The management of vascular injuries associated with total hip arthroplasty

Approximately 100,000 total hip reconstructions are done annually in the United States. The nature of the surgical technique in a field close to the iliac and femoral vessels makes the occurrence of vascular injury an occasional but serious complications. We have reviewed retrospectively our experience of five cases of vascular injuries with total hip replacement and an additional 63 cases in the literature to identify those patients at risk and to define the management of these injuries. For the entire group of 68 patients, most injuries were sustained on the left side (66%), and 39% were seen in revisions. Complications were related to cement incorporation of the iliac vessels (44%), aggressive medial retraction (17%), excessive traction on atherosclerotic vessels (10%), and improper technique in preparation of the acetabulum. The most commonly injured vessels were the external iliac artery (36), common femoral artery (17), and external iliac vein (6). Twenty-seven of these injuries required emergent surgery, most for hemorrhage (66%). Injuries consisted of thromboembolic complications leading to distal ischemia (46%), vessel lacerations (26%), pseudoaneurysms (25%), and arteriovenous fistulas (3%). Vascular repair was individualized and included suture repair, thrombectomy and patch angioplasty, embolectomy, and arterial and venous bypass procedures. There was an overall 7% mortality and a 15% incidence of limb loss. Risk factors include (1) revision procedures, (2) left-sided procedures, and (3) intrapelvic migration of the acetabular component of the hip prosthesis. Elective vascular workup and preliminary retroperitoneal exposure of the iliac vessels at time of hip arthroplasty is recommended for patients at risk.     

Iatrogenic pseudoaneurysms of the peripheral arteries

The aim of the study was to report our clinical experience with the surgical treatment of iatrogenic pseudoaneurysms of the peripheral arteries. The study is a retrospective review of 101 consecutive patients (52 males, 49 females, mean age 66.2 years, range 33-86), with iatrogenic pseudoaneurysms of the peripheral arteries, surgically treated in a vascular unit from October 1990 to June 2006. Duplex ultrasound scanning was employed to support the clinical findings. The surgical treatment consisted in direct closure with polypropylene sutures and, occasionally, patch angioplasty or bypass. Ultrasound compression was effective in one of 4 small aneurysms (< 2.5). No limb loss occurred. There were 4 wound complications (3.9%), one pulmonary embolism (0.99%), and 3 deaths (2.9%), 2 of which not related to vascular repair and one secondary to femoral endoarteritis and septic shock, unrelated to previous implantation of a percutaneous femoral closure device. Although iatrogenic pseudoaneurysms of the peripheral arteries are rarely observed in clinical practice, a significant number of peripheral artery complications may occur after cardiac catheterisation and coronary angioplasty. Failure of conservative treatment requires a traditional surgical repair. The results of our series included a significant mortality rate (2.9%), resulting from the severity of cardiac disease in 2 cases and from the vascular repair itself in one case (femoral endoarteritis). These results substantiate the common observation that patients who require surgery for an iatrogenic pseudoaneurysm are often affected by advanced cardiovascular disease and are liable to suffer the occurrence of complications, with a high risk of death. Therefore, any surgical treatment should be performed with strict adherence to sound vascular surgical principles.     

Incidence of Vascular Injuries after Use of the Angio-Seal Closure Device following Endovascular Procedures in a Single Center

Introduction Percutaneous closure devices have been used to obtain rapid hemostasis and early mobilization of the patient after arterial catheterization. However, we observed challenging problems with the sealing procedure that require further surgical intervention. The present report is a retrospective analysis of the patterns of injury and the final outcome of four cases of femoral artery injury following the use of Angio-Seal. Methods During the last 24 months, in a group of 175 patients (131 men, 44 women; median age 68.4 years, range 47–81 years) underwent percutaneous closure after diagnostic (n = 53) or therapeutic (n = 122) endovascular procedures. Among them we observed four patients (three men, one woman; median age 65.2 ± 10.8 years, range 47–75 years) who developed severe limiting claudication and required vascular repair of an iatrogenic vascular injury following deployment of the Angio-Seal. They had a femoral thrombosis due to narrowing/severe intimal dissection. Results All patients required operative intervention with removal of the device. We performed femoropopliteal thrombectomy and common femoral endarterectomy with patch angioplasty (n = 2), resection of the femoral bifurcation and reimplantation of the deep femoral artery (n = 1), and femoral bifurcation endarterectomy with direct arterial suture (n = 1). The median hospital stay was 6.5 ± 3.8 days (range 4–12 days). Limb salvage was achieved in all of the surviving patients at a mean follow-up of 7 months (range 1–12 months). Conclusions Vascular injuries are uncommon after use of the hemostasis closure device. When they occur, however, they are likely to require challenging surgical correction. This work was presented at the 4th International Central European Vascular Forum in Dubrovnijk, April–May 2004.     

