair (68.8%)
NS
Primary repair/lateral suture/ligation (33.3% each) Primary repair (54.5%)
Primary repair (71.9%)
NS
NS
Most Common Repair Technique
IVC (28.6%)/iliac Lateral repair/end-to-end vein (28.6%) anastomosis Femoral vein Saphenous vein (44%) graft (56%) Femoral vein Primary repair (52.4%) (28.6%)
Superficial femoral vein (27%) Femoral vein (33.3%) Neck veins (45.5%)
IVC (44.4%)
IVC (37.5%)
Femoral vein (90.9%)
Brachial vein (33.3%)
IVC (25%)
Portal vein (56.3%)
IVC (25%)
Most Common Vessel Injured
14%
0%
0%
NS
NS
NS
41%
67%
0%
0%
9.40%
67% IVC injury, 44% portal vein injury
NS
Mortality
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Figure 2. A, Risk of bias according to adapted QUADAS-2 assessment. B, Concerns for applicability according to adapted QUADAS-2 assessment.
(18.8%). There were 11 retrospective case series identified describing 232 noniatrogenic traumatic pediatric venous injuries occurring between the years 1957 and 2008 (Table 1). The IVC was again the most common venous injury, followed by femoral and popliteal vein injuries. Figure 3 summarizes the distribution of traumatic venous injuries reported in published literature.
Management of Venous Injuries in Pediatric Trauma In a series by Klinkner et al.,31 vascular injuries as a whole were managed predominantly by adult surgical specialists (70.9%), with pediatric surgeons managing a small proportion of injuries (29.1%). However, in one series, pediatric surgeons did not have a role in the management of pediatric venous injuries.25 Data regarding the specialist interest of surgeons responsible for the management of traumatic venous injuries in children were not available in other series. Nonoperative management of traumatic venous injury was rarely advocated; however, de Virgilio et al.26 did report a conservative approach for patients with the established thrombosis. Operative intervention was preferred, especially when there was evidence of concurrent arterial injury.27 In a series by Goz et al.,30 24 of 25 venous injuries were surgically repaired. Early intervention was commonly advocated; indeed, Cox et al.29 reported a mean time of only 43 minutes from clinical presentation to operative intervention. Although methods of control of bleeding were not described, Eren et al.27 highlighted the importance of replacing blood loss before surgical intervention. Expectant management was required in only 1% of reported cases. These cases involved significant retrohepatic IVC or hepatic vein injuries.25 Figure 4 summarizes techniques used in the surgical repair of all reported traumatic venous injuries, regardless of location. In open surgical repair, primary repair was the most frequently reported technique (38% of cases), followed by ligation (25%), end-to-end anastomosis (15%), saphenous vein interposition grafting (13%), and lateral repair (7%). Amputation was required in only 1% of cases due to late presentation.27 Corneille et al.25 reported that shear-type injuries, typically sustained from blunt trauma, were less likely to be suitable for primary repair than injuries sustained from penetrating trauma. Two centimeters was considered to be the maximum discrepancy for repair using end-to-end anastomosis.27 Where end-
to-end anastomosis was performed, absorbable interrupted sutures were the preferred technique for repair to allow for vessel growth.22,27,30 Eren et al.27 and Goz et al.30 reported surgical techniques specifically for repair of traumatic limb vein injury. Primary repair was not reported in limb vein repair. Ligation was the preferred technique for repair of injuries to the anterior and posterior tibial veins. End-to-end anastomosis and saphenous vein grafting were frequently used techniques for repair of major limb veins. Table 2 summarizes operative techniques used specifically for the repair of traumatic limb vein injuries in children. In cases of concurrent arterial injury, the vein was repaired first to reduce both venous and tissue compartment pressures and ensure adequate runoff following arterial repair.22,27,30 Injuries to the subclavian vein, the retrohepatic IVC, and the internal jugular vein were identified as technically challenging. Subclavian vein injury may be approached via a median sternotomy incision with supraclavicular extension;28 however, there are limited data to describe the success of this technique. Surgical approaches for other traumatic venous injuries
Figure 3. Distribution of traumatic venous injuries reported in published literature.
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were also found to have a high mortality rate, with 100% nonsurvival in those who were hemodynamically unstable at presentation.29 Fayiga et al.24 reported a mortality rate of more than 60% in those with abdominal venous injury and found that patients were more likely to die of exsanguinating venous injury than associated visceral injury. Following an analysis of pediatric trauma outcomes from cases included in the NTDB between the years 2000 and 2004, Hamner et al.20 found that the presence of any intra-abdominal venous injury may increase the risk for death by more than three times compared with patients with isolated arterial injury (relative risk, 3.5; p = 0.001). Similarly, in a retrospective series by Corneille et al.25 capturing traumatic vascular injuries in Texas, United States, between the years 1995 and 2008, the presence of any major venous injury was associated with a sevenfold increase in mortality rates (odds ratio, 7.25; p G 0.001).
DISCUSSION
Figure 4. Techniques used in the surgical repair of traumatic venous injuries.
were not described. Retrohepatic IVC injuries required packing and delayed repair to achieve successful outcomes.29 There is some evidence to suggest that injury to the internal jugular vein may be managed through ligation.22,24 There was a paucity of evidence to describe the optimal management of these challenging injuries. There were no reports of endovascular approach for repair of traumatic venous injuries.
