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Shaniv D, Simpson-Lavy Y, Hershkovich Shporen C. Management of iatrogenic acute limb ischaemia in the neonate. BMJ Case Rep 2024; 17:e261775. [PMID: 39231563 DOI: 10.1136/bcr-2024-261775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024] Open
Abstract
Iatrogenic acute limb ischaemia (ALI) in neonates is a rare but severe event with potentially deleterious outcomes. In the neonatal intensive care unit, this risk is increased due to the high rate of catheterisation procedures. ALI management includes pharmacological and non-pharmacological interventions, but no commonly accepted clinical guidelines are available. In the present case, a peripheral catheter was erroneously placed in the left brachial artery of a term infant, causing blockage and ischaemia in the limb. The catheter was immediately removed, the affected limb was elevated and warm compresses were applied to the contralateral limb. The patient was treated with fresh frozen plasma, heparin, iloprost and topical nitroglycerin. Three nerve block procedures were also performed. At 6-8 days of age, significant improvement was observed. The patient was discharged at 17 days of age with near-complete resolution, whereas complete resolution was observed at postdischarge follow-up.
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Affiliation(s)
- Dotan Shaniv
- Neonatal Intensive Care Unit, Kaplan Medical Center, Rehovot, Israel
- Pharmacy Services, Kaplan Medical Center, Rehovot, Israel
| | - Yael Simpson-Lavy
- Neonatal Intensive Care Unit, Kaplan Medical Center, Rehovot, Israel
| | - Calanit Hershkovich Shporen
- Neonatal Intensive Care Unit, Kaplan Medical Center, Rehovot, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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2
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Radványi Á, Röszer T. Interleukin-6: An Under-Appreciated Inducer of Thermogenic Adipocyte Differentiation. Int J Mol Sci 2024; 25:2810. [PMID: 38474057 DOI: 10.3390/ijms25052810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Adipose tissue inflammation is a key factor leading to obesity-associated immune disorders, such as insulin resistance, beta cell loss in the pancreatic islets, meta-inflammation, and autoimmunity. Inhibiting adipose tissue inflammation is considered a straightforward approach to abrogate these diseases. However, recent findings show that certain pro-inflammatory cytokines are essential for the proper differentiation and functioning of adipocytes. Lipolysis is stimulated, and the thermogenic competence of adipocytes is unlocked by interleukin-6 (IL-6), a cytokine that was initially recognized as a key trigger of adipose tissue inflammation. Coherently, signal transducer and activator of transcription 3 (STAT3), which is a signal transducer for IL-6, is necessary for thermogenic adipocyte development. Given the impact of thermogenic adipocytes in increasing energy expenditure and reducing body adiposity, functions of IL-6 in the adipose tissue have gained attention recently. In this review, we show that IL-6 signaling may protect from excess fat accumulation by stimulating thermogenesis in adipocytes.
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Affiliation(s)
- Ádám Radványi
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
| | - Tamás Röszer
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
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3
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Ferrari E, Guard T, Prakash V, Shih M, Kirkwood M, Siah M. Acute limb ischemia secondary to bullet embolism following a cardiac gunshot wound in a pediatric patient. J Vasc Surg Cases Innov Tech 2023; 9:101231. [PMID: 37799838 PMCID: PMC10547786 DOI: 10.1016/j.jvscit.2023.101231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/11/2023] [Indexed: 10/07/2023] Open
Abstract
Bullet embolism following a gunshot wound to the heart is a very unusual cause of acute limb ischemia. We report the case of a 3-year-old boy who sustained a penetrating cardiac trauma secondary to an accidental self-inflicted gunshot wound with a BB (ball bearing) gun. The BB pellet entered the left ventricle and embolized into the peripheral circulation, lodging at the bifurcation of the left common femoral artery. This resulted in acute left lower extremity ischemia. The patient was successfully treated by open common femoral artery exploration and foreign body removal.
