Management strategies for the treatment of iatrogenic vascular injuries in infants and children.

BACKGROUND

The care of ill children, from extremely premature infants to late adolescents, increasingly involves the use of invasive monitoring and percutaneous diagnostic and therapeutic interventions. Premature infants, neonates, and small children are at greatest risk for iatrogenic vascular injury. Given the often small diameter of the blood vessels and the ability to develop severe spasm, iatrogenic vascular injury is increasing. The very nature of their hemostatic mechanisms, small vascular diameters, tolerance of severe ischemia, and the potential for rapid growth and remodeling of collateral beds alters decision-making significantly from adults. Surgery, when required, may involve microsurgery and subtle changes in the methods of vascular dissection and arterial repair. There is little information available for the vascular surgeon to understand the risks and nature of these injuries and the options for treatment. This review addresses the mechanisms of and management strategies for the most common iatrogenic injuries.

METHODS

The National Task Force on Pediatric Vascular Care established jointly by the Society for Vascular Surgery and the American Pediatric Surgery Association appointed a working group with expertise in managing pediatric iatrogenic vascular injuries to develop a support document for vascular surgeons. To do this, the published literature was reviewed on pediatric iatrogenic injuries that vascular surgeons might be called to manage. Intracranial injuries and those associated with extracorporeal membrane oxygenation were excluded. The majority of injuries reported in the literature involved femoral and brachial artery cannulation sites. The literature was reviewed by the writing group and the most important of these selected. In addition, consensus expert opinion from the writing group was used when support from the literature was scant.

RESULTS

There were six major types of pediatric iatrogenic vascular injury identified: arteriovenous fistula, pseudoaneurysm, hemorrhage, arterial and venous thrombosis, and pharmacological ischemia. There is little uniform documentation on the diagnosis and treatment of these. Using the available literature and consensus expert opinion of the working group, each of the major categories of iatrogenic injury was defined and management strategies devised.

CONCLUSIONS

There is often a nonsurgical approach to the management of the six major types of iatrogenic injury. It is important for the vascular consultant to understand and incorporate these approaches to develop comprehensive management strategies for children with iatrogenic vascular injuries. When treatment of even the smallest of pediatric patients is undertaken with a clear understanding of the etiology and treatment options, a very high rate of success can be expected.