Mortality Associated With Venous Injury in Pediatric Trauma Mortality in pediatric trauma patients who had venous injury was reported as 0% to 67% in published series (Table 1). Poor surgical access, blunt mechanism of injury (shearing mechanism), delayed diagnosis, and concurrent head injury were identified as poor prognostic signs.28 Mortality was highest in the series in which the most frequently reported injury was of the IVC. Cox et al.29 reported a mortality rate of 64% in those with IVC injury who were hemodynamically unstable and 36% in those who were stable at presentation. Hepatic vein injuries
To our knowledge, this is the first systematic review of the epidemiology and management of noniatrogenic venous injuries in pediatric trauma. Our search identified 13 articles describing venous injury in pediatric trauma, including 3 formal reviews of the American College of Surgeons NTDB and 10 retrospective cohort studies. Venous injury is often described in the context of other traumatic injuries, and, as a consequence, there is a paucity of data describing clinical presentation, mechanism of injury, and diagnostic techniques. In total, there were 508 venous injuries described, most commonly with concurrent arterial injury. IVC injury was the most frequently reported venous injury in pediatric trauma. Primary repair was, overall, the most commonly used management option, although this differed according to the site of injury. Mortality associated with venous injury was highly variable; however, there is statistically significant evidence that the presence of intra-abdominal venous injury is associated with higher mortality rates in pediatric trauma. Diagnosis of venous injury in pediatric trauma is challenging as physiologic compensation will often mask the signs of blood loss.20,29 This may be the case even in the presence of injury to major veins.28 The presence of additional injuries may further cloud the diagnosis. In some instances, mechanism of injury may prompt a high level of clinical suspicion. For example, seat belt injury has been directly associated with IVC injury.32 However, our findings suggest that a wide range of injuries, both penetrating and blunt mechanism, may lead to
TABLE 2. Techniques Used for Surgical Repair of Major Limb Venous Injuries in Pediatric Trauma Axillary vein Brachial vein Cephalic vein Basilic vein Femoral vein Popliteal vein Anterior tibial vein Posterior tibial vein
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Primary Repair
Lateral Repair
Ligation
End-to-End Anastomosis
Saphenous Vein Interposition Graft
0% 0% 0% 0% 0% 0% 0% 0%
12.50% 0% 0% 0% 20.80% 25% 0% 0%
12.50% 11.10% 66.60% 20% 0% 0% 100% 100%
37.50% 55.60% 33.30% 20% 45.80% 31.30% 0% 0%
37.50% 33.30% 0% 60% 66.60% 43.80% 0% 0%
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significant venous injury. A high index of clinical suspicion is therefore required along with judicious use of specialist diagnostic tests. Clinical imaging techniques such as ultrasound, CT,33 CTA, traditional angiography, and digital subtraction angiography34 may be used as diagnostic aids; however, interpretation of results for clinical decision making may be difficult. In modern health care, CTA is often the first choice investigation35 and may show contrast blush in cases of vascular injury. In such cases, surgical intervention may often be necessary.29,30,36
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Novel imaging modalities such as multidetector CT scanning may be preferred to conventional imaging modalities in the future assessment of pediatric vascular trauma.37 This review of the literature has identified a significant trend toward increased morbidity and mortality in cases in which there is delayed diagnosis. Therefore, it is crucially important that, in each case, the risks associated with delay in definitive management must be carefully weighed against the benefits of imaging.
Figure 5. Evidence-based recommendations for management of venous injuries in children. * 2014 Lippincott Williams & Wilkins
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Our review found that abdominal venous injuries were associated with the highest rates of mortality. Such injuries are often sustained in conjunction with life-threatening visceral injury; however, data suggest that mortality is often from fatal hemorrhage earlier than from visceral injury alone.20,24,29 Surgeons should therefore consider early surgical intervention in all such cases and should be mindful that a delay in definitive management may have a detrimental effect on survival rates. Surgical repair of venous injury in children requires specialist surgical technique, instruments, and perioperative support. Our review has demonstrated a general consensus that interrupted sutures should be used for primary repair of venous injuries in children to allow for growth in later life.22,25,27,30 It has also been identified that vascular injuries suitable for grafting in adults may require a different approach in children and that synthetic grafts are generally unsuitable for venous repair in younger children.20,25,30,31 Pediatric venous injuries should ideally be managed in an established pediatric trauma center to optimize patient outcomes.38 Figure 5 summarizes lessons learned from this review of the literature and describes an evidence-based approach to the diagnosis and management of venous injuries in pediatric trauma. As part of the development of this protocol, there was formal discussion of evidence-based recommendations extracted from articles included within this review. A panel of practicing clinicians drawn from vascular and trauma surgery, vascular research, pediatric surgery, and pediatric medicine subsequently agreed on a recommended management strategy (Fig. 5). We aim to validate our approach through prospective data collection and formal review of clinical outcomes. Development of evidence-based management protocol is challenging given the paucity of high-quality evidence available. The studies included within this review capture pediatric venous injuries covering a significant period in which diagnostic and therapeutic technologies have evolved in a major way.22,33,37 Direct comparison of outcomes from currently available series is therefore not an ideal method for development of evidence-based management protocol. In addition, the degree of underreporting of injuries and publication bias is unclear. Anecdotally, there has been a shift in recent years toward a trial of conservative management in carefully selected cases; however, this trend is not reflected in the literature. Continuing developments in modern imaging technologies are changing the spectrum of injuries detected, and, as a consequence, decision making is an increasingly challenging task for acute care trauma surgeons. Although there is currently a paucity of evidence for conservative management of traumatic childhood venous injuries, there are reported instances in which this approach has been successful.26 To overcome these biases and to gather sufficient data for development of evidencebased management protocol, well-maintained national trauma registries should be developed worldwide.39
