Management of iatrogenic arterial injuries in infants and children

Abstract

Thirty-two patients with 33 suspected iatrogenic arterial injuries were evaluated from 1974 to 1982. Their mean age was 2.5 yr. Twenty-one injuries occurred after angiography and 7 followed umbilical artery catheterization. Of 5 clinical features of patient presentation, only the Doppler ultrasound examination permitted distinction of mechanical from functional arterial obstruction, detecting 92% of the mechanical obstructions. Twenty-one (64%) of the injuries were thought due to mechanical obstruction and 18 of these were due to thrombosis. Twelve injuries were due to spasm and were completely reversed without operation. Tissue loss occurred in 6 (18%), only 1 of whom received intravenous heparin. There were 7 deaths, 4 related to the vascular injury. Results in the first week after injury were excellent or acceptable in 74% of all injuries and 90% of those following angiography. Eight of 10 children (80%) treated with heparin had an acceptable or excellent late result, while only 9 of 16 children (56%) treated without heparin had acceptable or excellent results. Six early operations were performed; 4 were thrombectomies of which 2 were successful. Five late operations were performed, of which 2 resulted in correction of leg length discrepancy and 1 in relief of claudication. There were no complications of heparin therapy. We conclude that if there is no early return to normal clinical examination after a suspected iatrogenic arterial injury in an infant or young child, intravenous heparin therapy should be instituted. If the Doppler examination is not normal after 48 hr, thrombectomy should be pursued in otherwise well patients. If thrombectomy fails or if the child is seriously ill, continued observation is reasonable. Long-term follow-up should include scanograms for following leg length discrepancy. If aortic obstruction is suspected, early operative intervention may improve currently poor results. Thirty-two patients with 33 suspected iatrogenic arterial injuries were evaluated from 1974 to 1982. Their mean age was 2.5 yr. Twenty-one injuries occurred after angiography and 7 followed umbilical artery catheterization. Of 5 clinical features of patient presentation, only the Doppler ultrasound examination permitted distinction of mechanical from functional arterial obstruction, detecting 92% of the mechanical obstructions. Twenty-one (64%) of the injuries were thought due to mechanical obstruction and 18 of these were due to thrombosis. Twelve injuries were due to spasm and were completely reversed without operation. Tissue loss occurred in 6 (18%), only 1 of whom received intravenous heparin. There were 7 deaths, 4 related to the vascular injury. Results in the first week after injury were excellent or acceptable in 74% of all injuries and 90% of those following angiography. Eight of 10 children (80%) treated with heparin had an acceptable or excellent late result, while only 9 of 16 children (56%) treated without heparin had acceptable or excellent results. Six early operations were performed; 4 were thrombectomies of which 2 were successful. Five late operations were performed, of which 2 resulted in correction of leg length discrepancy and 1 in relief of claudication. There were no complications of heparin therapy. We conclude that if there is no early return to normal clinical examination after a suspected iatrogenic arterial injury in an infant or young child, intravenous heparin therapy should be instituted. If the Doppler examination is not normal after 48 hr, thrombectomy should be pursued in otherwise well patients. If thrombectomy fails or if the child is seriously ill, continued observation is reasonable. Long-term follow-up should include scanograms for following leg length discrepancy. If aortic obstruction is suspected, early operative intervention may improve currently poor results.