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Setia O, Chan SM, Ullrich S, Hornick MA, Ochoa Chaar CI. Cryptogenic acute lower extremities and multiorgan ischemia in an 8-year-old girl. J Vasc Surg Cases Innov Tech 2022; 8:565-568. [PMID: 36248384 PMCID: PMC9556621 DOI: 10.1016/j.jvscit.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/22/2022] [Indexed: 11/19/2022] Open
Abstract
Pediatric acute limb ischemia is rare but can have devastating effects on children. The most common causes of acute limb ischemia in the pediatric age group are iatrogenic injury during cardiac catheterization and traumatic vessel injury. Embolic events have been described less often. We present the case of an 8-year-old girl with cryptogenic extensive bilateral lower extremity ischemia and embolization to multiple visceral organs. Our findings have highlighted the importance of interdisciplinary workup, timely intervention, and the advantage of intraoperative imaging for revascularization.
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Affiliation(s)
- Ocean Setia
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | | | - Sarah Ullrich
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Matthew A. Hornick
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
- Correspondence: Cassius Iyad Ochoa Chaar, MD, MS, Division Vascular Surgery, Department of Surgery, Yale University, School of Medicine, 333 Cedar St, New Haven, CT 06510
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2
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Gensicke N, Nicholson R, Sharp W. Lower extremity aneurysmal degeneration of great saphenous venous allograft bypass in an adolescent boy. J Vasc Surg Cases Innov Tech 2022; 8:5-8. [PMID: 35024522 PMCID: PMC8731692 DOI: 10.1016/j.jvscit.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/10/2021] [Indexed: 12/05/2022] Open
Abstract
Chronic limb-threatening ischemia in the pediatric population is a rare phenomenon. When open repair is necessitated, an autogenous conduit is preferred. However, venous grafts are prone to their own long-term complications. We have presented the case of a 10-year-old boy with chronic limb-threatening ischemia due to popliteal artery thrombosis that was treated with an ipsilateral great saphenous vein bypass. Seven years after the initial procedure, the venous graft had developed aneurysmal degeneration with acute thrombosis, necessitating bypass revision. Through the present case, we have discussed the surgical approach and highlighted the importance of long-term postoperative surveillance after open repair in the pediatric population.
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Affiliation(s)
- Nicole Gensicke
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Rachael Nicholson
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - William Sharp
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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3
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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Baram A, Ahmad BJ, Izac AY, Falah F, Sherzad H. Pediatric vascular reconstruction after trauma and malignancy; a single centere case series. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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D'Oria M, Mani K, Rodriguez Lorenzo A. Microsurgical Salvage of Acute Lower Limb Ischemia after Iatrogenic Femoral Injury during Orthopedic Surgery in a Pediatric Patient. Ann Vasc Surg 2020; 69:452.e5-452.e11. [PMID: 32634560 DOI: 10.1016/j.avsg.2020.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/04/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
Acute lower limb ischemia (ALLI) in the pediatric population is rare but may lead to limb loss and life-long complications. We report the technique and outcomes of microsurgical salvage of ALLI in a preterm newborn after open reduction of congenital hip dysplasia. A 2-month-old girl was born premature at week 36 with congenital bilateral hip dysplasia. The initial management attempted was conservative and entailed placement of bilateral Von Rosen splints. The treatment was successful on the left side, but the patient had recurrent unstable hip dislocation on the right side. Subsequently, 2 attempts at close reduction under general anesthesia were done and both were unsuccessful in maintaining the right hip in the acetabulum. Therefore, an open reduction of the right hip was planned through a medial/obturator approach. During the surgical procedure, the neurovascular femoral bundle (including the superficial femoral artery [SFA], femoral vein [FV], and femoral nerve) was accidently transected with subsequent development of ALLI. Therefore, the FV was harvested distally to the injury site and a 4-cm long healthy segment was obtained. It was reversed, flushed with heparin, spatulated at both extremities, and interposed to the SFA in end-to-end fashion using two 9/0 polypropylene interrupted sutures under microscope. Reperfusion of the limb was noted immediately after releasing the vascular clamps. The final ischemia time at completion of the surgical procedure was 6 hr. Thereby, prophylactic 4-compartment fasciotomies were performed in the right leg. The patient tolerated the procedure well and the postoperative clinical course was free from adverse events. Duplex ultrasound examination at 6 weeks after the intervention confirmed sustained clinical success and showed no signs of venous thromboembolism. At the same time, X-ray examination of the right hip confirmed adequate and stable reduction of the joint in the acetabulum. ALLI due to accidental arterial injury during orthopedic surgical procedures for congenital defects in newborns is a rare but potentially devastating complication. Microsurgical salvage is a safe, feasible, and effective option to restore limb flow. Multidisciplinary expertise and meticulous technique are mandatory in order to achieve satisfactory and durable outcomes.