CONCLUSION Venous injury in pediatric trauma may be associated with significant morbidity and mortality due to delayed diagnosis and significant variation in management. Data regarding diagnosis and management are highly heterogeneous. Intra362
abdominal venous injuries, particularly those to the IVC and hepatic veins, are associated with high mortality from exsanguination. Early intervention is therefore essential in such cases. In cases of traumatic limb vein injury, ligation, end-to-end anastomosis, or saphenous vein grafting are the preferred techniques for repair, whereas primary repair is generally not recommended. There is a paucity of evidence describing the diagnosis and management of traumatic venous injuries in children, and thus, we recommend that worldwide national trauma registries should be developed to allow development of evidence-based management protocol to optimize patient outcomes. AUTHORSHIP S.P.R. performed the literature search and drafted the manuscript. B.D. repeated the literature search and helped in drafting the manuscript. H.M.M. helped draft the manuscript and was involved in critical review. K.D. collected manuscripts and was involved in critical review. A.H.D. supervised the review process, gave advice regarding manuscript structure, and performed critical review of the completed manuscript.
ACKNOWLEDGMENT We thank Ms. Louise Adamson, MRCS, Specialist Registrar in Paediatric Surgery, for her role in reviewing this manuscript.
DISCLOSURE The authors declare no conflicts of interest.
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treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res. 2010;5:25. Stanford JR, Evans WE, Morse TS. Pediatric arterial injuries. Angiology. 1976;27(1):1Y7. Richardson JD, Fallat M, Nagaraj HS, Groff DB, Flint LM. Arterial injuries in children. Arch Surg. 1981;116(5):685Y690. Evans WE, King DR, Hayes JP. Arterial trauma in children: diagnosis and management. Ann Vasc Surg. 1988;2(3):268Y270. Wolf YG, Reyna T, Schropp KP, Harmel RP. Arterial trauma of the upper extremity in children. J Trauma. 1990;30(7):903Y905. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529Y536. 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(7):1404Y1412. Hamner CE, Groner JI, Caniano DA, Hayes JR, Kenney BD. Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome. J Pediatr Surg. 2008;43(5):916Y923. Meagher DP Jr, Defore WW, Mattox KL, Harberg FJ. Vascular trauma in infants and children. J Trauma. 1979;19(7):532Y536. Myers SI, Reed MK, Black CT, Burkhalter KJ, Lowry PA. Noniatrogenic pediatric vascular trauma. J Vasc Surg. 1989;10(3):258Y265. Schnitzer JJ, Fitzgerald D. Peripheral vascular injuries from plastic bullets in children. Surg Gynecol Obstet. 1993;176(2):172Y174. Fayiga YJ, Valentine RJ, Myers SI, Chervu A, Rossi PJ, Clagett GP. Blunt pediatric vascular trauma: analysis of forty-one consecutive patients undergoing operative intervention. J Vasc Surg. 1994;20(3):419Y424; discussion 424Y425. 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(4):823Y828. 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(9):781Y784. Eren N, Ozgen G, Ener BK, Solak H, Furtun K. Peripheral vascular injuries in children. J Pediatr Surg. 1991;26(10):1164Y1168.
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28. Allison ND, Anderson CM, Shah SK, Lally KP, Hayes-Jordan A, Tsao KJ, et al. Outcomes of truncal vascular injuries in children. J Pediatr Surg. 2009;44(10):1958Y1964. 29. Cox CS Jr, Black CT, Duke JH, Cocanour CS, Moore FA, Lally KP, et al. Operative treatment of truncal vascular injuries in children and adolescents. J Pediatr Surg. 1998;33(3):462Y467. 30. Goz M, Cakir O, Eren N. Peripheral vascular injuries due to firearms in children. Eur J Vasc Endovasc Surg. 2006;32(6):690Y695. 31. Klinkner DB, Arca MJ, Lewis BD, Oldham KT, Sato TT. Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Pediatr Surg. 2007; 42(1):178Y182; discussion 182Y183. 32. DeCou JM, Abrams RS, Gauderer MW. Seat-belt transection of the pararenal vena cava in a 5-year-old child: survival with caval ligation. J Pediatr Surg. 1999;34(7):1074Y1076. 33. Patel RP, Hernanz-Schulman M, Hilmes MA, Yu C, Ray J, Kan JH. Pediatric chest CT after trauma: impact on surgical and clinical management. Pediatr Radiol. 2010;40(7):1246Y1253. 34. Soares G, Ibarra R, Ferral H. Abdominal aortic injury in a child: intravenous digital subtraction angiogram (IVDSA) for the diagnosis of pediatric vascular trauma. Pediatr Radiol. 2003;33(8):563Y566. 35. Hogan AR, Lineen EB, Perez EA, Neville HL, Thompson WR, Sola JE. Value of computed tomographic angiography in neck and extremity pediatric vascular trauma. J Pediatr Surg. 2009;44(6):1236Y1241; discussion 1241. 36. Cox CS Jr, Geiger JD, Liu DC, Garver K. Pediatric blunt abdominal trauma: role of computed tomography vascular blush. J Pediatr Surg. 1997;32(8):1196Y1200. 37. Oguz B, Karcaaltincaba M, Hazirolan T, Leblecioglu G, Haliloglu M. Pediatric extremity multidetector computed tomographic angiography findings. J Comput Assist Tomogr. 2009;33(5):770Y775. 38. Wang NE, Saynina O, Vogel LD, Newgard CD, Bhattacharya J, Phibbs CS. The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011. J Trauma Acute Care Surg. 2013;75(4): 704Y716. 39. Condello AS, Hancock BJ, Hoppensack M, Tenenbein M, Stewart TC, Kirwin D, et al. Pediatric trauma registries: the foundation of quality care. J Pediatr Surg. 2001;36(5):685Y689.
