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24 • Considerations for Conduit Repair of Vascular Injury 305
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Fig. 24.5 Repair of a combined arterial and venous wound of the left lower extremity. (A) Preoperative image of left leg with combined femoral
artery and vein injury. (B) Exposure of left femoral artery and vein injuries with shunts in place. (C) Completed repair of combined femoral artery and vein
injuries with saphenous vein interposition grafts. (Image courtesy of Todd Rasmussen, Mayo Clinic.)
Table 24.2 Conduit Class: Common Conduits in Trauma.
Conduit Type Accessibility Durability
Autologous vein
(e.g., GSV)
Prosthetic “Off the shelf” Not the same
Cryopreserved
allograft
GSV, Greater saphenous vein; IED, improvised explosive device.
Easily accessible if there is
not polytrauma (i.e., bilateral IED injury to the lower
extremities)
Accessible if cold storage
available
Extremely good Good if there is
as GSV but
adequate
Very good Numerous reports
Resistance to
Infection Size Matched Miscellaneous Issues
adequate tissue
coverage
Good; antibiotic
impregnation
available
for intraabdominal
replacement with
good success
Excellent for the
upper and lower
extremities
Excellent size for all
injuries
Very good for a
variety of sizes
Can lead to pseudoaneurysm
or blowout if not properly
covered
Can lead to pseudoaneurysm
or thrombosis if placed in
contaminated field
Requires freezer and time
to thaw; not available in
austere or military settings
during the wars in Afghanistan and Iraq—the percentage
of cervical and extremity vascular injuries has increased.40
Larger-diameter torso vascular injuries often require reconstruction with appropriately sized, off-the-shelf, ePTFE or
Dacron. These conduits are favored in the torso because of
their ready availability and their uniform and larger diameters. For smaller torso vessels, or in cases of enteric contamination, one may consider autologous vein as conduit.
In these cases, depending on the extent of injury, one may
use the deep femoral or the great saphenous vein.
The aorta is most commonly repaired primarily or with
a prosthetic conduit for reasons already mentioned. The
aorta may also be reconstructed with a bifurcated graft
comprised of the deep femoral veins sewn side-to-side for
5 cm to create a large common channel that approximates
the diameter of the aorta. This neoaorta procedure is
almost exclusively used in the elective or the semi-elective
setting following removal of an infected prosthetic aortic
graft and should rarely be used as the primary procedure for
trauma.41 Reconstruction of the iliac artery may be accomplished with prosthetic or with saphenous or femoral vein
depending on the setting. One strategy to construct a larger
caliber conduit using saphenous vein is referred to as a
“panel graft.” In this case, a long length of the great saphenous is opened longitudinally and divided into two approximately equal segments or “panels.” The panels are then
sewn side-to-side and closed over a small or midsized chest
tube. Variations of the panel graft exist, and the strategy
can result in an autologous vein conduit with a caliber that
is twice that of the original saphenous vein diameter.42 A
2018 retrospective review of this technique demonstrated
an 85% 1-year patency in repairs of multiple traumatically
injured vessels.
43
Because of the constraints involved with autologous
repair of torso vascular injuries, particularly with regard
to the larger-caliber vessels, repair has traditionally been
performed using prosthetic of collagen impregnated, woven
nylon, or ePTFE. Woven nylon grafts have the disadvantage
of stretching up to 40% over the lifetime of the graft. As
such, the diameter of the woven nylon graft should be relatively undersized compared to the diameter of the native
artery being repaired. ePTFE grafts are relatively porous
and are prone to leaching serous uid through the graft
material. This phenomenon, also referred to as “sweating,”
can lead to formation of seromas in the graft tract. In an
effort to mitigate each of these disadvantages, a multilayered woven nylon and ePTFE graft is available. The new
Triplex prosthetic conduit (Vascutek Terumo, Renfreswshire, Scotland) consists of three layers. The inner layer is a
standard uncoated Dacron graft (DuPont, Wilmington, DE),
and the outer is a standard ePTFE graft. These two layers are
fused together by a central layer of self-sealing elastomeric
membrane.