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Affiliation(s)
- Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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6
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Markovic MD, Cvetkovic SD, Koncar IB, Dragas MV, Markovic DM, Kukic BP, Kuzmanovic IB, Dimic AD, Sladojevic MM, Davidovic LB. Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center. INT ANGIOL 2019; 38:250-255. [PMID: 30994319 DOI: 10.23736/s0392-9590.19.04124-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity. METHODS Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas. RESULTS There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency. CONCLUSIONS Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.
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Affiliation(s)
- Miroslav D Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia - .,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia -
| | - Slobodan D Cvetkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Igor B Koncar
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Marko V Dragas
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Dragan M Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Biljana P Kukic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Ilija B Kuzmanovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Andreja D Dimic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Milos M Sladojevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Lazar B Davidovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
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Eslami MH, Saadeddin ZM, Rybin DV, Avgerinos ED, Eslami PW, Siracuse JJ, Farber A. Trends and Outcomes of Pediatric Vascular Injuries in the United States: An Analysis of the National Trauma Data Bank. Ann Vasc Surg 2019; 56:52-61. [DOI: 10.1016/j.avsg.2018.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/28/2018] [Accepted: 09/01/2018] [Indexed: 12/18/2022]
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8
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Mousa A, Zakaria OM, Hanbal I, Sultan TA, El-Gibaly AM, Zakaria MY, Nasr MA, Bosat BE, Sharabi A, Neinaa M, El-Hamid MA, Daoud MY, Amin MM, Odeh AM, Alhaieg OM, Farhan MA, Bubshait M, Al-Mulhim ARS. Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting. Asian J Surg 2018; 42:761-767. [PMID: 30396715 DOI: 10.1016/j.asjsur.2018.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/17/2018] [Accepted: 09/27/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting. METHODS A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported. RESULTS During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25 ± 4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases. CONCLUSION Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.
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Affiliation(s)
- Ahmed Mousa
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt; Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia.
| | - Ossama M Zakaria
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia; Divisions of Pediatric Surgery, Emergency Surgery, Department of General and Emergency Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ibrahim Hanbal
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Tamer A Sultan
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Amr M El-Gibaly
- Department of General, Visceral, Thoracic and Vascular Surgery, Hanse Klinikum Stralsund, University Medicine of Greifswald, Germany
| | - Mohamed Y Zakaria
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohammed A Nasr
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Al-Azhar University, Assiut Branch, Assiut, Egypt
| | - Bosat E Bosat
- Department of General Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Alaa Sharabi
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohamed Neinaa
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mohamed Abd El-Hamid
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohamed Y Daoud
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mahsoub M Amin
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Ahmed M Odeh
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Omer M Alhaieg
- Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mohamed A Farhan
- Divisions of Pediatric Surgery, Emergency Surgery, Department of General and Emergency Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mohamed Bubshait
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Abdul Rahman S Al-Mulhim
- Divisions of Vascular Surgery, Pediatric Surgery, Emergency Medicine, General Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
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Wang SK, Drucker NA, Raymond JL, Rouse TM, Fajardo A, Lemmon GW, Dalsing MC, Gray BW. Long-term outcomes after pediatric peripheral revascularization secondary to trauma at an urban level I center. J Vasc Surg 2018; 69:857-862. [PMID: 30292605 DOI: 10.1016/j.jvs.2018.07.