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Venous injuries in pediatric trauma: Systematic review of injuries and management Simon Peter Rowland, MRCS (Eng), Brahman Dharmarajah, MRCS (Eng), Hayley M. Moore, MRCS (Eng), Katie Dharmarajah, MRCPCH, and Alun H. Davies, FRCS, London, United Kingdom
Diagnosis of vascular injury in pediatric trauma is challenging as clinical signs may be masked by physiologic compensation. We aimed to (1) investigate the prevalence of noniatrogenic pediatric venous injuries, (2) discuss options in management of traumatic venous injury, and (3) investigate mortality from venous injury in pediatric trauma. Our objective was to provide the practicing clinician with a summary of the published literature and to develop an evidence-based guide to the diagnosis and management of traumatic venous injuries in children. METHODS: A systematic review of published literature (PubMed) describing noniatrogenic traumatic venous injury in the pediatric population (G17 years) was performed according to PRISMA [Preferred Reporting Items for Systematic Reviews and MetaAnalyses] guidelines. Data were retrieved systematically under the following headings: Study Design, Population Demographics (dates of recruitment, mean age, mechanism of injury), Diagnostic Approach, Vessel Injured, Management (operative technique), and Mortality. RESULTS: Thirteen articles were included in this systematic review. In total, 508 noniatrogenic traumatic venous injuries were reported in children between the year 1957 and present day. Mechanisms of injury included blunt trauma from seat beltYrelated injury and fall from height or penetrating trauma from gunshot and foreign object. Injury to the inferior vena cava was most frequently reported, followed by femoral vein and internal jugular injuries. Primary repair was the most frequently reported technique for surgical repair (38%), followed by ligation (25%) and end-to-end anastomosis (15%). Mortality in pediatric trauma patients who had venous injury was reported as 0% to 67% in published series, highest in the series in which the most frequently reported injury was of the inferior vena cava. CONCLUSION: Traumatic venous injury in the pediatric population is uncommon but may be associated with significant morbidity and mortality. Intra-abdominal venous injuries are associated with high mortality from exsanguination. Early diagnosis and intervention are therefore essential in such cases. (J Trauma Acute Care Surg. 2014;77: 356Y363. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Systematic review, level IV. KEY WORDS: Pediatric trauma; venous injury; IVC injury. BACKGROUND:
T
rauma is the leading cause of childhood death in the developed world.1 Early recognition of injuries is essential to avoid significant morbidity and mortality.2 However, diagnosis can be challenging in pediatric trauma as symptoms and signs of internal injury may be masked by physiologic compensation. Clinicians must therefore have a high index of suspicion for associated injuries. Knowledge of likely patterns of injury and management options is essential. Vascular injury in pediatric trauma may be associated with significant morbidity and mortality from acute or delayed ischemia secondary to acute blood loss, arterial dissection,3 pseudoaneurysm,4,5 aneurysm,6 thrombosis,7,8 or fistula formation.9,10 There are a number of published series describing arterial injuries;11Y17 however, little is known about the distribution and Submitted: December 7, 2013, Revised: April 15, 2014, Accepted: April 18, 2014. From the Academic Section of Vascular Surgery (S.P.R., B.D., H.M.M., A.H.D.), Imperial College London (S.P.R.); and Department of Paediatrics (K.D.), Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom. This study was presented at the XVII World Meeting of the International Union of Phlebology, September 8Y13, 2013, Boston, Massachusetts. Address for reprints: Alun H. Davies, FRCS, Academic Section of Vascular Surgery, Imperial College London, 4 North, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK; email: [email protected]. DOI: 10.1097/TA.0000000000000312
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management of venous injuries in pediatric trauma. As a consequence, management of such injuries is rarely evidence based. We aimed to (1) investigate the prevalence of noniatrogenic pediatric venous injuries, (2) discuss options in management of traumatic venous injury, and (3) investigate mortality from venous injury in pediatric trauma. Our objective was to provide the practicing clinician with a summary of the published literature for these aims and to develop an evidencebased guide to the diagnosis and management of traumatic venous injuries in children.