44
Adjunctive maneuvers such as presoaking a woven
nylon graft with rifampin (60 mg/mL) can be performed
as a measure to deliver antibiotic to the eld of injury and
306 SECTION 4 • The Management of Vascular Trauma
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to reduce the risk of graft infection. Similarly, ePTFE grafts
can be treated to decrease infections when placed in a contaminated eld. Fischer et al describes a method by which
minocycline and rifampin are bound to ePTFE graft using
a unique methylacrylate technology to promote controlled
antibiotic elution and to reduce infection risk.45 In vitro,
the antibiotic-bound ePTFE grafts sustained gradual local
release of the antibiotics that provided resistance from
infection by Staphylococcus aureus and Staphylococcus epider-
mis for up to 2 weeks. An additional in-vitro study of silver
impregnated Dacron demonstrated increased resistance to
infection with MRSA and Escherichia coli in dogs without
increasing biomarkers of a local inammatory response.
46
The available and best-suited conduit for the repair of
upper and lower extremity arterial injury is the greater
saphenous vein. It is generally recommended that this
autologous conduit be harvested from the leg contralateral to any injury to decrease the risk of venous congestion resulting from trauma. This is especially important if
the injured lower extremity has concomitant arterial and
venous injuries (see Fig. 24.5). In McCready's series of
patients with extremity trauma, it was found that 43 of 49
patients with femoral and popliteal artery injuries reconstructed with saphenous vein experienced an excellent
outcome 33 months after the event.47 Similar outcomes
have been reported in other series, although lack of followup with this subset of the population means longer-term
results are less well characterized.
48,49
Late thrombosis of
saphenous vein grafts does not necessarily mean catastrophe. In Rich's Vietnam experience, 24 of 34 patients who
experienced vein graft thrombosis required no operative
intervention because of adequate collateral circulation.
It is likely that other associated extremities injuries (e.g.,
bone, nerve) limited use of the limb and the degree to which
mild to moderate ischemia resulting from graft thrombosis
would result in symptoms such as claudication.
50
If saphenous vein is not available as conduit, the upper
extremity veins such as the cephalic and basilic can be used.
The basilic vein has been described for use in bypass and
exclusion of a popliteal artery aneurysm. The basilic vein
can be harvested from the arm while simultaneous exposure of the lower extremity artery is performed by another
surgical team. Tal et al. described basilic vein grafts used
to bypass and exclude popliteal artery aneurysm in ve
patients with good results up to 3 years after the repair.51
In another small series from Parmar et al., basilic vein
was employed as the replacement for infected prosthetic
grafts in the iliac and femoral arterial regions. The basilic
vein provided appropriate size match and was used for in
situ replacement.52 Although arm vein performs favorably
with respect to patency and limb salvage when compared
to synthetic conduit, it does require more frequent secondary interventions to maintain patency. In a series of 37 arm
vein bypasses, Varcoe et al. reported a 30-day primary and
secondary patency of 89% and 95%, respectively, with 95%
limb salvage.
53
If one is to reconstruct arterial injuries in the distal
extremities (e.g., forearm, leg), the conduit must be of
smaller caliber. Autologous artery or vein is still preferred in
these challenging situations. To obtain an appropriate size
match, the distal greater saphenous vein at the ankle or the
lesser saphenous vein provides relatively familiar options.
Rockwell et al. described use of epigastric artery and dorsal
hand vein transposition for thumb reimplantation following
traumatic amputation.54 The dorsal hand or foot veins are
of good caliber but harvesting them will leave a signicant
scar and there is potential for injury to the extensor tendons
of the hand or brotic scar formation resulting in decreased
function of the hand. In the case of hypothenar hammer
syndrome, trauma to the hypothenar eminence of the palm
causes injury to the ulnar artery often with formation of
a symptomatic aneurysm. Traditional vein graft repair of
a thrombosed ulnar artery using reversed saphenous vein
has been reported.55 However, Temming et al. proposed that
an arterial autograft would be superior conduit (i.e., better size, durability) compared to vein graft in this scenario.
This group subsequently reported three successful cases of
ulnar artery reconstruction using the descending branch of
the lateral circumex femoral artery. In this novel report,
patency of the reconstruction was conrmed by duplex
ultrasound at periods as long as 28 months after repair.