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Affiliation(s)
- Eliza Ferrari
- Division of Vascular Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Tiffany Guard
- Division of Vascular Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Vivek Prakash
- Division of Vascular Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Michael Shih
- Division of Vascular Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Melissa Kirkwood
- Division of Vascular Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Michael Siah
- Division of Vascular Surgery, University of Texas Southwestern Medical School, Dallas, TX
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4
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Liu LH, Lee MD, Huang TH, Chu SH, Hsieh MY. Case report: Endovascular treatment of acute limb ischemia in an adolescent with newly diagnosed lupus. Front Cardiovasc Med 2023; 10:1152929. [PMID: 37324623 PMCID: PMC10267874 DOI: 10.3389/fcvm.2023.1152929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
We report a 14-year-old adolescent who presented with acute limb ischemia caused by systemic lupus erythematosus-related antiphospholipid syndrome (APS). In the pediatric population, acute limb ischemia is rare. This case is unique in that after the initial medical treatment failed, interventional devices for acute stroke intervention were utilized to salvage the limb in our patient with a small tibial artery vessel to achieve procedural success. To provide limb salvage, operators may combine peripheral and neuro-intervention devices to maximize procedure success.
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Affiliation(s)
- Lu-Hang Liu
- Division of Cardiology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Ming-Dar Lee
- Division of Nephrology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Ting-Huan Huang
- Division of Hematology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Szu-Hung Chu
- Division of Immunology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Mu-Yang Hsieh
- Cardiovascular Center, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsin-Chu, Taiwan
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5
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Wangtiraumnuay N, Surakrattanaskul S, Wangkittikul C. Digital Gangrene and Antiphospholipid Syndrome in a Retinoblastoma Patient with Chromosome 13q Deletion: A Case Report. Case Rep Oncol 2023; 16:287-293. [PMID: 37123606 PMCID: PMC10134053 DOI: 10.1159/000530182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/06/2023] [Indexed: 05/02/2023] Open
Abstract
A 19-month-old girl with Cornelia de Lange-like dysmorphic features presented with left eye leukocoria. She was diagnosed with 13q deletion retinoblastoma grade 4 with high-risk features and bone marrow involvement. She underwent enucleation, and the first course of intravenous chemotherapy was initiated. On day 10 after the first chemotherapy dose, she developed digital gangrene of her left hand. She was diagnosed with acute artery occlusion and limb ischemia. Thrombophilia work-up revealed antiphospholipid antibodies, and paraneoplastic syndrome is another possible cause of digital gangrene. The patient's left thumb and index finger were amputated. After 1 month of hospitalization, she was discharged. Before the second course of chemotherapy, the patient died of systemic metastatic retinoblastoma with respiratory failure due to pneumonia. Our postulation of the mechanism for digital gangrene was the combination of chemotherapy, paraneoplastic syndrome, and antiphospholipid syndrome. Digital gangrene could be a poor prognostic indicator in patients with retinoblastoma.