PATIENTS AND METHODS A systematic review of the literature was conducted according to the PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] guidelines. We searched PubMed up until July 2013 with four search terms: paediatric venous trauma, pediatric venous trauma, paediatric vascular trauma, and pediatric vascular trauma. Two investigators independently assessed search results according to an agreed list of eligibility criteria. Reference lists were reviewed to identify additional articles. Articles were eligible for inclusion within the review if they described a case series of noniatrogenic extracranial venous injuries in individuals aged 1 year to 17 years written in English. We included all available case J Trauma Acute Care Surg Volume 77, Number 2
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series regardless of geographic location or injury setting. We excluded case reports, commentaries, and editorial articles. Case series describing iatrogenic injuries and trauma in infants (aged G 1 year) were also excluded, as were articles written in a language other than English. Digital venous injuries were excluded from analysis. Data were retrieved systematically under the following headings: Study Design, Population Demographics (dates of recruitment, mean age, mechanism of injury), Diagnostic Investigations, Vessel Injured, Management (operative technique), and Mortality. Two investigators assessed the methodological quality of each study using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool.18 The QUADAS-2 tool is recommended for use in systematic reviews to evaluate the risk of bias and applicability of primary diagnostic accuracy studies. Review-specific guidelines were developed locally for applicability of this tool, as recommended by published QUADAS-2 guidance notes. Because of the nature of the research question and the studies included within this review, the QUADAS-2 domain titled ‘‘Reference Standard’’ was omitted from our assessment process.
RESULTS Our search returned a total of 1,242 records (Fig. 1), which were reduced to 962 articles after removal of duplicates.
Following screening of titles and abstracts, there were 24 articles eligible for full-text review. After application of exclusion criteria, 13 studies were included for analysis (Table 1). Results of quality assessment using the QUADAS-2 tool are summarized in Figure 2. A quantitative summary analysis of the data extracted was not performed because of the significant heterogeneity of the articles included within this review.
Diagnosis of Venous Injuries in Pediatric Trauma Approaches to the diagnosis of venous injury in children differed according to the clinical picture at presentation. Hemodynamically unstable patients were highly likely to undergo early operative intervention without the use of other diagnostic modalities.20,21 Diagnosis was therefore made at laparotomy. In hemodynamically stable individuals, including those with clinical signs of arterial injury, there was variation in approach to diagnosis. Meagher et al.21 reported the earliest series of venous injuries included within this review. In this series, diagnosis was clinical, and there was a low threshold for surgical intervention. Preoperative angiography was rarely used. A similar approach was seen in a series reported by Goz et al.,30 in which only 6.8% underwent angiography; however, traditional angiography has been used to investigate suspected vascular injury in as many as 36% of cases in some series.26 In modern series, there has been a shift toward the use of radiologic investigations in hemodynamically stable individuals with suspected vascular injury. Hamner et al.20 reported that, of patients with confirmed vascular injury after blunt abdominal trauma, 70.1% had undergone preoperative imaging using computed tomography (CT), 25.4% had undergone CT and diagnostic peritoneal lavage, 3% had undergone only diagnostic peritoneal lavage, and ultrasound had been used in one patient. In a recent series, CT angiography (CTA) was the preferred diagnostic modality.28 Ultrasound and duplex investigations have been used to identify suspected vascular injury for individual patients;20,26 however, further imaging was subsequently required for definitive diagnosis.
Distribution of Venous Injuries in Pediatric Trauma
Figure 1. PRISMA literature review results.
In a review of vascular injuries recorded with the American College of Surgeons National Trauma Data Bank (NTDB) between the years 2002 and 2006, Barmparas et al.19 reported a total of 260 traumatic pediatric venous injuries. There were slightly more penetrating injuries (55.4%) compared with blunt injuries (44.6%). The inferior vena cava (IVC) was the most commonly injured vessel, making up 25% of all venous injuries. Most IVC injuries occurred in the 11-year to 16-year age group. There were 54 (20.8%) internal jugular, 40 (15.4%) femoral vein, and 22 (8.5%) hepatic vein injuries reported. Less frequently injured were the mesenteric veins (5.8%), the superior vena cava (5.8%), the saphenous vein (5.4%), the popliteal vein (5.4%), the portal vein (5.0%), and the splenic vein (1.9%). In a separate review of the NTDB, Hamner et al.20 summarized traumatic blunt abdominal injuries between the years 2000 and 2004. Venous injury was present in 13.6% of patients with concurrent arterial injury. There were 16 venous injuries in 14 patients, with the portal vein (56.3% of all injuries) most frequently injured. IVC injury occurred in 3 cases
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American College of Surgeons NTDB American College of Surgeons NTDB Retrospective cohort, Texas, US Retrospective cohort
Article Description
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Retrospective cohort Retrospective cohort study truncal injuries Retrospective cohort Retrospective cohort Retrospective cohort
NS, not specified.
