History and Physical Examination
Pediatric iatrogenic vascular trauma may present acutely or may manifest late after the original vascular procedure or trauma.
Usually, signs and symptoms of vascular injuries are immediately apparent. Patients with limb ischemia present with the classic signs of distal hypoperfusion or cold skin plus the "five Ps": pulselessness, pallor, paralysis, paresthesia, and pain. Pulses can be difficult to palpate in infants and small children. However, Doppler technology can be used to confirm flow and compare pressures with those in the contralateral uninvolved limb.
Signs may be transient or may progress quickly to gangrene. Vascular spasm in children is inversely proportional to the size and age of the patient. Simple spasm usually subsides spontaneously within 3 hours. However, lesions suggestive of vascular compromise should not be attributed to spasm. (See the images below.)
Newborn baby boy with right femoral artery lesion during venous cutdown. Artery was surgically repaired. He postoperatively developed severe vasospasm and partial thrombosis, managed with thrombolytics. He had adequate Doppler signal and eventually recovered.
Right-hand gangrene and necrosis secondary to use of brachial artery catheter in very-low-birth-weight baby girl.
Distal right-foot ischemia with fingertip gangrene in newborn baby girl with central venous catheter in right femoral vein, which, after multiple cannulation attempts with accidental arterial catheter placement, developed thrombus that migrated distally and produced ischemia and necrosis.
Assessment of pulses after a procedure is crucial in the early recognition of vascular injury. [4] It is important to note, however, that the presence of pulses distal to the lesion does not completely rule out a vascular injury, because as many as 25% of patients may have distal pulses even in the presence of a vascular insult. If a change in vascular observation of the limb is identified after a procedure, the clinician should consider whether the poor perfusion state is due to arterial injury, vasospasm, or hypoperfusion from shock.
Measurement of the ankle-brachial index (ABI) can also be used to assess arterial perfusion. Whereas an ABI of 1 is considered normal in adults and older children, the normal value for the ABI in children younger than 2 years is 0.88. [2]
A delayed presentation is more likely in patients with certain vascular injuries, including arteriovenous fistulas (AVFs), mycotic aneurysms, pseudoaneurysms, renal vascular occlusion with renovascular hypertension, intermittent claudication, or growth retardation of the affected extremity. Signs and symptoms may be subtle. Particular attention must be paid to poor capillary refill, coolness, diminished pulses, bruits, thrills, blanching, bluish discoloration, lack of movement, and mottling.
Not all patients with thrombosis develop clinical symptoms. On occasion, the vessel is only partially blocked, and collateral blood flow is adequate. This occurs with thromboses associated with umbilical artery catheters. In a series of 4000 patients, only 1% of patients developed clinical symptoms of thrombosis. [11] Patients with acute aortic thrombosis secondary to umbilical artery catheters can present with hypertension or congestive heart failure.
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Right-hand gangrene and necrosis secondary to use of brachial artery catheter in very-low-birth-weight baby girl.
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Superior vena cava syndrome in patient with IV access device (Port-A-Cath) in right subclavian vein. Note facial and upper torso edema and prominent collateral veins.
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Close-up photograph of same patient with port incision and prominent collateral veins characteristic of superior vena cava syndrome secondary to catheter-related thrombotic complication.
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Six-month-old boy with severe superior vena cava syndrome after congenital cardiac surgery. Note severe facial, neck, and upper-chest swelling and distended superficial veins.
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Chest radiograph from same patient above, demonstrating soft-tissue swelling, lung infiltrates, and severely widened mediastinum. Central venous catheter is seen in place. Patient developed superior vena cava thrombosis secondary to central line.
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Caval venogram depicts considerable narrowing of infradiaphragmatic vena cava secondary to right hepatic trisegmentectomy. Patient developed mild inferior vena cava syndrome, was treated nonsurgically (with heparinization), and recovered adequately, developing collateral circulation without sequelae.
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Expanded polytetrafluoroethylene (e-PTFE) graft placed between right brachiocephalic trunk and right common carotid artery in 8-year-old boy with locally advanced medullary thyroid carcinoma, in which artery was resected en bloc with tumor. Neuroprotection was employed during anesthesia. Patient recovered uneventfully without neurologic problems. Graft was placed slightly long to accommodate growth.
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Screen showing internal jugular vein (arrow) and common carotid artery. Duplex blood flow and longitudinal view of internal jugular vein with needle inside (white arrow).
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Proposed algorithm in treatment of pediatric vascular injury. UH = Unfractionated heparin, rt-PA = recombinant-tissue plasminogen activator.
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Neonate boy with high supracondylar left lower limb amputation secondary to thrombosis of femoral artery with arterial line in place. Patient came to our department with signs of irreversible ischemia and extensive necrosis.
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Distal right-foot ischemia with fingertip gangrene in newborn baby girl with central venous catheter in right femoral vein, which, after multiple cannulation attempts with accidental arterial catheter placement, developed thrombus that migrated distally and produced ischemia and necrosis.
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Left-hand fingertip necrosis due to arterial line in brachial artery.
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Newborn baby boy with right femoral artery lesion during venous cutdown. Artery was surgically repaired. He postoperatively developed severe vasospasm and partial thrombosis, managed with thrombolytics. He had adequate Doppler signal and eventually recovered.