Peripheral arterial trauma in children. A fifteen year review

A 15 year retrospective evaluation of peripheral vascular trauma in infants and children was undertaken. Forty-eight affected limbs in 47 patients (mean age 5.1 years) were explored for peripheral arterial injury. There were 40 iatrogenic, five penetrating and three blunt injuries. Thrombectomy alone, thrombectomy with autogenous saphenous vein patch angioplasty, direct angioplasty, segmental resection with end-to-end anastomosis and interposition-bypass grafting were the most common reparative procedures used. Circulation was normal within 24 hours of surgery in 35 of the 45 limbs (77.8%) whose patency was restored. In patients less than three years or 12.5 kg with iatrogenic injuries, patency rate was significantly lower (p 0.05). Four children died of congenital heart disease. All six children with failed vascular reconstruction suffered late sequelae.     

Minimizing mortality and morbidity from iatrogenic arterial injuries: the need for early recognition and prompt repair

Seventy-one cases of iatrogenic arterial injury requiring repair at our institution from 1972 through 1984 were retrospectively analyzed. Cardiac catheterization accounted for most of the injuries (62%). Ten injuries (14%) resulted from angiography or percutaneous transluminal angioplasty; four injuries (5.6%) occurred after invasive monitoring devices were inserted. Six injuries (8.45%) stemmed from complications of intra-aortic balloon pump insertion, whereas the remainder occurred during various surgical procedures. Most injuries were in the femoral (42.3%) and brachial (38.1%) locations. Thrombectomy (23.9%) and resection with end-to-end anastomosis (35.2%) were the repairs most commonly performed. Morbidity and mortality were low; only one case resulted in limb loss, and neither of the two deaths resulted from the vascular repair itself. On the basis of our experience, we can make certain recommendations with regard to specific injuries. First, the conservative approach to brachial artery thrombosis occurring after catheterization is early exploration and repair. Second, although most injuries can be managed simply with thrombectomy and primary repair, iliofemoral injuries are more likely to require complex reconstructive techniques. Third, large-bore catheter injuries to the carotid artery require immediate exploration and repair to prevent thrombosis, pseudoaneurysm, and cerebral embolism. Fourth, symptoms of nerve compression after transaxillary arteriography require prompt exploration. Our results indicate that, depending on the site of injury, individualized techniques of varying complexity are required for repair. In general, serious sequelae can be minimized by early recognition, prompt operation, and adherence to sound vascular surgical principles.     

Optimal limb salvage in penetrating civilian vascular trauma

To evaluate current treatment of peripheral vascular trauma, we reviewed our recent experience with noniatrogenic penetrating vascular injuries of the extremities. Between 1979 and 1984, 139 patients sustained 204 vascular injuries inflicted by single gunshots (64%), stabbings (24%), and shotguns (12%). Eighty-four percent of patients underwent preoperative arteriography, which revealed occult arterial injury in 13 patients (9%). Compartmental hypertension necessitated fasciotomy in 19% of patients and was required more often after combined arterial and venous injuries (29%) than after isolated arterial injury (14%). Arterial continuity was restored by interposition grafting with reversed saphenous vein (62%), end-to-end anastomosis (19%), vein patch angioplasty (8%), or primary repair (4%). After arterial repair, completion angiography detected the need for revision in 8% of patients. Arterial ligation was performed in 7% of injuries and was only used in the treatment of tibial and distal profunda femoris injuries. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. No deaths occurred, and a single patient required amputation. We conclude that a protocol of preoperative arteriography, liberal. use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates that approach 100% after penetrating vascular trauma to the extremities.     