Klinkner et al.31
Goz et al.30
Cox et al.29
Allison et al.28
Eren et al.27
32
1957Y1977
27 15
1995Y2008
1984Y1994
1993Y2005
1985Y2004
1986Y1996
1997Y2006
21
25
21
11
39
24
1976Y1993
1978Y1988
11
1988Y1989
6
16
2000Y2004
1985Y1988
260
2002Y2006
NS
NS
NS
NS
NS
NS
NS
NS
14.3
14
NS
8.6
NS
NS
0%
NS
NS
NS
NS
NS
100%
0%
0%
NS
NS
44.62%
NS
0%
NS
NS
NS
NS
NS
0%
0%
33.30%
NS
NS
55.38%
NS
100.00%
NS
NS
NS
NS
NS
0%
100.00%
66.60%
NS
NS
NS
Mean Age of Venous Injury Venous Injury Venous Injury Patient No. Venous Patients With Mechanism: Mechanism: Mechanism: Recruitment Injuries Venous Injuries, y Blunt Penetrating Gunshot
Demographics, Injuries, and Management of Traumatic Pediatric Venous Injuries
Schnitzer and Retrospective cohort Fitzgerald23 lower limb plastic bullet injuries Fayiga et al.24 Retrospective cohort Corneille Retrospective et al.25 cohort de Virgilio Retrospective et al.26 cohort
Myers et al.22
Meagher et al.21
Hamner et al.20
Barmparas et al.19
Author
TABLE 1.
End-to-end anastomosis (48.7%) NS
Primary repair (53.3%)
Primary repair (68.8%)
NS
Primary repair/lateral suture/ligation (33.3% each) Primary repair (54.5%)
Primary repair (71.9%)
NS
NS
Most Common Repair Technique
IVC (28.6%)/iliac Lateral repair/end-to-end vein (28.6%) anastomosis Femoral vein Saphenous vein (44%) graft (56%) Femoral vein Primary repair (52.4%) (28.6%)
Superficial femoral vein (27%) Femoral vein (33.3%) Neck veins (45.5%)
IVC (44.4%)
IVC (37.5%)
Femoral vein (90.9%)
Brachial vein (33.3%)
IVC (25%)
Portal vein (56.3%)
IVC (25%)
Most Common Vessel Injured
14%
0%
0%
NS
NS
NS
41%
67%
0%
0%
9.40%
67% IVC injury, 44% portal vein injury
NS
Mortality
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Figure 2. A, Risk of bias according to adapted QUADAS-2 assessment. B, Concerns for applicability according to adapted QUADAS-2 assessment.
(18.8%). There were 11 retrospective case series identified describing 232 noniatrogenic traumatic pediatric venous injuries occurring between the years 1957 and 2008 (Table 1). The IVC was again the most common venous injury, followed by femoral and popliteal vein injuries. Figure 3 summarizes the distribution of traumatic venous injuries reported in published literature.
Management of Venous Injuries in Pediatric Trauma In a series by Klinkner et al.,31 vascular injuries as a whole were managed predominantly by adult surgical specialists (70.9%), with pediatric surgeons managing a small proportion of injuries (29.1%). However, in one series, pediatric surgeons did not have a role in the management of pediatric venous injuries.25 Data regarding the specialist interest of surgeons responsible for the management of traumatic venous injuries in children were not available in other series. Nonoperative management of traumatic venous injury was rarely advocated; however, de Virgilio et al.26 did report a conservative approach for patients with the established thrombosis. Operative intervention was preferred, especially when there was evidence of concurrent arterial injury.27 In a series by Goz et al.,30 24 of 25 venous injuries were surgically repaired. Early intervention was commonly advocated; indeed, Cox et al.29 reported a mean time of only 43 minutes from clinical presentation to operative intervention. Although methods of control of bleeding were not described, Eren et al.27 highlighted the importance of replacing blood loss before surgical intervention. Expectant management was required in only 1% of reported cases. These cases involved significant retrohepatic IVC or hepatic vein injuries.25 Figure 4 summarizes techniques used in the surgical repair of all reported traumatic venous injuries, regardless of location. In open surgical repair, primary repair was the most frequently reported technique (38% of cases), followed by ligation (25%), end-to-end anastomosis (15%), saphenous vein interposition grafting (13%), and lateral repair (7%). Amputation was required in only 1% of cases due to late presentation.27 Corneille et al.25 reported that shear-type injuries, typically sustained from blunt trauma, were less likely to be suitable for primary repair than injuries sustained from penetrating trauma. Two centimeters was considered to be the maximum discrepancy for repair using end-to-end anastomosis.27 Where end-
to-end anastomosis was performed, absorbable interrupted sutures were the preferred technique for repair to allow for vessel growth.22,27,30 Eren et al.27 and Goz et al.30 reported surgical techniques specifically for repair of traumatic limb vein injury. Primary repair was not reported in limb vein repair. Ligation was the preferred technique for repair of injuries to the anterior and posterior tibial veins. End-to-end anastomosis and saphenous vein grafting were frequently used techniques for repair of major limb veins. Table 2 summarizes operative techniques used specifically for the repair of traumatic limb vein injuries in children. In cases of concurrent arterial injury, the vein was repaired first to reduce both venous and tissue compartment pressures and ensure adequate runoff following arterial repair.22,27,30 Injuries to the subclavian vein, the retrohepatic IVC, and the internal jugular vein were identified as technically challenging. Subclavian vein injury may be approached via a median sternotomy incision with supraclavicular extension;28 however, there are limited data to describe the success of this technique. Surgical approaches for other traumatic venous injuries
Figure 3. Distribution of traumatic venous injuries reported in published literature.
