Imaging Studies
The diagnosis of iatrogenic vascular trauma must be made promptly so that appropriate treatment can be initiated. Most often, the diagnosis of vascular injury is made clinically through recognition of hard signs of vascular injury (eg, bleeding or expanding hematoma). In the absence of these signs, however, imaging studies are useful for making the diagnosis.
After a change in postprocedural neurovascular observations, arterial duplex ultrasonography (US) should be performed. [4] At present, routine postprocedural US has not been shown to be beneficial. [4] Duplex US is sensitive in diagnosing vascular occlusions, arteriovenous fistulas (AVFs), and pseudoaneurysms. [4] It is the preferred imaging modality in the pediatric population, in that it is noninvasive and does not involve exposure to ionizing radiation.
In the diagnosis of AVFs, computed tomography (CT) angiography (CTA) or magnetic resonance angiography (MRA) may be used to achieve better definition of the anatomy. [4] Although CTA provides excellent imaging resolution, its risks and benefits must be carefully considered, given the known risk of radiation exposure in children.
Digital subtraction arteriography (DSA) and high-resolution US are newer techniques that may further facilitate the diagnosis and management of these injuries.
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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.