56
Conduit in Austere and Military
Settings
AUTOLOGOUS CONDUITS
Conduit other than greater saphenous vein is often not
available or feasible in military or civilian scenarios of damage control surgery. In this context, one must consider the
patient's overall injury pattern and injury severity (i.e.,
polytrauma) when considering harvest of autologous conduit and vascular reconstruction. The benets of autologous conduit include its familiarity and demonstrated
effectiveness in scenarios of elective revascularization for
chronic limb ischemia. Additionally, retrospective studies
have shown the effectiveness of vein as a conduit in extremity trauma. Nonetheless, one notable drawback of greater
saphenous vein is the time and expertise required to harvest
and prepare the conduit. Keen reviewed the experience with
autologous vein repair in extremity injury (n=134) in a
busy trauma setting and estimated that it required 10 minutes to harvest and prepare the conduit. To many, including
the authors of this text, the nding of 10 minutes is a low
estimate. In most experiences, harvesting and preparing
the saphenous vein requires at least 30 minutes and longer
if difculties are encountered with a dual or duplicate system, or if one includes wound closure in the time estimate.
Keen and colleagues reported no vein graft infections in
their population and attributed this success to liberal use of
rotational muscle aps and routing the autologous grafts in
an extra-anatomic manner, out of the contaminated sites
of injury.
or around the zone of injury and contamination (i.e., extraanatomic) should be understood by military surgeons. Several studies have demonstrated that vein grafts are prone
to undergoing transmural necrosis or anastomotic disruption when they are placed in a contaminated eld without
viable soft-tissue coverage. In this setting, the conduit can
degrade or break down because of bacterial contaminated
with or without desiccation of the main body of the graft
or at the anastomotic sites. In general, it is uncommon to
57
The observations of success-related routing grafts out of
24 • Considerations for Conduit Repair of Vascular Injury 307
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or possibly amputated, there is often no saphenous vein to
use as conduit for vascular repair. These complex scenarios have required military surgeons to innovate either by
using temporary vascular shunts for long periods of time
(i.e., “extreme shunting”) or by using ePTFE as a rst (but
likely temporary) interposition graft material. One series
described using ePTFE rst as a damage control option,
even in the setting of severe contamination and poor tissue
coverage, with the plan to remove the prosthetic graft for a
longer-term solution in the days following the initial operation (Fig. 24.7).59 In this setting, the patient and ePTFE graft
are monitored closely for graft disruption and the prosthetic
is removed and a more viable reconstruction performed
within 5 to 10 days (Fig. 24.8). Revising the vascular repair,
at even this modest time interval, often allows for procurement of an alternative vein conduit or rerouting of a revised
reconstruction through an extra-anatomic location.
58
In the civilian setting, prosthetic grafts such as ePTFE
Fig. 24.6 Short-length interposition saphenous graft in the brachial
artery.
have been used more commonly with satisfactory results.59
In the treatment of chronic limb ischemia, ePTFE grafts
have been reported, in some studies, to have similar patency
as saphenous vein, and Feliciano et al. reported 5-year
require a long segment of vein for reconstruction of vascular trauma (Fig. 24.6). In up to 40% of military extremity
vascular injuries, the patient has a concomitant orthopedic fracture. In these scenarios, exposing and controlling
the vascular injury with or without the use of a vascular
shunt is accomplished rst. Then the contralateral saphenous vein is harvested while the fracture is reduced and
stabilized. After the orthopedic injury is stabilized, the vascular injury is re-exposed, any temporary vascular shunt is
removed, and the injury is reconstructed with the harvested
vein (i.e., graft, patch angioplasty). If the greater saphenous
vein is not available, the lesser saphenous, the cephalic, or
the basilic veins should be considered. Most commonly, circumstances such as patient positioning, other injuries, or
indwelling intravenous lines exclude exposure and procurement of these alternative vein conduits.
patency of approximately 70% for arterial injuries man-
aged with ePTFE.
60,61
In contrast, this same group reported
poor results with the use of ePTFE for repair of extremity
veins with all reconstructions having thrombosed during
follow-up. In the military experience, prosthetic grafts too
often fail to incorporate with surrounding soft-tissue coverage. In some cases, this is because of primary soft tissue
injury or bacterial or fungal contamination, and in others it
may simply be due to a noninfected seroma surrounding the
ePTFE graft. Even if the original cause is not infectious, the
presence of a seroma and nonincorporated graft in a polytrauma patient is prone to become infected and evolve to an
anastomotic disruption. As such, ePTFE has been discouraged in the recent wartime experience, and closely monitored in scenarios when it has been used because of the lack
of autologous vein. As described, ePTFE can be removed or
revised in an elective or more controlled setting (i.e., staged
PROSTHETIC CONDUITS
removal) if needed in the weeks and months following the
initial injury.