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The purpose of this investigation was to determine our limb-related contemporary pediatric revascularization perioperative and follow-up outcomes after major blunt and penetrating trauma. METHODS A retrospective review was performed of a prospectively maintained pediatric trauma database spanning January 2010 to December 2017 to capture all level I trauma activations that resulted in a peripheral arterial revascularization procedure. All preoperative, intraoperative, and postoperative continuous variables are reported as a mean ± standard deviation; categorical variables are reported as a percentage of the population of interest. RESULTS During the study period, 1399 level I trauma activations occurred at a large-volume, urban children's hospital. The vascular surgery service was consulted in 2.6% (n = 36) of these cases for suspected vascular injury based on imaging or physical examination. Our study population included only patients who received an arterial revascularization, which was performed in 23 of the 36 consultations (1.6% of total traumas; median age, 11 years). These injuries were localized to the upper extremity in 60.9% (n = 14), lower extremity in 30.4% (n = 7), and neck in 8.7% (n = 2). The mean Injury Severity Score in the revascularized cohort was 14.0 (±7.6). Bone fractures were associated with 39.1% of the vascular injuries (90% of blunt injuries). Restoration of in-line flow was achieved by an endovascular solution in one patient and open surgery in the remainder, consisting of arterial bypass in 59.1% and direct repair in 40.9%. Within 30 days of the operation, we observed no deaths, no infections of the arterial reconstruction, and no major amputations. One patient required perioperative reintervention by the vascular team secondary to the development of a superficial seroma without evidence of graft involvement. Mean follow-up in our cohort was 43.3 (±35.4) months. During this phase, no additional deaths, amputations, chronic wounds, or limb length discrepancies were observed. All vascular repairs were patent, and all but one patient reported normal function of the affected limb at the latest clinic visit. CONCLUSIONS Traumatic peripheral vascular injury is rare in the pediatric population but is often observed secondary to a penetrating force or after long bone fracture. However, contemporary perioperative and long-term outcomes after surgical revascularization are excellent as demonstrated in this institutional case series.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind.
| | - Natalie A Drucker
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Jodi L Raymond
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Thomas M Rouse
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Gary W Lemmon
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Brian W Gray
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
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10
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Lim S, Javorski MJ, Halandras PM, Kuo PC, Aulivola B, Crisostomo P. Epidemiology, treatment, and outcomes of acute limb ischemia in the pediatric population. J Vasc Surg 2018; 68:182-188. [DOI: 10.1016/j.jvs.2017.11.064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 11/05/2017] [Indexed: 10/17/2022]
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Arterial reconstructions for chronic lower extremity ischemia in preadolescent and adolescent children. J Vasc Surg 2017; 67:1207-1216. [PMID: 29162367 DOI: 10.1016/j.jvs.2017.08.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/23/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Chronic lower extremity ischemia in pediatric patients is uncommon. The intent of this study was to better define the arterial reconstructive options and their long-term durability in preadolescent and adolescent children having clinically relevant arterial occlusions affecting the lower extremity. METHODS The medical records of 33 consecutive pediatric patients who underwent lower extremity revascularization for chronic ischemia at the University of Michigan from 1974 to 2016 were reviewed. Patients were categorized by age, clinical manifestation, surgical intervention undertaken, and outcomes. RESULTS Operative treatments involved 26 preadolescent children (mean age, 6.1 years; range, 3-9 years) and 7 adolescent children (mean age, 13.9 years; range, 10-17 years). Occlusions were due to earlier injury related to catheter (14), cannula (2), or both catheter and cannula (14); penetrating trauma (2); and vasculitis (1). Preoperative manifestations included symptomatic extremity ischemia (25), growth retardation manifested by documented limb length discrepancies (21), and scoliosis (5). Primary arterial reconstructions were delayed after the precipitating vascular event an average of 5.3 and 11.2 years in the preadolescent and adolescent children, respectively. Primary procedures involved revascularizations of 36 extremities (in preadolescents and adolescents) including autologous vein (26/5), polyethylene terephthalate (Dacron; 1/0), and expanded polytetrafluoroethylene (0/3) bypasses and vein patch angioplasty (0/1). Vein grafts traversing the abdominal cavity (15) were wrapped with a synthetic mesh. Excluding one early graft occlusion, there were no major early postoperative complications after the primary procedures. Secondary operations followed 31% of the primary operations, being performed an average of 8.8 and 6.7 years later (in 8 preadolescent and 3 adolescent children, respectively) for late graft occlusions (6), graft stenoses (3), aneurysmal vein grafts (2), and anastomotic pseudoaneurysm (1). The unassisted primary graft patency rate was 69%, and the assisted secondary graft patency rate was 94%. Symptomatic ischemia resolved in all but two children. Mean postoperative ankle-brachial indices improved to 1.08 from 0.76 preoperatively. Among children having postoperative documentation of limb lengths, the limb length discrepancies became less (11), were unchanged (1), or progressed (3). Follow-up averaged 8.0 years. There was no operative mortality in this experience. CONCLUSIONS Primary lower extremity arterial reconstructions in children with chronic lower extremity ischemia can be successfully undertaken with excellent results. Nevertheless, the potential for late primary graft failures, evident in nearly a third of this experience, mandates careful long-term follow-up and may necessitate secondary interventions to maintain satisfactory outcomes.