医源性股动脉假性动脉瘤的治疗方法

目的 评估超声引导下局部压迫和手术治疗医源性股动脉假性动脉瘤的疗效并介绍治疗经验.方法 1995年4月至2008年4月对197例医源性股动脉假性动脉瘤病人进行治疗,其中171例首选超声引导下局部压迫治疗(假性动脉瘤稳定者),26例(假性动脉瘤破裂或瘤腔直径≥40 mm者)直接手术治疗.结果 压迫治疗的171例中137例压迫成功,有效率80%,34例失败者改行手术治疗.直接手术治疗的26例及上述改行手术的34例中,47例行股动脉假性动脉瘤切除、动脉壁破口修补术,6例行自体大隐静脉补片成形术,7例行人工血管转流术.围手术期所有手术病例无出血、神经痛、淋巴瘘、动静脉瘘等严重并发症和死亡.随访1个月至5年,均未见假性动脉瘤复发或肢体缺血症状.随访期间无死亡.结论 局部压迫疗法治疗医源性股动脉假性动脉瘤安全、有效、经济,可作为大部分稳定病人的首选治疗方法.不适合压迫治疗者及压迫治疗失败的病人可手术治疗,疗效确切.     

Traumatic peripheral vascular injuries

Summary 2–4 % of vascular injuries need operative reconstruktion. In polytraumatized patients the rate is even 10 %. Arterial vascular repair should precede venous reconstruction and orthopaedic stabilization due to limb threatening ischemia. Penetration or blunt vascular trauma result either in acute blood loss, ischemia or compartmental compression. Reperfusion syndrom leads to vital threat of patient. Clinical assessment, measurement of limb pressures using a Doppler device and use of duplex ultrasonography are reliable adjuncts in the rapid evaluation. Arteriography is rarely indicated and should be spared for patients with abnormal physical examination. Minimizing ischemia (6–8 h) is an important factor in maximizing limb salvage. Vascular repair include direct anastomosis or lateral suture repair mostly combined with primary shortening of the extremity. In most cases autogenous vein graft is required. Rethrombosis, arteriovenous fistula and pseudoaneurysms are possible complications. Stabilisation of the fracture has priority over vascular reconstruction. The initial steps to success are surgical debridement, adequate bony stabilization mostly by external fixation, revascularisation of vascular injury, immediate fascial decompression and early soft-tissue reconstruction. The best results are obtained when a multidiciplinary approach is used combining expertise in orthopedic surgery, vascular surgery and plastic surgery.      

Femoral endarteritis associated with percutaneous suture closure: new technology,challenging complications

OBJECTIVE: Use of percutaneous suture closure devices after catheter-based interventions is increasing. We recently have seen several severe femoral arterial wall infections after use of such devices. The purpose of this study was to examine the incidence, comorbid associations, and management of femoral arterial infections associated with percutaneous suture closure devices. METHODS: We retrospectively reviewed all infectious complications that occurred after 2223 consecutive cardiac catheterization procedures performed over 12 months in a university-affiliated community teaching hospital. Outcome variables included demographics, procedural details, infection, type of arterial reconstruction required, mortality, and limb loss. RESULTS: During this study, 822 patients received percutaneous suture devices. Infection developed in 6 patients (0.7%). The incidence of diabetes in the population undergoing percutaneous suture closure was 219 of 822 patients (26.6%). Three comorbid conditions, noted in multiple patients with infectious complications, included diabetes mellitus, obesity, and placement of a percutaneous suture closure device within the past 6 months. Invasive femoral endarteritis developed in 4 patients. Gram-positive cocci predominated in 4 patients. In 1 patient with polymicrobial infection catastrophic complications developed, including multiple anastomotic ruptures and hemorrhage. A new method of repair that incorporated double-thickness everted saphenous vein was used in 2 patients, and safe arterial closure was achieved. There was 1 late fatality on postoperative day 36. Limb salvage was achieved in all patients. CONCLUSIONS: Femoral endarteritis complicating percutaneous suture closure is a challenging new problem for vascular surgeons and can result in catastrophic complications. Customary techniques that use saphenous vein patch or interposition grafting are not adequate in all circumstances. Successful outcome requires operative exploration in patients with suspected infection. Removal of the percutaneous suture closure device and debridement to normal arterial wall is recommended in all patients with suspected femoral endarteritis, based on positive intraoperative Gram stains or abnormal appearance of the adjacent femoral artery. Early success with an autologous bolstered repair is reported. Caution is advised when considering the use of a percutaneous suture closure device in patients with comorbid conditions including diabetes, obesity, and previously implanted devices.     