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Affiliation(s)
- Nutsuchar Wangtiraumnuay
- Department of Ophthalmology, Queen Sirikit National Institute of Child Health, Bangkok, Thailand
| | - Supawan Surakrattanaskul
- Department of Ophthalmology, Queen Sirikit National Institute of Child Health, Bangkok, Thailand
| | - Chonthida Wangkittikul
- Division of Hematology and Oncology, Department of Pediatrics, Chonburi Hospital, Chonburi, Thailand
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6
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Silverberg D, Hater H, Ismail O, Kenet G, Halak M. Acute Limb Ischemia in Pediatric Intensive Care Units. Ann Vasc Surg 2022; 92:65-70. [PMID: 36549473 DOI: 10.1016/j.avsg.2022.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND To determine the outcome of children treated for acute limb ischemia (ALI) in pediatric intensive care units (ICUs). METHODS A single-center, retrospective cohort study including all patients diagnosed with ALI between 2005 and 2022 in 2 different pediatric ICUs: respiratory and cardiac ICU. Data collected included patients demographics and comorbidities, location and cause of arterial occlusion, and type and duration of therapy. Primary end point was freedom from amputation. Secondary end point was all-cause mortality. RESULTS A total of 78 patients (58% male) with ALI were included in the study. Median age was 3.8 months (range 0.03-201). The lower extremity was involved in 55 (70%) patients. The limb ischemia was caused by arterial instrumentation in 94% of the patients. Anticoagulation was administered as the first-line therapy in all patients. Unfractionated heparin was administered for a median duration of 5 days (range 1-48). Low molecular weight heparin was continued for a median period of 28 days (range 4-420). Thrombolytic therapy was administered in 5 patients and 2 required surgical revascularization, all for failure of anticoagulation therapy. Mean follow-up was 21 months (range 1-188 months). None of the patients required major upper or lower extremity amputations during or after the index admission. Overall survival at 30 months was 68%. The causes of mortalities were unrelated to the limb ischemia. CONCLUSIONS This large, single-center study demonstrates that ALI in the pediatric ICU population can be treated conservatively and is associated with a low amputation rate following nonoperative management. The favorable outcome exists regardless of the etiology of the ALI and underlying diseases.
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Affiliation(s)
- Daniel Silverberg
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel.
| | - Haitam Hater
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Omar Ismail
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Gili Kenet
- The Institute of Thrombosis & Hemostasis, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Moshe Halak
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
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7
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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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8
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Veitenheimer TG, Johnson EB, Chenoweth BA. Successful Emergent Treatment of Limb-Threatening Amniotic Constriction Band in a Neonate with a 2-year Follow-up: A Case Report. JBJS Case Connect 2022; 12:01709767-202209000-00007. [PMID: 35833644 DOI: 10.2106/jbjs.cc.22.00132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE A 29-week-old gestational age neonate born by emergent cesarean delivery was found to have a circumferential upper arm amniotic constriction band. Initial removal of the amniotic band at the time of delivery uncovered a circumferential skin band with profound venous obstruction but preserved Doppler arterial flow. Emergent excision of the constricted skin band with fasciotomies of the arm and forearm was performed shortly after birth to preserve the extremity. CONCLUSION This report outlines a visualized constriction band at the time of delivery causing neurovascular compromise to an extremity of a neonate. Prompt intervention ensued preserving both form and function with an excellent 2-year follow-up.
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Affiliation(s)
- Travis G Veitenheimer
- Oklahoma Children's Hospital with OU Health, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
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9
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Sanches SMV, Aquino MDA, Leite BDL, Cerqueira MMBDF. Tratamento conservador de isquemia aguda de extremidades em lactente - relato de caso. J Vasc Bras 2022; 21:e20220010. [DOI: 10.1590/1677-5449.202200101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Resumo A isquemia aguda de extremidades é um evento raro na população pediátrica, com incidência estimada em 26 a cada 100.000 internações, sendo a maioria associada a trauma ou iatrogenia. O tratamento ideal para esses quadros não está bem estabelecido pela literatura, havendo a tendência ao tratamento não invasivo. Relatamos o caso de uma lactente que apresentou isquemia dos quatro membros secundária a complicações hemodinâmicas após realização de cirurgia cardíaca complexa, apresentando preservação tecidual expressiva com o tratamento conservador.
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10
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Sanches SMV, Aquino MDA, Leite BDL, Cerqueira MMBDF. Conservative treatment of acute limb ischemia in a child - case report. J Vasc Bras 2022. [DOI: 10.1590/1677-5449.202200102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract Acute limb ischemia is a rare event in the pediatric population, with an estimated incidence of 26 per 100,000 admissions, the majority of which are associated with trauma or iatrogeny. The ideal treatment for these cases is not well-established in the literature, although there is a tendency to choose noninvasive treatment. We report the case of an infant who suffered ischemia to all four limbs secondary to hemodynamic complications after complex heart surgery and in whom significant tissue preservation was achieved with conservative treatment.