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were also found to have a high mortality rate, with 100% nonsurvival in those who were hemodynamically unstable at presentation.29 Fayiga et al.24 reported a mortality rate of more than 60% in those with abdominal venous injury and found that patients were more likely to die of exsanguinating venous injury than associated visceral injury. Following an analysis of pediatric trauma outcomes from cases included in the NTDB between the years 2000 and 2004, Hamner et al.20 found that the presence of any intra-abdominal venous injury may increase the risk for death by more than three times compared with patients with isolated arterial injury (relative risk, 3.5; p = 0.001). Similarly, in a retrospective series by Corneille et al.25 capturing traumatic vascular injuries in Texas, United States, between the years 1995 and 2008, the presence of any major venous injury was associated with a sevenfold increase in mortality rates (odds ratio, 7.25; p G 0.001).
DISCUSSION
Figure 4. Techniques used in the surgical repair of traumatic venous injuries.
were not described. Retrohepatic IVC injuries required packing and delayed repair to achieve successful outcomes.29 There is some evidence to suggest that injury to the internal jugular vein may be managed through ligation.22,24 There was a paucity of evidence to describe the optimal management of these challenging injuries. There were no reports of endovascular approach for repair of traumatic venous injuries.
Mortality Associated With Venous Injury in Pediatric Trauma Mortality in pediatric trauma patients who had venous injury was reported as 0% to 67% in published series (Table 1). Poor surgical access, blunt mechanism of injury (shearing mechanism), delayed diagnosis, and concurrent head injury were identified as poor prognostic signs.28 Mortality was highest in the series in which the most frequently reported injury was of the IVC. Cox et al.29 reported a mortality rate of 64% in those with IVC injury who were hemodynamically unstable and 36% in those who were stable at presentation. Hepatic vein injuries
To our knowledge, this is the first systematic review of the epidemiology and management of noniatrogenic venous injuries in pediatric trauma. Our search identified 13 articles describing venous injury in pediatric trauma, including 3 formal reviews of the American College of Surgeons NTDB and 10 retrospective cohort studies. Venous injury is often described in the context of other traumatic injuries, and, as a consequence, there is a paucity of data describing clinical presentation, mechanism of injury, and diagnostic techniques. In total, there were 508 venous injuries described, most commonly with concurrent arterial injury. IVC injury was the most frequently reported venous injury in pediatric trauma. Primary repair was, overall, the most commonly used management option, although this differed according to the site of injury. Mortality associated with venous injury was highly variable; however, there is statistically significant evidence that the presence of intra-abdominal venous injury is associated with higher mortality rates in pediatric trauma. Diagnosis of venous injury in pediatric trauma is challenging as physiologic compensation will often mask the signs of blood loss.20,29 This may be the case even in the presence of injury to major veins.28 The presence of additional injuries may further cloud the diagnosis. In some instances, mechanism of injury may prompt a high level of clinical suspicion. For example, seat belt injury has been directly associated with IVC injury.32 However, our findings suggest that a wide range of injuries, both penetrating and blunt mechanism, may lead to
TABLE 2. Techniques Used for Surgical Repair of Major Limb Venous Injuries in Pediatric Trauma Axillary vein Brachial vein Cephalic vein Basilic vein Femoral vein Popliteal vein Anterior tibial vein Posterior tibial vein
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Primary Repair
Lateral Repair
Ligation
End-to-End Anastomosis
Saphenous Vein Interposition Graft
0% 0% 0% 0% 0% 0% 0% 0%
12.50% 0% 0% 0% 20.80% 25% 0% 0%
12.50% 11.10% 66.60% 20% 0% 0% 100% 100%
37.50% 55.60% 33.30% 20% 45.80% 31.30% 0% 0%
37.50% 33.30% 0% 60% 66.60% 43.80% 0% 0%
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significant venous injury. A high index of clinical suspicion is therefore required along with judicious use of specialist diagnostic tests. Clinical imaging techniques such as ultrasound, CT,33 CTA, traditional angiography, and digital subtraction angiography34 may be used as diagnostic aids; however, interpretation of results for clinical decision making may be difficult. In modern health care, CTA is often the first choice investigation35 and may show contrast blush in cases of vascular injury. In such cases, surgical intervention may often be necessary.29,30,36
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Novel imaging modalities such as multidetector CT scanning may be preferred to conventional imaging modalities in the future assessment of pediatric vascular trauma.37 This review of the literature has identified a significant trend toward increased morbidity and mortality in cases in which there is delayed diagnosis. Therefore, it is crucially important that, in each case, the risks associated with delay in definitive management must be carefully weighed against the benefits of imaging.