Experience with latrogenic pediatric vascular injuries. Incidence, etiology, management, and results

During a 32-month period, 79 extremities in 76 children (age 1 day-13 years, mean = 31 months) were evaluated with regard to iatrogenic vascular injuries. Prospectively, 42 children were studied pre- and post-cardiac catheterization. Ten of these children sustained vascular injuries (incidence = 24%). Thirty-four additional children were referred because of 35 iatrogenic vascular injuries as a result of transfemoral cardiac catheterization (n = 20), umbilical artery catheterization (n = 10), or recent surgery (n = 5). All 45 injuries were evaluated by lower extremity segmental Doppler pressure measurements in addition to routine physical examination at the time of injury and at frequent follow-up. An ankle/brachial pressure index (ABI) less than 0.9 was considered abnormal. Selected children (ABI less than 0.9 for greater than 30 days) underwent orthoroentgenograms to assess limb growth. The average ABI immediately following injury was 0.34 +/- 0.33. Thirty-four injuries were treated nonoperatively. Twelve injuries were excluded from further study due to death (n = 7) or being lost to follow-yp (n = 5). A return of ABI to normal was seen from 1 day to 2 years in 93% of children treated with heparin (n = 14) compared to 63% of children who were simply observed (n = 8) (p less than 0.10). The initial severity of ischemia did not correlate with the subsequent rate of improvement. Only patients with absent femoral pulses were selected for operative intervention, which consisted of aortic thrombectomy (n = 2), femorofemoral bypass (n = 2), femoral artery patch angioplasty (n = 1), or femoral artery thrombectomy (n = 7) with no mortality. Nine patients had immediate return of a normal ABI after surgery. A delayed return of ABI to normal occurred in the other two. Nine per cent of surgically treated children and 23% of nonsurgically treated children developed leg length discrepancies (0.5-3.0 cm) as a result of ischemia lasting greater than 30 days. Overall, 91% of the children in this series eventually regained normal circulation following injury and no child lost a limb. This study indicates that iatrogenic pediatric vascular injuries are common and can result in significant limb growth impairment. Immediate operative intervention is highly successful when the injury is proximal to the common femoral artery bifurcation and avoids the prolonged ischemia seen with nonoperative therapy. For more distal occlusions, heparin therapy provides better results than simple observation. Although therapeutic intervention for these injuries is generally successful, a limb length discrepancy rate of 14% mandates that indications for invasive vascular monitoring and diagnostic procedures be strict.     

Management of iatrogenic common femoral artery injuries in pediatric patients using primary vein patch angioplasty

Background

Invasive therapeutic and diagnostic procedures remain the most frequent causes of pediatric vascular injuries. Ideal management, especially the indication for surgical treatment, remains controversial. This study evaluates the outcome of surgical repair for iatrogenic common femoral artery (CFA) injuries in pediatric patients using primary vein patch angioplasty.

Methods

From January 1996 through February 2006, 8 patients were identified in the vascular registry of the Vienna General Hospital in Austria. A retrospective office chart review was performed on this consecutive series of patients treated for iatrogenic CFA injuries using primary vein patch angioplasty.