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12
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Andraska EA, Jackson T, Chen H, Gallagher KA, Eliason JL, Coleman DM. Natural History of Iatrogenic Pediatric Femoral Artery Injury. Ann Vasc Surg 2017; 42:205-213. [PMID: 28341498 DOI: 10.1016/j.avsg.2016.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Iatrogenic femoral artery trauma complicates the course of critically ill neonates and children. Complications from persistent arterial occlusion may include claudication and limb length discrepancies. Data supporting risk factors for such and need for revascularization are lacking. METHODS Review of a prospectively maintained database at a tertiary institution of iatrogenic pediatric femoral artery injuries incurred between 2013 and 2014 was performed. Additional injuries were identified by review of pediatric arterial duplex performed between 2008 and 2013. Demographics, risk factors, and outcomes were queried. Data analysis utilized Fischer's exact t-test and logistic regression. RESULTS Seventy-six patients were identified of which 68 presented with acute limb ischemia (ALI) and 8 with chronic iliofemoral arterial occlusion resulting in claudication (n = 6) or limb length discrepancy (n = 2). Mean weight at injury was 6.3 kg; mean age at injury was 49 weeks (50% aged <3 months). Mean follow-up was 14 months (out to 11 years). Six patients required surgery for ALI, and 6 required delayed operation for limb length discrepancy (n = 4) or for persistent external iliac artery (EIA) occlusion. Mean age at delayed revascularization was 6 years (range: 2-13 years). Vasopressor use, mechanism/location of injury, and concomitant venous thrombosis were not significantly correlated with need for operation; trends suggested that cardiac catheterization and EIA thrombosis may correlate with chronic disease. Increased age at injury was associated with need for operation. CONCLUSIONS Although a majority of children with ALI may be successfully treated medically, 9% will require operation for ALI and 16% ultimately required revascularization during follow-up. Persistent iliofemoral arterial thrombosis is a likely risk factor for limb length discrepancy with growth; identifying risk factors for this and improved methods for surveillance requires ongoing investigation.
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Affiliation(s)
- Elizabeth A Andraska
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Tatum Jackson
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Huiting Chen
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Katherine A Gallagher
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Jonathan L Eliason
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Dawn M Coleman
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
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Outcomes of arterial vascular extremity trauma in pediatric patients. J Pediatr Surg 2016; 51:1885-1890. [PMID: 27497495 DOI: 10.1016/j.jpedsurg.2016.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/26/2016] [Accepted: 07/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vascular trauma in children, although rare, carries significant risk for repair. Here we report outcomes from a single trauma center for children with extremity vascular trauma, proximal to the digits. METHODS Retrospective chart review of patients less than age 18years with an acute, non-iatrogenic traumatic arterial vascular injury of the upper and/or lower extremity between January 2008 and December 2013. Abstracted patient demographics, injury characteristics, surgical management, and disposition were summarized and compared with nonparametric methods. RESULTS 23 children comprised the study cohort: median age of 8years (IQR: 4.6-12), 61% (n=14) males, 100% survival. Penetrating injuries were the predominate mechanism (n=17, 74%). The median time to presentation was 154min (IQR: 65-330). Acute operations for revascularization included a primary repair (n=15, 65%) or reversed vein graft (n=7, 30%). Fasciotomies were done for 3 (13%) patients. Three amputations were done for failed revascularization. Upper extremity vascular injury (n=15, 65%) was more common. The rate of associated extremity fracture was similar between upper (21%) and lower (33%) extremities (p=0.643). Eight (35%) patients required additional surgery most commonly for debridement, washouts and dressing changes. Three patients' hospital stays were complicated by infection. Impaired function was the most common short- and long-term complication (60%, 75%). CONCLUSION Pediatric vascular injuries are commonly associated with penetrating injuries and male gender and occurred more frequently in the upper extremities. Overall patency rates after repair were 87%. Fasciotomies were done in 13% of patients, and the overall surgical amputation rate was 13%. There was no mortality in this cohort; however, multiple operations are commonly required, including the return to OR for washouts, debridements and dressing changes. The most common short- and long-term complication was impaired function. Overall good results are achievable in pediatric vascular trauma treated with revascularization.