62,63
Prosthetic conduits such as Dacron and ePTFE have been
employed in civilian trauma for a number of years and offer
a wide range of sizes. However, most studies examining the
Future Considerations
use of prosthetic grafts in trauma have been in the civilian
setting where the level of soft-tissue injury and contamina-
BIOENGINEERED BLOOD VESSELS
tion are less than in the military setting. Rich's experience
from Vietnam demonstrated that the majority of prosthetic
grafts used for reconstruction of vascular trauma were
associated with complications, either infection or thrombosis. These observations have been corroborated during
the wars in Afghanistan and Iraq, and the use of prosthetic
graft material to reconstruct wartime vascular injury is
generally discouraged. Clouse et al. reviewed 301 arterial
injuries in Iraq and found that 3% were repaired using prosthetic grafts, whereas 57% were managed with autogenous
vein repair.
58
The severity of extremity injury during the wars in
Afghanistan and Iraq, including those described by the
Dismounted Complex Blast Injury Task Force, presented a
particular challenge related to use of autologous vein. Specically, in cases where both lower extremities are mangled
The limitations associated with the currently available
autologous conduits have led to numerous efforts to create
articial blood vessels. Teebken outlined the desired characteristics of an articial blood vessel as follows: (1) compliance, (2) lack of thrombogenicity, and (3) resistance to
infection.64 Indeed, these traits and the availability of a wide
range of uniform, off-the-shelf sizes would be ideal for elective and trauma situations. Kakisis and colleagues reviewed
the literature on the creation of articial blood vessels and
identied the three basic elements required for construction of a blood vessel as follows: (1) a structural scaffold, (2)
cells, and (3) a nurturing environment.65 Most scaffolds are
created from a collagen matrix, and in 1986 Weinberg created the rst in vitro vessel based on this matrix.66 The inner
surface of the graft was seeded with bovine endothelial
308 SECTION 4 • The Management of Vascular Trauma
AB
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Fig. 24.7 Operative photos of penetrating right common carotid artery injury repaired using an 8-mm ePTFE interposition graft. (A) The patient's head
is turned to the left, and the jugular vein is to the anatomic right of the interposition graft. At the top aspect of the photo, the intact right facial vein
can be observed crossing the more distal common carotid and carotid bifurcation. The small, hand-held, Bookwalter retractor is at the base of the neck
at the sternoclavicular junction. (B) The wound is closed over a closed suction drain. The second drain at the top of this photo is of a negative pressure
wound therapy device placed over the débrided entrance wound. ePTFE was chosen as a conduit in this instance because of its ready, “off-the-shelf”
availability and its excellent size match. Of note, in this case there was minimal soft-tissue injury and no esophageal (i.e., enteric) trauma. (Image courtesy
of Todd Rasmussen, Mayo Clinic.)
cells, and Dacron mesh was embedded into the wall. In
models created without the mesh, the burst strength was
very low compared to those with mesh.
Scaffold-free techniques use free sheets of cells which
then assemble into multilayer constructs. These layered
sheets are then wrapped into a cylindrical shape to achieve
a multiply layered vessel. New techniques with threedimensional printing have also shown promise in development of tissue-engineered vascular grafts with the ability
to produce a predened, computer-generated structure consisting of multiple layers of different cell types. Cells used to
create these constructs vary from embryonic stem cells with
full differentiation potential to progenitor cells with limited
differentiation ability.
67,68
One of the issues that inuences the strength of engineered vessels is the orientation of the smooth muscle cells
on the scaffold. Numerous techniques, including the application of pulsatile ow and magnetic elds, have been used
to reorient the smooth muscle cells in a favorable, circumferential axis. Edelman identied that, although articial
the risk of infection due to the prolonged duration of culture, and the need to investigate the use of new biopolymers (as opposed to using the preexisting scaffolds).65 A
more comprehensive discussion of tissue-engineered arteries is beyond the scope of this chapter, but it is likely that
advances in this eld will lead to the development of articial blood vessels as technology advances.