Results

The mean age was 5.8 years (range, 0.3-10.9 years). Surgical repair was performed for 5 ischemic limbs and 3 pseudoaneurysms. Urgent repair was necessary in 5 children (62.5%). After a median follow-up of 9 months (range, 1.8-77.6 months), palpable pedal pulses were present in all patients. No aneurysmatic degeneration of vein patches occurred, and no patient sustained any additional sequelae related to the arterial reconstruction.

Conclusion

Routine use of a vein patch eases CFA repair, especially in the very young.     

The continuing challenge of popliteal vascular injuries

During a 6 year period, 35 patients with 56 popliteal vascular injuries were treated. Thirty-three arteries and 23 popliteal veins were affected. Fifty-four percent of the patients had both an arterial and a venous injury. Twenty injuries were due to penetrating trauma and 15 injuries to blunt force. An overall amputation rate of 16 percent followed attempts at vascular repair. Blunt injuries were associated with a 30 percent amputation rate, whereas penetrating injuries were associated with only a 5 percent amputation rate. When our results were reviewed and compared with those of others, several factors important for determining the rate of limb salvage in popliteal vascular injuries were noted: (1) early recognition and prompt treatment, (2) absence of blunt injury with attendant soft tissue damage; (3) resection of damaged arterial tissue with end-to-end anastomosis or saphenous vein grafting in conjunction with the liberal employment of local heparin and a Fogarty catheter thrombectomy, (4) repair of concomitant popliteal venous injuries; (5) use of completion arteriography to reveal technical errors amenable to correction at time of operation; and (6) fasciotomy, used liberally but selectively.     

An experience with upper-extremity vascular trauma

In this 6-year study of 101 limbs requiring surgical intervention for upper-extremity vascular trauma, most patients were male, young, and injured by penetrating objects. Injured vessels included 13 axillary/subclavian, 23 brachial, 40 radial, and 25 ulnar arteries. Concomitant injuries included nerve injury in 50 cases, tendon laceration in 29, and bony fracture in 11. Arterial repair was accomplished by primary repair in 54 limbs, vein graft in 26 limbs, and vein patch in 3 limbs. Seventeen arterial injuries were ligated. Ancillary procedures included 30 nerve or 27 tendon repairs. The limb salvage rate was 99%. No functional deficits were noted in those cases with only a vascular injury. In 64% and 25% of patients with nerve or musculoskeletal injury, respectively, the arm was functionally impaired. Prompt diagnosis and surgical intervention eliminate vascular injury as a factor in upper-extremity limb loss or disability. Functional deficits are the result of nerve or orthopedic injuries.     

Iatrogenic vascular injury. A reducible problem

During a six-year period 46 patients were treated for iatrogenic vascular injuries at the University of Texas Health Science Center, San Antonio. Diagnostic procedures led to 24 injuries, while therapeutic procedures were responsible for 22 vascular injuries. Trauma to the brachial and femoral arteries and the subclavian vein accounted for the majority of injuries. The most frequently encountered injuries were intimal tear, thrombosis, and laceration. Lateral suture, thrombectomy, and intimal repair were the most commonly employed forms of vascular repair. Postoperative complications were not related to the vascular injuries. Conclusions drawn from this review were as follows: (1) most injuries occur in nonsurgical areas of the hospital; (2) most injuries are related to improper placement, use, or manipulation of catheters; (3) mortality in these cases is caused by the underlying disease process; and (4) long-term sequelae secondary to the vascular injuries are rare.     

Surgical treatment of femoral artery pseudoaneurysms after cardiac catheterization