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11
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Resch JC, Hedstrom R, Steiner ME, Said SM, Somani A. Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort. Front Pediatr 2022; 10:1011171. [PMID: 36683785 PMCID: PMC9849792 DOI: 10.3389/fped.2022.1011171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes. METHOD Institutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes. RESULTS Hirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement. CONCLUSION This case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.
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Affiliation(s)
- Joseph C Resch
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Rachel Hedstrom
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Marie E Steiner
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Sameh M Said
- Department of Pediatric Cardiac Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Arif Somani
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
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12
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Thromboangiitis Obliterans (Buerger's Disease) in an Adolescent Male. J Pediatr Hematol Oncol 2021; 43:e759-e762. [PMID: 32925405 DOI: 10.1097/mph.0000000000001933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/12/2020] [Indexed: 11/26/2022]
Abstract
Arterial occlusive disease of the limb is very rare in children. Buerger's disease (BD) is a nonatherosclerotic, segmental inflammatory arteritis affecting the small and medium-sized vessels of the extremities. We report BD in a 16-year-old male presenting with arterial insufficiency of left foot and history of smoking cigarettes and cannabis for 2 years. BD was diagnosed based on history of smoking in combination with clinical, laboratory, and radiologic findings. Pediatric hemato-oncologists should consider BD in the differential diagnosis in adolescents who smoke cigarettes and/or cannabis and present with vascular insufficiency of the hands and/or feet.
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13
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Tang T, Zhang M, Li W, Hu N, Du X, Ran F, Li X. Oral Anticoagulant and Antiplatelet Therapy for Peripheral Arterial Disease: A Meta-analysis of Randomized Controlled Trials. Clin Appl Thromb Hemost 2021; 27:1076029621996810. [PMID: 33783251 PMCID: PMC8013910 DOI: 10.1177/1076029621996810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Peripheral artery disease (PAD) is a common disease affecting over 200 million people worldwide. PAD is associated with significant limb and cardiovascular morbidity and mortality which is reduced by antiplatelet and antithrombotic therapy. However, the optimal type, dose, and time of antithrombotic therapy is still uncertain.We searched 4 electronic databases from January 1, 1990, to June 1, 2020, for randomized controlled trials of patients who received oral anticoagulant and antiplatelet therapy for PAD. The primary outcome was a composite of acute limb ischemia, major amputation, myocardial infarction, ischemic stroke, death from cardiovascular events, or death from any cause. Secondary outcomes included major bleeding, fatal bleeding, and intracranial hemorrhage events.We identified 3 studies that satisfied inclusion and exclusion criteria. Compared with antiplatelet alone, oral anticoagulant plus antiplatelet therapy improved acute limb ischemia (p < 0.00001), stroke (p = 0.005), and major amputation events (p = 0.11). However, oral anticoagulant plus antiplatelet therapy was not effective for prevention of myocardial infarction (p = 0.23), death from cardiovascular events (p = 0.65), or death from any cause (p = 0.66). Additionally, a significant increase in major bleeding events was demonstrated (p < 0.00001). There was no significant difference in fatal bleeding (p = 0.16) or intracranial hemorrhage events (p = 0.43). This meta-analysis showed that oral anticoagulant plus antiplatelet therapy for PAD may improve acute limb ischemia and major amputation or stroke risk compared with antiplatelet therapy alone, but could increase the risk of major bleeding events. On the other hand, measuring myocardial infarction, death, fatal bleeding, or intracranial hemorrhage risk remains controversial.