In one of the most innovative, and now clinically promising efforts to date, a group of scientists, engineers, and
clinicians with Humacyte (Durham, North Carolina) have
devised a method to grow human vessels in vitro using
human vascular smooth muscle cells that are cultured on a
biodegradable scaffold. These newly grown vessels are then
rendered acellular by a decellula rization process that gently removes antigenic material, preserving the extracellular
matrix proteins and mechanical integrity of the conduit,
resulting in a human acellular vessel or HAV.70 The HAV is
an off-the-shelf conduit of uniform caliber that can be used
as a patch, or as an interposition or bypass conduit. Because
the HAV is a non-antigenic biologic, evidence suggests that,
blood vessels may not have the ideal properties of native
vessels, the implanted vessels should ideally grow or incorporate to the local environment if they are composed of
viable tissue.69 Kakisis identied constraining factors in the
use and development of articial vessels as the long period
of preparation required to produce bioengineered products,
recipient patient.29 The HAV is not yet FDA-cleared, but successful use of this conduit for arteriovenous access has been
reported in phase I/II clinical studies.71 In 2020, Gutowski et
al. reported the results of a rst-in-human, phase II trial of
the HAV as a bypass conduit (above-knee, femoral popliteal
24 • Considerations for Conduit Repair of Vascular Injury 309
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A
B
C
Fig. 24.8 Operative photo of a mangled right upper extremity and axilla resulting from an explosive mechanism. Limb salvage was pursued despite a
brachial artery injury and massive soft-tissue damage because the median and radial nerves were visualized intact and there was no injury to the wrist
or hand. The right forearm wound is a fasciotomy incision. (A) The brachial artery has been reconstructed with a 6-mm ePTFE graft as a damage control
maneuver. This graft was placed at the initial operation with the expectation that it would be temporary and replaced by an autologous vein graft during subsequent operations if the attempt at limb salvage was continued. (B) This photograph was taken 2 weeks later, after the soft-tissue wound had
been stabilized over the course of four operations. The ePTFE graft has been replaced with an autologous reversed greater saphenous vein interposition
graft. In this image, a right latissimus dorsi rotational flap had been accomplished to fill in the soft-tissue defect and to cover the autologous vascular
reconstruction. (C) This shows the injury at the completion of the operation with the right extremity wound controlled using an extensive negative
pressure wound therapy mechanism. (Image courtesy of Todd Rasmussen, Mayo Clinic.)
position), in patients with chronic limb ischemia from
peripheral arterial disease. The Gutowski study showed the
HAV to be safe, have acceptable patency, and a low rate of
infection. Histologic examination of biopsies of the HAV
revealed vascular remodeling and repopulation of the conduit by host cells.31 The US military has supported the development and clinical study of the HAV in the hopes that it
may provide an off-the-shelf conduit that becomes incorporated and resistant to infection the setting of wartime vascular injury.
32
IMPROVEMENTS IN STORAGE AND HARVEST
It is worth noting that the development of new and efcacious preservation techniques for human vascular allografts
would also be useful for vascular trauma. Although vascular allografts have many advantages, they currently require
procurement, cryopreservation and storage at −135°C.
The grafts must then be shipped at this temperature and
require approximately 30 to 40 minutes to thaw before use,
limiting signicantly their applicability for trauma (military and civilian).
72–75
An analysis by Cullen found that the
patency of cryopreserved conduits performed for ischemic
disease correlated with the warm ischemia time of the host
from which the graft was harvested. This gives hope that
perhaps future advances in the understanding of these conduits will lead to improved patency.
76
Conclusion
When conduit is required for the management of vascular
trauma, several options are available. When it is accessible
and of good quality, autologous saphenous vein is preferred
for extremity vascular injury. Because of its “off-the-shelf ”
availability and range of size, prosthetic conduit, such as
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Dacron and ePTFE, is preferable for torso and cervical injuries. The selection of a conduit is at the surgeon’s discretion
and there are scenarios in which autologous saphenous vein
should be used to repair torso and cervical vascular injuries
and synthetic used to repair extremity vascular trauma. The
ability to route the conduit out of the zone of injury is important in scenarios in which there is extensive contamination
and a paucity of soft-tissue coverage. Wartime experience
has shown that synthetic conduit can be used as an initial,
damage control strategy to restore perfusion even in heavily contaminated elds. In these situations, the prosthetic
functions as a temporary conduit that is observed closely
for a short period of time after which a staged revision is
performed in a more controlled setting. Off-the-shelf autogenous conduits are being grown using innovative regenerative medicine techniques with several having demonstrated
promise in translational and clinical studies.