AIM: To report a clinical experience about surgical treatment of iatrogenic peripheral artery pseudoaneurysms (FPA).\METHODS: This is a retrospective review of 90 consecutive patients (46 males, 44 females, mean age 66.2 years, range 33-86) with FPA complicating coronary angiography or angioplasty, observed between October 1990 through June 2006. \RESULTS: A 3 cm pseudoaneurysm or larger was confirmed by duplex ultrasound scanning in 90 out of 21 454 cardiac patients (0.42%), occurring more frequently in interventional (59/3 983) rather than diagnostic (31/17 471) procedures (1.48% vs 0.17%). The surgical treatment consisted in direct closure with polypropilene suture and occasionally, patch angioplasty or bypass. No limb loss occurred. There were 4 wound complications (4.4%), one pulmonary embolism (1.1%), 3 deaths (3.3%).\CONCLUSION: Classical results reported in literature demonstrate that the surgical repair of femoral pseudoaneurysms following cardiac catheterization is safe, effective and durable. In these series, although low major morbidity (1.1%) and no cases of limb loss were reported, the authors observed 3 death (4.4%), resulting from the severity of cardiac disease in 2 cases and from the vascular repair itself in one case (femoral endoarteritis). These results substantiate the common observation that patients who actually require invasive coronary diagnosis and treatment are often affected by advanced cardiovascular disease and suffer the occurrence of complications, having a high risk of death. Therefore, any surgical treatment should be performed with strict adherence to sound vascular surgical principles.     

Surgical treatment of post—traumatic pseudoaneurysms and arteriovenous fistulas

Objective:To report the experience in the diagnosis and treatment of post-traumatic pseudoaneurysms and arteriovenous fistulas.Methods:A series of 30 patients(11 women and 19 men) with posttraumatic pseudoaneurysms were reviewed retrospectively.Among them 7 patients (5 women and 2 men) were associated with arteriovenous fistula.Results:The causes included sharp penetration trauma(18 cases),blunt trauma (6 cases) and iatrogenic arterial injury (6 cases).The main clinical manifestations consisted of local pulsatile mass (26 cases),vascular bruits (19 cases),thrill (13 cases),ischemia of distal limb (9 cases),neuropathy (5 cases) and pseudoaneurysm rupture (2 cases).All patients underwent surgery.The operations included:ligation of the vessels (12 cases),surgical resection and primary suture repain of the vascular defect or anastomosis (11 cases),vascular reconstruction with autogenous saphenous vein (3 cases) and synthetic vascular graft (4 cases).Conclusions:Because of the imminent clinical course,early operation is usually indicated.The operative treatment is effective and safe for most of the patients with post-traumatic pseudoaneurysms and arteriovenous fistulas.     

Complex upper extremity vascular trauma in an urban population

Eighty patients with upper extremity vascular trauma were treated during a 4-year period. Of 123 vascular injuries, 95 were arterial, 1 was primary venous, and 27 were associated venous injuries. Causes included penetrating (64%), blunt (27%), and iatrogenic injuries (9%). Arteries injured were ulnar (34), radial (28), brachial (22), subclavian (6), and axillary (5). Numbers of patients with associated injuries were nerve (53), vein (27), bone (23), and soft tissue injuries (60). The most common techniques of arterial repair were end-to-end anastomosis (50), followed by interposition saphenous vein grafting (40). Fasciotomy was used in 36 patients. Two arterial repairs failed during surgery and required revision (1) or thrombectomy (1). One radial artery repair thrombosed during late follow-up, with maintenance of normal extremity perfusion via the ulnar artery. No amputations were required, and 83% of all patients treated for nerve injuries resolved or improved their neurologic deficits. Two or more operations for surgical debridement and subsequent wound closure were required in 35 patients. This study supports an aggressive approach to diagnosis and treatment of complex upper extremity vascular trauma emphasizing meticulous surgical technique, liberal use of fasciotomy, and aggressive intraoperative debridement and repair of associated injuries.     

Open surgical repair of children less than 13 years old with lower extremity vascular injury

PURPOSE: We sought to review the diagnosis and treatment of children with lower extremity vascular injury. METHODS: We performed a query of our vascular surgery database from 1996 through 2002 to determine those with lower extremity vascular injuries requiring surgery who were also less than 13 years of age. Patient demographics, presentation, cause, surgical specifics, and outcome were sought. RESULTS: Six children (2 girls and 4 boys) with an average age of 6.8 years (range, 2-9 years) were found. The causes were 3 blunt injuries, 2 iatrogenic injuries, and 1 penetrating injury. Associated injuries were common. There were 3 femoral and 3 popliteal artery injuries. Two were pseudoaneurysms (common femoral and popliteal artery), and 4 were acute occlusions, of which 3 experienced a delay in diagnosis. There was one primary below-knee amputation. Four reverse vein bypasses were performed, and one vein patch repair of a pseudoaneurysm was performed. Generally, 7 to 9 O interrupted Prolene (Ethicon, Inc, Somerville, NJ) repairs were performed. A delay in diagnosis (2 blunt injuries) resulted in 2 major amputations and 1 insensate foot. Four reconstructions are functioning with viable limbs (follow-up, 5-49 months). An associated brain injury resulted in the only death. CONCLUSIONS: Vascular blunt injury is especially insidious in children. However, an aggressive approach of vascular repair, even extensive bypasses with reverse vein, will allow limb salvage in the absence of a diagnostic delay.     