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Affiliation(s)
- Tao Tang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, 66506The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,*They contributed equally to this work
| | - Ming Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, 66506The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,*They contributed equally to this work
| | - Wendong Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, 66506The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,*They contributed equally to this work
| | - Nan Hu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, 66506The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiaolong Du
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, 66506The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Feng Ran
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, 66506The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, 66506The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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14
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Femoral artery thrombosis in an extremely preterm newborn. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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15
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Upper limb ischemia in a newborn following difficult delivery. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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16
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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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Ramirez JL, Kuhrau CR, Wu B, Zarkowsky DS, Conte MS, Oskowitz AZ, Nijagal A, Vartanian SM. Natural history of acute pediatric iliofemoral artery thrombosis treated with anticoagulation. J Vasc Surg 2020; 72:2027-2034. [PMID: 32276025 DOI: 10.1016/j.jvs.2020.02.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/11/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Acute iliofemoral artery thrombosis (IFAT) can occur in critically ill neonates and infants who require indwelling arterial cannulas for monitoring or as a consequence of cardiac catheterization. Guidelines suggest treatment with anticoagulation, but evidence supporting the optimal duration of therapy and the role of surveillance ultrasound is limited. The objectives of this study were to characterize the kinetics of thrombus resolution and to define an appropriate duration of anticoagulation and interval for surveillance ultrasound. METHODS This was a single-center retrospective cohort study of pediatric patients with acute IFAT from 2011 to 2019. Medical records and vascular laboratory studies were reviewed. Patients with one or more surveillance ultrasound examinations were included. Thrombus resolution was defined as multiphasic flow throughout the index limb without evidence of echogenic intraluminal material by ultrasound. Time to resolution of thrombus was assessed using Kaplan-Meier analysis. RESULTS Fifty-four limbs in 50 patients were identified with acute IFAT. The median age was 9.9 weeks (interquartile range, 3.1-21.7 weeks), with a median weight of 4.2 kg (interquartile range, 3.3-5.5 kg). The majority of limbs (65%) with acute IFAT presented with a diminished pedal Doppler signal, commonly after cardiac catheterization (55%). Forty-eight (89%) limbs had complete arterial occlusion on index ultrasound, and flow could not be detected below the ankle in 48%. The median number of ultrasound examinations per limb was three (range, two to seven), and 61% of limbs had a surveillance ultrasound within 7 days of diagnosis. At 14 and 30 days, 33% and 64% of patients, respectively, treated with anticoagulation had an estimated complete resolution of thrombus. Nine (17%) patients did not receive anticoagulation, and only two of these patients experienced IFAT resolution. At the time of diagnosis, one patient underwent open thrombectomy because of a contraindication to anticoagulation, and one patient was treated with thrombolysis. There were no instances of tissue loss or amputation CONCLUSIONS: Management of IFAT with anticoagulation resulted in successful short-term outcomes. Based on the observed rate of resolution, management should start with anticoagulation, followed by surveillance ultrasound at 2-week intervals. With treatment by anticoagulation, resolution can be expected to occur in one-third of patients every 2 weeks.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Christina R Kuhrau
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Bian Wu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Devin S Zarkowsky
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Adam Z Oskowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Amar Nijagal
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Shant M Vartanian
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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Maithel S, Fujitani RM, Grigorian A, Kabutey NK, Gambhir S, Sheehan BM, Nahmias J. Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma. Ann Vasc Surg 2020; 66:242-249. [PMID: 31978483 DOI: 10.1016/j.avsg.2020.01.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.
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Affiliation(s)
- Shelley Maithel
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA.
| | - Roy M Fujitani
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
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Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
Replantation and revascularization in the pediatric extremity has unique challenges that provide a fertile field of research and clinical experience. Children regenerate peripheral nerves rapidly, resulting in good sensory and motor function. They adapt well to functional deficits and mismatch errors of reinnervation. The technical aspects of microsurgical care in children can be challenging because the structures are small. Additional technical challenges include preservation of growth centers, prevention of vasospasm, protection of the reconstruction, and psychosocial care. Despite these challenges, children show excellent functional outcomes with minimal complications.
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Affiliation(s)
- Amir H Taghinia
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 1, Boston, MA 02115, USA.
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