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14
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Unusual cause of acute lower extremity ischemia in a healthy 15-year-old female: A case report and review of popliteal artery aneurysm management in adolescents. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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15
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Affiliation(s)
- Ahmed AR. Ammar
- Department of Cardiovascular Surgery, Ibn Al-Bitar Center for Cardiac Surgery, Baghdad, Iraq
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A Lower Extremity Musculoskeletal and Vascular Trauma Protocol in a Children's Hospital May Improve Treatment Response Times and Appropriate Microvascular Coverage. J Orthop Trauma 2015; 29:239-44. [PMID: 25272203 DOI: 10.1097/bot.0000000000000246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Pediatric lower extremity (LE) vascular injuries present many issues: microvascular surgeons are usually unavailable to stand-alone pediatric institutions, and the rate of morbidity including limb loss can be high if revascularization is delayed beyond the critical period of 8 hours. We assessed if time to revascularization was impacted by institution of a lower extremity vascular trauma protocol (LEVP). DESIGN Level II retrospective prognostic. SETTING Level I pediatric trauma center. PATIENTS/PARTICIPANTS Pediatric patients presenting with ischemic lower extremities requiring urgent management (2000-2013). INTERVENTION LEVP-a team of specialized microvascular surgeons, who have developed and manage a call schedule for our pediatric trauma center to offer care 24 h-1·d-1, 7 d-1·wk-1, and 365 d-1·y-1 to our children's hospital. MAIN OUTCOME MEASUREMENTS Treatment team expertise, time to revascularization, and use of time-delaying preoperative radiographic vascular studies performed before and after initiation of LEVP. RESULTS We identified 22 patients with ischemic LEs (16 patients treated before/6 patients treated after LEVP initiation). Mean time from admission to definitive vascular care was 6.4 hours preprotocol (20% > 8 hours)/4.6 hours postprotocol (0% > 8 hours). Before protocol initiation, 38% of LE vascular injuries were treated by LE microvascular repair-capable surgeons, and 37.5% had a preoperative radiographic vascular study compared with 100% and 0%, respectively, postprotocol initiation. Before protocol initiation, 37.5% had a preoperative radiographic vascular study compared with 0% after protocol initiation. CONCLUSIONS Since LEVP initiation, we have required no preoperative radiographic vascular studies, there has not been a revascularization delay of >8 hours, and with appropriate staff surgeon coverage, the flow of care has improved with the new ability to address and care for these challenging injuries. To potentially improve the timeliness of vascular care and better match the skills of the practitioner to the injury, pediatric centers should consider implementation of an LEVP within their institutions. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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17
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Butterworth JW, Butterworth WA, Wu R. Three-year delayed presentation of femoral pseudoaneurysm after penetrating limb trauma. Ann Vasc Surg 2014; 29:362.e11-5. [PMID: 25462544 DOI: 10.1016/j.avsg.2014.09.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 09/24/2014] [Accepted: 09/25/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Delayed presentations of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare. METHODS After presentation of this rare case report, we review relevant published literature. RESULTS We report a rare case of a 55-year-old man with a progressively enlarging mass measuring 15 cm by 15 cm on his right anteromedial thigh 3 years after penetrating trauma. Computer tomography angiogram revealed this to be a large pseudoaneurysm supplied by a side branch artery from the right superficial femoral artery. Using an open approach, the pseudoanerysm was successfully repaired with the side branch oversewn, and the patient made a good recovery being discharged from hospital 4 days later. CONCLUSIONS Surgeons must retain pseudoaneurysm as a prominent differential for a patient presenting with a progressively enlarging, expansile mass of an extremity after penetrating trauma to ensure urgent investigation and prompt vascular intervention. Both open surgical ablation and endovascular embolization of pseudoaneurysms of the extremities are effective techniques with low rates of complications and morbidity reported in published literature.
