Peripheral

Vascular

Injuries

in Children

By Nesimi Eren, Gijkalp bzgen, Behqet K. Ener, Hasan Solak, and Kamil Furtun

Diyarbakir, Turkey l We report 94 arterial injuries in 91 children treated at the Department of Thoracic and Cardiovascular Surgery, Medical School of Dicle University, between 1978 and 1988. The average age was 10.3 (range, 3 to 14) years. Stab wounds were seen in 37 patients (40%). Gunshot wounds were seen in 21 patients (23%). and two cases were caused by iatrogenesis. Vein damage was present in 39 patients (44.4%). and nerve loss was observed in 20 patients (21.2%). Twenty-one cases (23.3%) were associated with fractures. Diagnosis of arterial injury was made by clinical findings. Arteriography was used in 15 patients (16.5%) as the diagnostic method. The surgical interventions performed for arterial repair in our series were end-to-end anastomosis in 61 (64.5%). interposition of autogenous reversed saphenous vein grafts in 22 (23.4%). lateral suture in 8 (8.3%). and ligation in 3 (3.9%) patients. Four patients (5.3%) underwent limb amputation. Copyright Q 1991 by W.B. Saunders Company INDEX WORDS: Vascular injury; amputation; struction.

vascular recon-

R

ECONSTRUCTION in pediatric vascular injuries is a relatively recent consideration. Suggestions that extremity vitality will be maintained by collateral circulation in even major peripheral vascular injuries have few supporters at this time. The high amputation rate of 50% after ligation of injured major arteries and 75% after ligation of femoropopliteal arteries in World War II demonstrated the need for vascular reconstruction in the Korean War. Reconstruction of damaged arteries has decreased the rate of limb amputation from 50% to 13%.‘,2 In light of these results, even lower rates of limb amputation have become unacceptable in children and young adults. In this report, we discuss the results of methods undertaken in 94 arterial injuries of 91 children.

Causes of vascular injury were stab wounds in 37 patients (40%), gunshot wounds in 31 patients (34%), blunt trauma (traffic accidents) in 21 patients (23%), and iatrogenesis in two patients (2.2%) (Table 2). The time to arrival in the hospital was 8 hours in 33 cases (36.2%), 8 to 12 hours in 26 cases (28.5%) 12 to 18 hours in 14 cases (15.3%) and more than 18 hours in 21 cases (23%). Injured peripheral arteries were localized in the upper extremities in 43 patients (45.7%) and in the lower extremities in 51 patients (54.3%). The most commonly damaged artery in the upper extremities was the brachial artery in 21 cases (22.3%). In the lower extremities, the most frequently injured arteries were the superficial femoral artery in 18 patients (19.1%) and the popliteal artery in 14 patients (14.8%). Distribution of injured peripheral arteries according to their localizations is shown in Tables 3 and 4.

Clinical Findings The main clinical findings in this study were open wounds in the region of arterial route and external hemorrhage in 48 cases (51%), pulselessness distal to the area of injury in 83 cases (91.2%) cyanosis in 6 cases (6.6%), coldness in 47 cases (51.6%), pallor in 39 cases (42.8%) pseudoaneurysm in 9 cases (9.6%), and arteriovenous fistula in 4 cases (4.2%). In peripheral arterial injuries, there were 39 cases (44.4%) of venous damage, 20 cases (21.2%) of nerve loss, 12 cases of tendon injury, 21 cases (22.3%) of fracture, and 1 case (1.1%) of dislocation. In addition, double arterial injury was seen in 3 cases. These arteries were radial and ulnar arteries in 1 of 3 cases and anterior, posterior tibia1 arteries in 2 cases.

Surgical Treatment Injuries to 94 arteries and 39 veins in 91 children were treated surgically. We performed end-to-end anastomosis in 61 patients (64.8%) autogenous saphenous vein graft replacement in 22 patients (23.4%), lateral suture in 8 patients (8.5%), and ligation in 3 patients (3.9%) (Tables 3 and 4). In venous injuries, we carried out end-to-end anastomosis in 19 patients (48.8%), lateral suture in 6 patients (15.4%), saphenous vein graft replacement in 4 patients (10.2%), and ligation in 10 patients (25.6%) (Tables 5 and 6). Arterial ligation resulted from radial arterial injury in I patient and anterior and posterior tibia1 arterial injury in 2 patients. RESULTS

MATERIALS AND METHODS From 1978 to 1988, 91 children with 94 arterial injuries were treated surgically in the Department of Thoracic and Cardiovascular Surgery. The mean age was 10.3 years (range, 3 to 14 years). The ratio of females to males was 1:9. Distribution of patients in accordance with their age groups is shown in Table 1.