Noniatrogenic pediatric vascular trauma

Twenty-four noniatrogenic pediatric vascular injuries in 20 patients (75% male; mean age, 14 years) were treated during a 3-year period. Of 18 arterial and six venous injuries, 65% were penetrating and 35% were blunt injuries. Eighty percent of all patients had significant associated injuries that required repair. Angiography was performed in 13 of 20 patients, with four performed during surgery. Repair methods were ligation in two of six venous injuries and three of 18 arterial injuries, primary repair in three of six venous injuries and six of 18 arterial injuries, and autogenous saphenous vein graft in seven of 18 arterial injuries. Exploration and debridement, thrombectomy, and nonoperative management were used in one arterial injury each. Fasciotomy was employed in six of 13 arterial injuries in the extremities. There was one operative death, no reoperations, and no early or late amputations. Mean follow-up of 27 months demonstrated normal palpable and Doppler pulses (by noninvasive testing) distal to all arterial repairs. This study supports an aggressive approach to the diagnosis and treatment of noniatrogenic pediatric vascular trauma, emphasizing the liberal use of fasciotomy and meticulous vascular repair for the successful management of these challenging injuries.     

Surgical intervention for complications caused by femoral artery catheterization in pediatric patients

PURPOSE: This study evaluated the risk factors and surgical management of complications caused by femoral artery catheterization in pediatric patients. METHODS: From January 1986 to March 2001, the hospital records of all children who underwent operative repairs for complications caused by femoral artery catheterization were reviewed. A prospective cardiac data bank containing 1674 catheterization procedures during the study period was used as a means of determining risk factors associated with iatrogenic femoral artery injury. RESULTS: Thirty-six operations were performed in 34 patients (age range, 1 week-17.4 years) in whom iatrogenic complications developed after either diagnostic or therapeutic femoral artery catheterizations during the study period. Non-ischemic complications included femoral artery pseudoaneurysms (n = 4), arteriovenous fistulae (n = 5), uncontrollable bleeding, and expanding hematoma (n = 4). Operative repairs were performed successfully in all patients with non-ischemic iatrogenic femoral artery injuries. In contrast, ischemic complications occurred in 21 patients. Among them, 14 patients had acute femoral ischemia and underwent surgical interventions including femoral artery thrombectomy with primary closure (n = 6), saphenous vein patch angioplasty (n = 6), and resection with primary anastomosis (n = 2). Chronic femoral artery occlusion (> 30 days) occurred in seven patients, with symptoms including either severe claudication (n = 4) or gait disturbance or limb growth impairment (n = 3). Operative treatments in these patients included ileofemoral bypass grafting (n = 5), femorofemoral bypass grafting (n = 1), and femoral artery patch angioplasty (n = 1). During a mean follow-up period of 38 months, no instances of limb loss occurred, and 84% of children with ischemic complications eventually gained normal circulation. Factors that correlated with an increased risk of iatrogenic groin complications that necessitated surgical intervention included age younger than 3 years, therapeutic intervention, number of catheterizations (>or= 3), and use of 6F or larger guiding catheter. CONCLUSION: Although excellent operative results can be achieved in cases of non-ischemic complications, acute femoral occlusion in children younger than 2 years often leads to less satisfactory outcomes. Operative intervention can provide successful outcome in children with claudication caused by chronic limb ischemia. Variables that correlated with significant iatrogenic groin complications included a young age, therapeutic intervention, earlier catheterization, and the use of a large guiding catheter.