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25
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Management of Pediatric
Vascular Injury
MATTHEW A. GOLDSHORE and JEREMY W. CANNON
Introduction
In the United States, injuries account for approximately
10,000 childhood fatalities every year.1 Unintentional
injury results in one in four pediatric medical visits, and the
direct cost of these injuries is estimated to be over $50 billion annually.
Vascular injuries represent a small proportion of this
disease burden (0.6%–1%), and the incidence of noniatrogenic pediatric vascular injury rates may be decreasing due
principally to public health initiatives centered on motor
vehicle safety. However, unsafe handling and storage of rearms remain an important risk factor for penetrating vascular trauma in young children,
represent an increasingly recognized cause of both blunt
and penetrating pediatric vascular trauma. Iatrogenic
injury represents another important cause of pediatric vascular compromise, and the incidence of these injuries has
increased with widespread use of catheter-based procedures, especially in tertiary pediatric hospitals.
Although the overall incidence of pediatric vascular injury
is relatively small, children with vascular injury require
signicantly more surgical and procedural interventions,
have longer hospitalizations, and have a higher mortality
than those without vascular compromise.
despite advances in trauma care, the mortality rate of children who have sustained vascular injury has not improved
over the past decade
Signicant variability exists in the initial evaluation,
diagnostic work-up, therapeutic approach, and follow-up
of children with vascular injuries for a number of reasons
(Box 25.1). In an effort to minimize this variability in the
future, this chapter begins with a brief overview of the epidemiology of both iatrogenic and noniatrogenic vascular
trauma as well as anatomic and physiologic considerations
unique to children. We examine diagnostic modalities and
therapeutic approaches available to the pediatric vascular
surgery team as well as outline specic injury patterns in
the head/neck, torso, and upper and lower extremities. We
conclude with a discussion of postinjury surveillance and
future directions for the eld of pediatric vascular surgery.
Key points of emphasis in the diagnosis and management
of pediatric vascular trauma are summarized in Table 25.1.
2,3
4,5
and combat operations
7,9–11
ranging from 3% to 23%.
4,6–8
Furthermore,
Epidemiology
Approximately half of all vascular injuries in children are
iatrogenic with most of these injuries occurring in neonatal
and school-age children.12 Causes of these iatrogenic vascular injuries include diagnostic catheterization, cannulation
for extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass, umbilical artery catheter placement,
arterial line placement, arterial puncture for blood gas analysis, and complications from routine venipuncture. Vascular complication rates from these procedures vary from 2%
to 45% depending on patient age, the type of procedure, size
of catheter, and proceduralist experience. Unfortunately, as
noted above, the true demographics of iatrogenic vascular
injuries remains unknown due to underreporting and lack
of multi-institutional observational research.
Noniatrogenic vascular injuries are more common than
iatrogenic in children age 7 and above, and of these injuries, approximately 75% result from a penetrating mechanism. Since 2010, there have been nearly 16,000 injuries
and 2711 deaths from gunshot wounds in children aged
between 0 and 19 in the United States.5 Firearms are the
second leading cause of trauma-related deaths in the pediatric population, and among those who survive, 50% suffer
long-term disability. Analysis of the National Trauma Data
Bank revealed that rearm-associated vascular injury was
the most lethal mechanism, and whereas injuries associated
with motor vehicle crashes have decreased, the incidence of
rearm injury in 2007–12 was unchanged compared with
2002–06.
Modern warfare commonly occurs in proximity to civilian populations leading to injuries in host-nation children.
In contrast to civilian vascular injuries, combat injuries
tend to result from high-velocity weapons or from explosions. These mechanisms cause signicant disruption of
4
Box 25.1 Sources of Variable Recommendations
in the Approach to Pediatric Vascular Injuries
Low incidence of pediatric vascular injury
- Evidence largely single-center case series
- No prospective studies
Wide range of specialties involved in management
- Surgical specialties:
- Pediatric Surgery
- Vascular Surgery
- Plastic Surgery
- Orthopaedic Surgery
- Interventional radiology
- Interventional cardiology
Limited long-term outcome data
- Outcomes for operative vs. nonoperative management unclear
- Success of endovascular options uncertain
Limited translatability from adult experience
- Smaller diameter vessels
- Increased vasomotor tone
- Lower circulating blood volume
312
25 • Management of Pediatric Vascular Injury 313
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Table 25.1 Key Management Principles of Pediatric
Vascular Injuries as Compared with Adult Vascular
Injuries.