From the Department of Thoracic and Cardiovascular Surgery, School of Medicine, Dicle University, Diyarbakir, Turkey. Date accepted: September 11, 1990. Address reprint requests to Nesimi Eren, MD, Associated Professor, Department of Thoracic and Cardiovascular Surgery, School of Medicine, Dicle University, Diyarbakir, Turkey. Copyright o 1991 by WB. Saunders Company 0022-346S/9I/2610-0005$03.00/0 1164

Postoperative infection was seen in eight patients, three of whom were referred to the hospital after more than 18 hours and also had preoperative infected open wounds. In five of these patients, postoperative infection developed. Distal pulses were nonpalpable in nine patients; in five of them, reoperation Table 1. Distribution of Patients in Accordance With Age Groups Age(vrl o-5

NO.

%

5

5.5

5-10

26

28.5

IO-14

60

66

Total

91

100

JournatofPediatricSurgery,

Vol26,NolO

(Octobet),1991: ~~1164-1168

PERIPHERAL VASCULAR INJURIES IN CHILDREN

1165

Table 2. Causes of Vascular Injuries Etiology

NO.

Table 5. Veins Injured and Surgical Treatments %

Penetrating wound

37

40.7

Gunshot wound

31

34.1

Blunt trauma

21

23

2

latrogenic (surgical cutdown) Total

91

Used in Upper

Extremities Veins No. (%I

Injured

2.2 100

DISCUSSION

In papers related to pediatric vascular injuries,3-5 the usual cause of vascular injury is reported to be invasive monitorization or catheterization. In our series, the main cause of injury was penetrating trauma (74%) due to childhood movements of violence. Iatrogenic vascular wounds in two patients (2.2%) occured after surgical cut down to establish venous access. In peripheral traumas adjacent to the great vessels, clinical findings have a significant role in determining arterial interruption. Persistent bleeding, hypotension with hematoma, diminished or absent distal pulses, and coldness, pallor, and cyanosis are the principal features of vascular injury in blunt or penetrating trauma close to the peripheral arterial route.6 Generally, the presence of these symptoms is

Lateral Suture

Axillary

2 (14.3)

1

Srachial

4 (28.6)

4

Cephalic

6 (42.8)

2

Basilic

2 (14.3)

Total

was performed and thrombi extracted. The remaining four patients required amputation (5.3%) (Table 7). Fractures were present in three of them with injury of popliteal artery, vein, and nerve and in another one patient with injury of brachial artery, vein, and nerve. In all patients who underwent limb amputation, the time interval from trauma to operation was more than 18 hours.

End-to-End Anastomosis

-

1 -

4

-

7

14 (100)

Ligation

2 1

6

adequate for diagnosis and requires early surgical exploration. In our series, there was bleeding in 48 cases (51%) diminished or absent distal pulses in 83 cases (91.2%) and coldness in 47 cases (50%). The symptoms mentioned above cannot be manifest in vascular injuries associated with fractures. The clinical picture is more complex in nonpalpable distal pulses after reduction of fractures and in situations in which it cannot be determined whether skin changes are caused by arterial spasm or arterial injury of contusion. In such cases, arteriography is the best method to apply.’ We recorded 21 cases (23%) of peripheral arterial injuries with fractures. Moreover, we saw complete interruption of the popliteal artery due to dislocation of the knee joint in a patient. We prefer preoperative angiography for (1) determining the injury for efferent branches of bifurcation below major arteries and extremity injuries close to major arteries or bifurcated arteries (common carotid, brachial, common femoral, popliteal); (2) evaluating extremities with multiple fractures; (3) evaluating nonpulsatile hematoma cases; (4) evaluating injuries in which the bullet trajectory lies parallel to the arterial route; (5) avoiding arbitrary exploration

Table 3. Arteries Injured and Surgical Treatments Used in Upper Extremities

Artery Injured

No. (%)

Subclavian

3

(7)

End-to-End

Lateral

Saphenous

Anastomosis

Suture

Vein Graft

1

-

9

-

Brachial

21 (48.8)

12

Radial Ulnar

13 (30.2) 6 (14)

12 4

2

-

Total

43 (100)

29

2

11

-

Table 4. Arteries Injured and Surgical Treatments

Artery Injured

Common femoral Superficial femoral Profund femoral Popliteal

No. (%I

1

Used in Lower Extremities Lateral

Saphenous

Anastomosis

Suture

Vein Graft

2

18 (35.3)

14

-

3 (5.9) 14 (27.4)

1 -

End-to-End

3 (5.9)