Figure 5. Evidence-based recommendations for management of venous injuries in children. * 2014 Lippincott Williams & Wilkins
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Our review found that abdominal venous injuries were associated with the highest rates of mortality. Such injuries are often sustained in conjunction with life-threatening visceral injury; however, data suggest that mortality is often from fatal hemorrhage earlier than from visceral injury alone.20,24,29 Surgeons should therefore consider early surgical intervention in all such cases and should be mindful that a delay in definitive management may have a detrimental effect on survival rates. Surgical repair of venous injury in children requires specialist surgical technique, instruments, and perioperative support. Our review has demonstrated a general consensus that interrupted sutures should be used for primary repair of venous injuries in children to allow for growth in later life.22,25,27,30 It has also been identified that vascular injuries suitable for grafting in adults may require a different approach in children and that synthetic grafts are generally unsuitable for venous repair in younger children.20,25,30,31 Pediatric venous injuries should ideally be managed in an established pediatric trauma center to optimize patient outcomes.38 Figure 5 summarizes lessons learned from this review of the literature and describes an evidence-based approach to the diagnosis and management of venous injuries in pediatric trauma. As part of the development of this protocol, there was formal discussion of evidence-based recommendations extracted from articles included within this review. A panel of practicing clinicians drawn from vascular and trauma surgery, vascular research, pediatric surgery, and pediatric medicine subsequently agreed on a recommended management strategy (Fig. 5). We aim to validate our approach through prospective data collection and formal review of clinical outcomes. Development of evidence-based management protocol is challenging given the paucity of high-quality evidence available. The studies included within this review capture pediatric venous injuries covering a significant period in which diagnostic and therapeutic technologies have evolved in a major way.22,33,37 Direct comparison of outcomes from currently available series is therefore not an ideal method for development of evidence-based management protocol. In addition, the degree of underreporting of injuries and publication bias is unclear. Anecdotally, there has been a shift in recent years toward a trial of conservative management in carefully selected cases; however, this trend is not reflected in the literature. Continuing developments in modern imaging technologies are changing the spectrum of injuries detected, and, as a consequence, decision making is an increasingly challenging task for acute care trauma surgeons. Although there is currently a paucity of evidence for conservative management of traumatic childhood venous injuries, there are reported instances in which this approach has been successful.26 To overcome these biases and to gather sufficient data for development of evidencebased management protocol, well-maintained national trauma registries should be developed worldwide.39
CONCLUSION Venous injury in pediatric trauma may be associated with significant morbidity and mortality due to delayed diagnosis and significant variation in management. Data regarding diagnosis and management are highly heterogeneous. Intra362
abdominal venous injuries, particularly those to the IVC and hepatic veins, are associated with high mortality from exsanguination. Early intervention is therefore essential in such cases. In cases of traumatic limb vein injury, ligation, end-to-end anastomosis, or saphenous vein grafting are the preferred techniques for repair, whereas primary repair is generally not recommended. There is a paucity of evidence describing the diagnosis and management of traumatic venous injuries in children, and thus, we recommend that worldwide national trauma registries should be developed to allow development of evidence-based management protocol to optimize patient outcomes. AUTHORSHIP S.P.R. performed the literature search and drafted the manuscript. B.D. repeated the literature search and helped in drafting the manuscript. H.M.M. helped draft the manuscript and was involved in critical review. K.D. collected manuscripts and was involved in critical review. A.H.D. supervised the review process, gave advice regarding manuscript structure, and performed critical review of the completed manuscript.
ACKNOWLEDGMENT We thank Ms. Louise Adamson, MRCS, Specialist Registrar in Paediatric Surgery, for her role in reviewing this manuscript.
DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Centers for Disease Control and Prevention. Ten leading causes of death and injury [database online]. 2010. Available at: http://www.cdc.gov/injury/ wisqars/leadingcauses.html. Accessed July 1, 2014. 2. Pelaez Mata DJ, Medina Villanueva A, Garcia Saavedra S, Prieto Espunes S, Concha Torre JA, Menendez Cuervo S, et al. Importance of initial management in severe pediatric trauma. Cir Pediatr. 2005;18(1):17Y21. 3. Tan MA, Armstrong D, MacGregor DL, Kirton A. Late complications of vertebral artery dissection in children: pseudoaneurysm, thrombosis, and recurrent stroke. J Child Neurol. 2009;24(3):354Y360. 4. Yardeni D, Polley TZ Jr, Coran AG. Splenic artery embolization for posttraumatic splenic artery pseudoaneurysm in children. J Trauma. 2004; 57(2):404Y407. 5. Saad DF, Gow KW, Redd D, Rausbaum G, Wulkan ML. Renal artery pseudoaneurysm secondary to blunt trauma treated with microcoil embolization. J Pediatr Surg. 2005;40(11):e65Ye67. 6. Reig AS, Simon S, Mericle RA. Embolization of a giant pediatric, posttraumatic, skull base internal carotid artery aneurysm with a liquid embolic agent. J Neurosurg Pediatr. 2009;4(5):449Y452. 7. Gallanos M, Hafner JW. Posttraumatic internal jugular vein thrombosis presenting as a painful neck mass in a child. Pediatr Emerg Care. 2008; 24(8):542Y545. 8. Zitsman JL. Pseudoaneurysm after penetrating trauma in children and adolescents. J Pediatr Surg. 1998;33(10):1574Y1577. 9. Bowers AL, Bautista SR, Bassora R, Kaye R, Wells L. Traumatic lower extremity arteriovenous fistulae in children. Orthopedics. 2008;31(6):612. 10. Oguzkurt L, Balkanci F, Ariyurek M, Demirkazik FB. Traumatic aneurysm and arteriovenous fistula of the splenic artery. Pediatr Radiol. 1996;26(3): 195Y197. 11. Milas ZL, Dodson TF, Ricketts RR. Pediatric blunt trauma resulting in major arterial injuries. Am Surg. 2004;70(5):443Y447. 12. Mills RP, Robbs JV. Paediatric arterial injury: management options at the time of injury. J R Coll Surg Edinb. 1991;36(1):13Y17. 13. Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, et al. Traumatic extremity arterial injury in children: epidemiology, diagnostics,
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