Etiology Most commonly from iatrogenic injuries
Anatomy/Physiology Small-caliber vessels more prone to vasospasm
Diagnosis If pulses are diminished without hard signs of
Operative
management
From Cannon JW, Villamaria CY, Peck MA. Pediatric vascular injury. In:
Rasmussen TE, Tai NRM, eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia,
PA: Elsevier; 2016, permission pending.
ABI, Ankle-brachial index; CTA, computed tomography angiography; IEI,
injured extremity index.
vascular injury, resuscitate, rewarm, and then
re-assess
Normal IEI/ABI in children 2 years and younger
is 0.88
Normal IEI/ABI in children over 2 years is 1
CTA is a reliable diagnostic tool for large vessels
Use interrupted, nonabsorbable monofilament
suture
Spatulate the anastomosis
surrounding tissue, making repair more complex. In a
series of 155 pediatric patients with vascular injuries representing 3.5% of pediatric admissions, 96% were caused
by a penetrating mechanism, and 66% involved extremity
vessels13 (Fig. 25.1).
Anatomic and Physiologic
Considerations
Numerous anatomic factors contribute to iatrogenic vascular injuries in children. Pediatric vascular access involves
cannulation of small vessels in remarkably compact anatomic spaces with relatively large catheters. Ultrasound
studies have shown that as many as 12% of femoral vessels
in children from birth to 9 years old are either partially or
completely overlapping.14 Thus, landmark-based attempts
at venous access in the groin can easily result in inadvertent
arterial puncture. The use of inappropriately sized arterial
catheters also predisposes the child to vasospasm, increasing the risk of limb ischemia.
Physiologic factors in children who undergo invasive
vascular procedures often promote arterial occlusion. Compromised cardiac output, polycythemia, and low intravascular volume secondary to hemorrhage can all contribute
to thrombosis. Furthermore, severe persistent vasospasm
(lasting hours) and spontaneous arterial thrombosis both
suggest pediatric vessels are hyperreactive as compared
with the adult vasculature.
A wide array of injuries can lead to complete vascular occlusion including intimal flaps, arterial dissections, and avulsion injury. The inciting traumatic event
may cause luminal obstruction and/or local vasospasm
with resultant thrombosis. Limb hypoperfusion can also
occur as a result of traumatic arteriovenous (AV) fistulae, pseudoaneurysm, or complete vascular transection
following venous or arterial puncture. Traumatic AV
fistulae can also result in high-output cardiac failure in
children.
15
Diagnosis and Evaluation
Diagnosis of pediatric vascular injuries requires a high
index of suspicion and a careful physical examination as the
presentation of vascular occlusion may be more nuanced
compared with adults. A thorough vascular examination in patients with potential vascular injury includes an
assessment of potential sites of injury for both hard and
soft signs of vascular injury, skin color, capillary rell, and a
thorough assessment of both central and peripheral pulses.
Before performing invasive vascular procedures, establishing
a preprocedure baseline pulse examination is essential for
subsequent detection of subtle blood ow compromise. In the
multiply injured child, hemorrhagic shock alone may cause
extremity hypoperfusion in the absence of vascular injury.
With resuscitation and rewarming, vasospasm will tend to
resolve, whereas a major vascular injury will not improve.
In the setting of penetrating trauma, hard signs of vascular injury include pulsatile hemorrhage, an expanding
hematoma, obvious distal ischemia, or ndings of a bruit
or thrill on auscultation of the site of injury. In more subtle
cases with a potential injury, measurement of the injury
extremely index (IEI) using continuous-wave Doppler is a
reliable, noninvasive means of initially assessing for pediatric arterial injury. Accurate and precise IEI relies on measurement with appropriately sized blood pressure cuffs. The
cuff should easily encircle the circumference of the arm
and should cover 75% of the extremity length. A continuous-wave Doppler probe is used to determine the pressure at
which the arterial signal occludes with cuff ination. The
calculation is taken from the branchial artery in an uninjured extremity. If both arms are uninjured, the higher of
the two occlusion pressures is used as the denominator of
the ratio equation. For lower extremity injury, an appropriately sized cuff is positioned just proximal to the ankle
and Doppler occlusion pressures are measured at both the
dorsalis pedis and posterior tibial arteries. The highest value
is used as the numerator to calculate the IEI ratio. If an
injured upper extremity is being assessed, the cuff is placed
distal to the injury and the occlusion pressure measured
at the wrist, taking the higher value of the radial or ulnar
artery occlusion pressure. An abnormally low IEI (less than
0.9 in children over 2 and less than 0.88 in children 2 and
under) indicates a potential vascular injury that warrants
further assessment.