8

Ligation

2

Ligation

1

-

2

2

-

2

1

-

6

-

1

-

-

Anterior tibia1

6 (11.8)

5

Posterior tibia1

7 (13.7)

3

1

-

2

51 (100)

32

5

11

2

Total

EREN ET AL

1166

Table 6. Veins Injured and Surgical Treatments Veins Injured

End-to-End Anastomosis

No. (X)

Femoral

Used in Lower Extremities Lateral Suture

Saphenous Vein Graft

Ligation

13 (52)

8

3

2

-

Popliteal

8 (32)

4

2

2

-

Anterior tibia1

3 (12)

-

-

-

Posterior tibia1

1 (4)

-

-

-

Total

25 (100)

12

although clinical symptoms are evident and establishing the definite localization of arterial inju# (Figs 1 and 2). We performed preoperative angiography in 15 patients (16.5%) who met these criteria. Replacement of preoperatively diminished blood volume is necessary before performing the reconstruction in peripheral vascular injuries. Arterial and venous repairs made in situations with low cardiac output increase the risk of postoperative thrombosis. We restored the diminished blood volume caused by hemorrhage with an average of 1 unit of whole blood in each of 48 patients (51%). Early surgical treatment for children who have definite vascular injury is essential, as it is in adults?” Conservative observation of an injured artery is far from generally accepted.“,” Defects in development and growth of extremities have been seen after 2 to 3 years, even if limb vitality is maintained, in patients who had certain vascular occlusion and were observed conservatively.6.‘3,‘4 Miller and Welch suggest that repair of the injured artery must be carried out within 6 to 8 hours, but this period is not safe for lower limbs.” No amputation was seen in 33 patients (36.2%) who were treated within the first 8 hours after injury. The average time of vascular repair in our series was 10.8 hours. Reconstruction techniques in children are similar to those in adults, but there is a difference in that children have vessels of smaller diameter. We used wide-spectrum antibiotics preoperatively and heparin (1 mg/kg) intraoperatively after clamping proximal and distal segments of the injured artery. We continued routine heparinization for 3 days. We carried out debridement to the ends of vessel, then cleaned proximal and distal segments using a Fogarty embolectomy catheter and flashed with heparinized saline solution in cases of vascular injuries in which the

5

3 1

4

4

length of the damaged segment did not exceed 1.5 to 2 cm. Anastomoses were made by separated sutures with 6/O nonabsorbable suture material because development of vessel was taken into consideration. Extensive debridement of the wound is necessary, and masserated tissues should be removed carefully. The repaired artery should be covered with vital tissue. If there is minimal arterial defect, a simple lateral suture should be used. The chance of revascularization will be brillant in the presence of profuse back flow from the distal segment of injured artery. We used end-to-end anastomosis in 61 patients (64.8%) and lateral suture in 8 patients (8.5%) who met these criteria. We preferred autogenous saphenous vein as a vascular graft in vascular injuries in which the length of damaged segment was more than 1.5 to 2 cm and in vascular injuries located in the region of the knee and elbow. We cleaned the autogenous vein with heparinized saline solution then destroyed its

Table 7. Results of Surgical Treatments No. of Cases

PostoperativeOutcome Good

runoff

77

Infection

8

Pulselessness

9 (4 amputation)

Total

94

Fig 1. Preoperative femoral artery.

arteriogram

showing injury of the superficial

PERIPHERAL VASCULAR

INJURIES IN CHILDREN

1167

Fig 3. Arteriogram showing pseudoaneurysm carotid artery with arteriovenous fistula.

of the left common

nous saphenous vein graft in situations in which the venous defect exceeded 2 cm. Anastomoses were made by separated sutures using 6/O nonabsorbable suture material. Valves of venous graft were protected during reconstruction. We performed end-toend anastomosis in 19 cases (48.8%), lateral suture in

Fig 2. Postoperative arteriogram autogenous saphenous vein graft.

showing

interposition

of the

valves by injection of pressured 0.9% NaCl solution and later reversed the process. Anastomosis of the distal end of the vein graft to the proximal segment of the artery and the proximal end of the vein graft to the distal arterial segment was performed using 6/O nonabsorbable sutures. Venous grafts used in children have been reported to be occluded with thrombi, although these grafts prevent acute amputation following ligation.16 We used autogenous saphenous vein in 22 cases (23.4%) (Figs 3 and 4). Venous reconstruction is necessary in patients who have both arterial and venous injury because venous return from the repaired venous system will provide sufficient flow when runoff from the repaired arterial system begins. We carried out principally reconstruction of major veins, such as the femoral, popliteal, and brachial veins, which were associated with arterial injury. We used end-to-end anastomosis in patients with venous injury in which the length of damaged segment did not exceed 2 cm and autoge-