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Affiliation(s)
| | | | - Roxanne Wu
- Department of Surgery, Cairns Base Hospital, Cairns, Queensland, Australia
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18
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Kayssi A, Shaikh F, Roche-Nagle G, Brandao LR, Williams SA, Rubin BB. Management of acute limb ischemia in the pediatric population. J Vasc Surg 2014; 60:106-10. [DOI: 10.1016/j.jvs.2014.01.051] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 01/13/2014] [Accepted: 01/20/2014] [Indexed: 11/28/2022]
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19
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Bakia JM, Tordoir JHM, van Heurn LWE. Traumatic dissection and thrombosis of the popliteal artery in a child. J Pediatr Surg 2012; 47:1299-301. [PMID: 22703810 DOI: 10.1016/j.jpedsurg.2012.03.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 02/27/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
Injuries of the popliteal artery have the highest rate of limb loss compared with other peripheral vascular injuries. Particularly, blunt popliteal artery trauma is known to be associated with a high rate of amputation. Traumatic vascular injuries are usually associated with dislocations and fractures. We describe the radiographic findings as well as the delayed presentation and management of a crush injury of the left leg in an 8-year-old girl resulting in dissection of the popliteal artery without a dislocation or fracture.
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Affiliation(s)
- J-M Bakia
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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20
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Pradka SP, Akbari CM, Ricotta JJ, Keshishian JM. Durability of saphenous vein grafts: 44-year follow-up of a saphenous vein interposition graft in a pediatric patient. J Vasc Surg 2012; 56:216-8. [PMID: 22521803 DOI: 10.1016/j.jvs.2011.12.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 12/19/2011] [Accepted: 12/22/2011] [Indexed: 11/25/2022]
Abstract
We report the 44-year follow-up of a 9-year-old girl who underwent a saphenous vein interposition graft in 1964 after suffering extensive pelvic trauma with complete disruption of the right common femoral artery. The patient recovered from this injury and experienced no disability or pain until 2008, when she suddenly developed numbness in the right leg. Evaluation at that time showed a new occlusion of the saphenous vein graft, and she underwent uneventful repeat revascularization with autogenous vein. To our knowledge, this 44-year patency is the longest reported for a saphenous vein graft.
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Affiliation(s)
- Sarah P Pradka
- Division of Vascular Surgery, Washington Hospital Center, Washington, DC 20010, USA.
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21
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Matos JM, Fajardo A, Dalsing MC, Motaganahalli R, Akingba GA, Murphy MP. Evidence for nonoperative management of acute limb ischemia in infants. J Vasc Surg 2012; 55:1156-9; discussion 1158-9. [DOI: 10.1016/j.jvs.2011.09.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 09/15/2011] [Accepted: 09/26/2011] [Indexed: 10/14/2022]
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22
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Henke PK. Contemporary Management of Acute Limb Ischemia: Factors Associated with Amputation and In-Hospital Mortality. Semin Vasc Surg 2009; 22:34-40. [PMID: 19298934 DOI: 10.1053/j.semvascsurg.2009.01.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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Quintana-Rivera A, Baza-Meléndez J, Gainza E, Ysa-Figueras A. Pseudoaneurisma femoral gigante en un lactante de 5 meses. ANGIOLOGIA 2009. [DOI: 10.1016/s0003-3170(09)11008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Bowman JN, Ellozy SH, Ting J, Ghiassi S. Successful repair of popliteal artery pseudoaneurysm after tibial lengthening osteotomy in a 7-year-old boy. Vasc Endovascular Surg 2008; 42:610-4. [PMID: 18621890 DOI: 10.1177/1538574408320023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Popliteal artery injury is a known but rare complication of elective orthopedic procedures. This case report describes the diagnosis and treatment of a popliteal artery pseudoaneurysm and arteriovenous fistula after a tibial lengthening osteotomy in a 7-year-old boy.