In a child with clinical concern for vascular injury
who does not respond appropriately to resuscitation,
localizing and confirmatory studies should be pursued.
In children, duplex ultrasound is extremely safe, can confirm vascular occlusion and is able to localize the site of
injury as well as diagnose the presence of an AV fistula
or pseudoaneurysm. Sonography can also differentiate
acute occlusion and vasospasm. Limitations of ultrasound include limited utility for small vessels, and a steep
learning curve for optimal image acquisition. Moreover,
sedation may be necessary for complete sonographic
examination in a young child.
Computed tomography angiography (CTA) is being
used more often in children for the diagnosis of vascular
injury and has been shown to be more reliable for truncal
and great vessel trauma than for injuries of the peripheral
vasculature17 (Fig. 25.2). If the diagnosis remains unclear
16
314 SECTION 4 • The Management of Vascular Trauma
AB
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Head/neck/face
Abdomen/pelvis
Fig. 25.1 Distribution of 185 pediatric vascular injuries in 155 patients managed during
Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF). Numbers are n (%).
(From Cannon JW, Villamaria CY, Peck MA. Pediatric vascular injury. In: Rasmussen TE, Tai NRM,
eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia,
PA: Elsevier; 2016.)
15 (9)
Upper extremity
46 (29)
Thoracic
12 (7)
Lower extremity
60 (37)
28 (17)
B
Fig. 25.2 Computed tomography angiography can be used to evaluate for vascular injuries in large vessels including the carotid artery
(A, black arrow) and the subclavian artery (B, white arrow). Contrast
should be injected contralateral to the suspected injury. In very small
children, a hand injection may be necessary. In both instances, the
injuries resulted from a tiny metal fragment (B, black arrowhead). The
carotid pseudoaneurysm (A) was managed with open exploration
and repair with an interposition graft, whereas the subclavian artery
injury was repaired with a vein patch angioplasty. (A, From Cannon JW,
Peck MA. Vascular injuries in the young. Perspect Vasc Surg Endovasc Ther.
2011;23:100–110; B, courtesy Jerry Pratt.) (From Cannon JW, Villamaria CY,
Peck MA. Pediatric vascular injury. In: Rasmussen TE, Tai NRM, eds. Rich’s
Vascular Trauma. 3rd ed. Philadelphia, PA: Elsevier; 2016.)
despite noninvasive testing, conventional angiography can
be useful to identify the site of injury or to differentiate
vascular injury from vasospasm. In the setting of hemodynamic compromise or if invasive and noninvasive tests are
inconclusive, surgical exploration is indicated.
Therapeutic Approach
Historically, short of exsanguinating hemorrhage following major arterial disruption, pediatric vascular injury
was managed with systemic anticoagulation. However,
poor long-term results from this medical management
approach are now more widely recognized, including
early tissue loss and long-term limb length disparity.
Historic concerns of a high negative exploration rate due
to vasospasm and seemingly poor postoperative results in
children less than 2 years old15 have been assuaged with
improved diagnostic imaging and more experience with
operative exploration across all age groups.
11,18–20
more, mounting evidence of the negative consequences
of even relatively short warm ischemia times compels
early intervention to optimize long-term functional out-
10,21,22
comes.
OPEN SURGICAL EXPLORATION AND REPAIR OF
EXTREMITY VASCULAR INJURIES
Pediatric vascular injuries can be managed with the full
range of accepted vascular repair and reconstruction
techniques including primary repair, vein patch angioplasty,
and interposition grafting using reversed greater saphenous vein (GSV) or other autologous vessels. Minimal injuries such as clean transections or a simple laceration can be
reconstructed primarily or with a vein patch, respectively.
These techniques have been used exclusively in multiple case
reports and several case series. These repair techniques are
acceptable for low-velocity penetrating injuries, as well as in
certain blunt injuries, as they minimize size mismatch and
luminal growth issues at the repair site.
11,23,24
6,15
Further-
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