Fig 4. Brachial arts&gram graft interposition.

showing autogenous saphenous vein

EREN ET AL

1168

6 cases (15.4%), saphencus vein graft replacement in 4 cases (10.2%), and ligation in 10 cases (25.6%). The prognosis of the limb is poor in patients who have arterial injury associated with both damage of the compounding vein and nerve and fractures; major nerve injury is the most important factor that affects adversly the restoration of the extremity functions.” In complicated injuries, including arterial injuries, venous injuries, nerve lesions, and fractures, we preferred to perform first vascular repair then nervous repair and internal fixation of fractured bones during the same operation to diminish the ischemia time. We routinely continue postoperative antibiotherapy for 7 to 10 days. Heparinization is stopped on the third postoperative day, and oral anticoagulant is used for 1 week. We did not see any complications of hemorrhage with this kind of anticoagulation. We applied postoperative angiography in situa-

tions in which pulses were absent or diminished but limb vitality was safeguarded. The decrease in distal pulses may be misleading, especially in patients with saphenous vein grafts. Unfortunately, we did not obtain long-term follow-up more than 1 year in our cases. We were obliged to perform amputation in four patients (5.3%) after vascular reconstruction. In patients who underwent amputation, vein and nerve damage and fractures were present. Time from trauma to operation was more than 18 hours. These cases were caused by popliteal arterial injury in three patients and brachial arterial injury in one. Our results are similar to those of O’NeilP (123 cases), those of Meagher et al (55 cases),” and the 90% rate of suscessful repair of Flanigan et a1.l’ In our opinion, the most suitable surgical treatment of vascular injuries in children is reconstruction of injured arteries.

REFERENCES 1. De Bakey ME, Simeone FA: Battle injuries of the arteries in the World War 11 and analysis of 2471 cases. Ann Surg 123:534579,1946 2. Hughes CW: Arterial repair during the Korean War. Ann Surg 147:555-561,1958 3. Klein MD, Coran AG, Whitehouse WM, et al: Management of iatrogenic arterial injuries in infants and children. J Pediatr Surg 17:933-939,1982 4. Mortenson W: Angiography of the femoral artery following percutaneous catheterization in infants and children. Acta Radio1 Diag 17:581-593,1976 5. Wigger HJ, Brainsilver BR, Blanc WA: Thromboses due to catheterization in infants and children. J Pediatr 76:1-11,197O 6. O’Neill JA Jr: Vascular injuries, in Pediatric Surgery. Chicago, IL, Year Book, 1986, pp 216-220 7. Eren, N, Gzgen G, Giirel A, et al: Vascular injuries and Amputation following limb fractures. Thorac Cardiovasc Surg 38:48-50,199O 8. Gzgen G, Eren N, Solak H: Peripheral arterial injuries with gunshot wounds: Surgical treatments and results. Vast Surg 23:443-448, 9. Mansfield PB, Gazzaniga AB, Litwin SB: Management of arterial injuries related to cardiac catheterization in children and young adults. Circulation 42:501-507,197O 10. White JJ, Talbert JL, Haller JA Jr: Peripheral arterial injuries in infants and children. Ann Surg 167:757-766, 1968

11. Freed MD, Keane JF, Rosenthal A: The use of heparinization to prevent arterial thrombosis after percutaneous cardiac catheterization in children. Circulation 50:565-569,1974 12. Simith C, Green RM: Pediatric vascular injuries. Surgery 90:20-31,198l 13. Bloom JD, Mozersky DJ, Buckley CJ, et al: Defective limb growth as a complication of catheterization of the femoral artery. Surg Gynecol Ostet 138:524-526,1974 14. Whitehouse WM, Coran AG, Stanley JC, et al: Pediatric vascular trauma: Manifestations, management, and sequelae of extremity, arterial injury in patients undergoing surgical treatment. Arch Surg 111:1269-12751976 15. Miller HH, Welch CS: Quantative studies on time factors in arterial injuries. Ann Surg 130:428, 1949 16. Drapanas T, Hewtt RL, Weichert RF, et al: Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 172:351-360,197O 17. Rang M: Fractures with vascular damage, in Children’s Fractures. Philadelphia, PA, Lippincott, 1974, p 29 18. Meagher DP, Defore WW, Mattox KL, et al: Vascular trauma in infants and children. J Trauma 19523-536, 1979 19. Flanigan DP, Keifer TJ, Schuler JJ, et al: Experience with iatrogenic pediatric vascular injuries: Incidence, etiology, management and results. Ann Surg 198:430-442,1983