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Affiliation(s)
- Jonathan N Bowman
- Department of Vascular Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
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25
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Peck MA, Clouse WD, Cox MW, Bowser AN, Eliason JL, Jenkins DH, Smith DL, Rasmussen TE. The complete management of extremity vascular injury in a local population: A wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq. J Vasc Surg 2007; 45:1197-204; discussion 1204-5. [PMID: 17543685 DOI: 10.1016/j.jvs.2007.02.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 02/05/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the management of vascular injury in coalition forces during Operation Iraqi Freedom has been described, there are no reports on the in-theater treatment of wartime vascular injury in the local population. This study reports the complete management of extremity vascular injury in a local wartime population and illustrates the unique aspects of this cohort and management strategy. METHODS From September 1, 2004, to August 31, 2006, all vascular injuries treated at the Air Force Theater Hospital (AFTH) in Balad, Iraq, were registered. Those in noncoalition troops were identified and retrospectively reviewed. RESULTS During the study period, 192 major vascular injuries were treated in the local population in the following distribution: extremity 70% (n=134), neck and great vessel 17% (n=33), and thoracoabdominal 13% (n=25). For the extremity cohort, the age range was 4 to 68 years and included 12 pediatric injuries. Autologous vein was the conduit of choice for these vascular reconstructions. A strict wound management strategy providing repeat operative washout and application of the closed negative pressure adjunct was used. Delayed primary closure or secondary coverage with a split-thickness skin graft was required in 57% of extremity wounds. All patients in this cohort remained at the theater hospital through definitive wound healing, with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations (median 3) from the initial injury to definitive wound closure. Major complications in extremity vascular patients, including mortality, were present in 15.7% (n=21). Surgical wound infection occurred in 3.7% (n=5), and acute anastomotic disruption in 3% (n=4). Graft thrombosis occurred in 4.5% (n=6), and early amputation and mortality rates during the study period were 3.0% (n=4) and 1.5% (n=2), respectively. CONCLUSIONS To our knowledge, this study represents the first large report of wartime extremity vascular injury management in a local population. These injuries present unique challenges related to complex wounds that require their complete management to occur in-theater. Vascular reconstruction using vein, combined with a strict wound management strategy, results in successful limb salvage with remarkably low infection, amputation and mortality rates.
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Affiliation(s)
- Michael A Peck
- 332nd Air Force Theater Hospital (AFTH), Balad, Iraq, and Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Megalopoulos A, Siminas S, Trelopoulos G. Traumatic pseudoaneurysm of the popliteal artery after blunt trauma: case report and a review of the literature. Vasc Endovascular Surg 2007; 40:499-504. [PMID: 17202099 DOI: 10.1177/1538574406290037] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pseudoaneurysms of the popliteal artery following trauma are rare lesions. We present 3 cases of pseudoaneurysms of the popliteal artery (4, 20, and 45 years old respectively) with a delayed presentation, following blunt trauma, presenting over a 3-year period, and a short review of the relevant literature. A delayed pattern of presentation, over 2 years after blunt popliteal trauma, was observed in all patients. They presented with a painful pulsatile mass in the popliteal fossa, and their peripheral pulses were normal. Orthopedic and rheumatologic evaluation findings were negative. Diagnostic evaluation included triplex, arteriography, and computed tomography angiography. A posterior popliteal approach was used, and after aneurysmal excision, reversed great saphenous vein and lesser saphenous vein (1 patient) grafts were used. After 2 to 4 years of follow-up, all grafts remain patent and the patients have fully functional limbs. A literature search revealed 70 cases of pseudoaneurysms of the popliteal artery reported in civilian settings. These lesions should be repaired shortly because their complications (rupture, thromboembolic episodes) carry a high risk for limb dysfunction and amputation. Penetrating or blunt trauma is the main causative factor (62.5%), but iatrogenic trauma accounts for an increasing number of reports (37.5%). Strict follow-up of popliteal trauma is essential. A high level of suspicion and awareness can lead to early diagnosis and treatment of pseudoaneurysms of the popliteal artery and prevent the serious complications associated with these lesions.
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Affiliation(s)
- Aggelos Megalopoulos
- 1st Surgical Clinic, General Hospital "G. Papanikolaou," Exohi, Thessaloniki, Greece
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Abstract
BACKGROUND To evaluate the use and advantage of microsurgical intervention and intravenous iloprost administration in delayed infantile artery injuries. METHODS AND RESULTS Four patients were followed up and treated in our clinic between June 2003 and June 2006 for infantile artery injuries and distal ischemia. The average age of the 4 infants (3 girls, 1 boy) was 134.7+/-33.6 days. The reason for all of the artery injuries was iatrogenic. Tissue necrosis started in patches in 2 babies who were admitted at the 12(th) hour after ischemia (19(th) and 22(nd) hours), and therefore the artery was repaired by microsurgery. Iloprost infusion was also used in addition to the conservative treatments. The other 2 patients were assessed before the first 12 h after distal ischemia and were treated by iloprost without any surgical intervention. None of the patients lost any tissue or extremities during the 9 months (average) follow-up time. One of our patients died following the ventricular septal defect repair at the 9(th) month after a successful repair of artery. DISCUSSION We believe that intravenous iloprost infusion is very effective in the treatment of distal ischemia when used in addition to the conservative treatment methods for artery injuries in infants.
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Affiliation(s)
- Erkan Iriz
- Department of Cardiovascular Surgery, Gazi University.
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28
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Dalsing MC. Invited commentary. J Vasc Surg 2006. [DOI: 10.1016/j.jvs.2006.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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29
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Angiletta D, Impedovo G, Pestrichella F, Marotta V, Perilli F, Regina G. Blunt femoropopliteal trauma in a child: Is stenting a good option? J Vasc Surg 2006; 44:201-4; discussion 205. [PMID: 16828446 DOI: 10.1016/j.jvs.2006.02.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Accepted: 02/04/2006] [Indexed: 11/22/2022]
Abstract
Vascular injuries resulting from blunt trauma are uncommon in the pediatric age. In children, there are particular factors that should be taken into account when vascular traumatic lesions are treated: small vessel size or vessel spasm, a higher risk of infection, a tendency for restenosis, and rapid body growth. The endovascular procedure is a minimally invasive, quick technique that restores blood flow immediately. The stent's fate is the Achille's heel of this technique; this is the reason why a careful follow-up and further studies are required.
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30
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Lazarides MK, Georgiadis GS, Papas TT, Gardikis S, Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities. J Vasc Surg 2006; 43:72-6; discussion 76. [PMID: 16414390 DOI: 10.1016/j.jvs.2005.09.031] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2004] [Accepted: 09/21/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies have suggested that open repair of arterial injuries in very young children often leads to less satisfactory outcomes. The aim of this study is to describe a decade's experience in the management of pediatric arterial trauma of the limbs, with an additional specific objective to evaluate the long-term outcome of arterial traumas in preschool children treated conservatively. METHODS Hospital charts were reviewed for all children aged < or =13 years with arterial trauma of the extremities who underwent operative or nonoperative treatment. Twenty-three children were located who had arterial traumas equally divided between the upper extremity (13) and lower extremity (10). RESULTS The method of treatment was either open surgical repair or medical treatment consisting of systematic heparin administration. In 11 of 12 school-aged children (>6 years; mean age, 10 years), open surgical repair was performed. In six of 11 preschool children (< or =6 years; mean, 3.2 years) medical treatment was offered. Open repair was deferred in all children <2.5 years. Autologous vein interposition grafting was the most common surgical procedure and was performed in 10 patients. There were no deaths, and 87% limb salvage (21/23) was achieved. Two patients, both in the surgical arm, underwent lower limb amputation. The long-term outcome of those treated conservatively was excellent in all but one child, in whom minor limb-length discrepancy was detected. CONCLUSION Surgical repair can be performed in school-aged children as in adults. Surgical treatment of arterial injuries in neonates, infants, and those children <2.5 years old might best be deferred in ischemic but nonthreatened limbs. In a nonthreatened ischemic extremity in this age group, systemic heparinization is an alternative safe method of management. Limb loss is rare if distal Doppler signals are present; but as children grow, limb shortening is a threat. In preschool children, the risks of an open surgical repair must be weighed against any potential benefits.
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Affiliation(s)
- Miltos K Lazarides
- Department of Vascular Surgery, Demokritos University Hospital, Alexandroupolis, Greece.
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