Articles

Management strategies for the treatment of iatrogenic vascular injuries in infants and children. [1]White JV et al., J Vasc Surg. 2025 Aug;82(2):359-374. PMID: 40107521

Iatrogenic vascular injuries can complicate the care of some of the most fragile pediatric patients, including premature infants, patients requiring central venous access or cardiac catheterization procedures, patients with severe hemodynamic or respiratory failure requiring ECMO support, or children undergoing surgical management of congenital anomalies. Research on how best to manage these injuries is limited in both scope and volume.

This study provides a systematic framework for the pediatric surgical and vascular teams to evaluate a patient with possible iatrogenic vascular injury, including history and physical exam findings, imaging studies, and management strategies. This should serve as a reference article both for practicing pediatric surgery and trainees, but also for providers managing children in the pediatric emergency department, neonatal intensive care unit, and pediatric intensive care unit.

- For arteriovenous fistulae, the authors recommend a period of observation with elective repair (either ligation/ vascular repair or endovascular coiling) after several weeks unless signs of cardiopulmonary compromise are identified.

- For pseudoaneurysms, the first line treatment is direct pressure with ultrasound guidance and holding anticoagulation if present and deemed safe by the treating team. Persistent active bleeding should be managed urgently with vascular repair, while a small pseudoaneurysm can usually be successfully managed nonoperatively; small pseudoaneurysms that fail to resolve can be repaired electively. It is critical to avoid re-puncturing the same vessel in patients with a history of pseudoaneurysm and note should be made of this in the patient’s record if possible.

- Management of hemorrhage, usually related to either complications of vessel cannulation or coagulopathy, is managed blood resuscitation if needed, direct pressure and correction of any coagulopathy, and is usually followed by surgical repair of the vascular injury unless hemostasis is rapidly achieved. - - Arterial thrombosis is most commonly seen in use of an oversized cannula in a small vessel or multiple attempts at access, particularly in small infants. As in adult vascular surgery, management is dictated by evidence of the severity of acute limb ischemia, as evaluated by pulse oximetry on the affected limb as well as motor, sensation, and pain. Preserved sensation and motor function are reassuring and the patient should be anticoagulated with unfractionated or low molecular weight heparin as appropriate which is successful in 85-100% of children; lack of improvement in 4 hours suggests the need to consider possible lytic therapy vs vascular exploration and thrombectomy. For patients with paresis/ paralysis of the extremity, vascular intervention is indicated, and fasciotomies should be considered. Infants requiring surgical intervention may need to be managed by a multi-disciplinary team, including a surgeon comfortable with microsurgery such as a plastic surgeon or neurosurgeon, as well as a vascular surgeon. For the smallest premature infants, operative intervention is limited technically and they are most effectively managed with anticoagulation and monitoring.

- Venous thrombosis is usually treated by removal of the cannula if possible followed by systemic anticoagulation. Direct oral anticoagulants are approved for use in infants and children and make long term management much less complicated. Extensive thrombosis or extreme swelling or even progression to phlegmasia can be managed with lytic therapy or thrombectomy as appropriate as long as the child is large enough to permit placement of a venous device larger than 5 french.

- Pharmacologic vascular injury is most often seen in the setting of pressors used for maintaining central pressures/ perfusion often at the expense of peripheral vasoconstriction leading to ischemia. Treatment is limited to supportive care since the offending agents cannot usually be discontinued. Gentle warming of the affected extremity and use of topical nitroglycerin have been shown to improve rates of limb salvage, but direct heat application should be avoided because of the risk of thermal injury.

Results of nonoperative management of acute limb ischemia in infants. [2]Wang SK et al., J Vasc Surg. 2018 May;67(5):1480-1483. PMID: 29224940

Nonoperative management of acute limb ischemia is often pursued in small infants due to the technical challenges. This study presents a single institution’s experience over a decade with nonoperative management of both iatrogenic and non-iatrogenic cases of acute limb ischemia.

This study demonstrates the safety and efficacy of anticoagulation as the primary approach to acute arterial thrombosis, even in premature infants, and is the largest population with the best reported follow-up. Eighty percent of children were deemed appropriate for an unfractionated heparin infusion with management recommendations from the hematology service. Patients were transitioned to LMWH or warfarin for a total of 4 weeks, with surveillance imaging at 4 week intervals until resolution of the occlusion. They report that no infant was on anticoagulation after the 3 month mark, and a 96% success rate of limb salvage. Patients who were not anticoagulated due to a prohibitively high risk of bleeding, including concern for possible intraventricular hemorrhage. Thrombolysis was safely and successfully performed for two infants with progressive disease while on heparin.

Natural History of Iatrogenic Pediatric Femoral Artery Injury. [3]Andraska EA et al., Ann Vasc Surg. 2017 Jul;42:205-213. PMID: 28341498

Iatrogenic injury to the femoral artery occurs following cardiac catheterization, ECMO cannulation or arterial line placement. Nonoperative management of iatrogenic femoral artery injury in neonates is generally considered to be safe and effective. Few studies have prospectively followed patients following nonoperative management, so there is little data to guide an evidence-based post injury surveillance strategy.

This study followed a cohort of over 80 patients with iatrogenic acute femoral injury. While the majority were managed with nonoperative management, eight patients required acute operative intervention including patch angioplasty, primary repair and/or distal thrombectomy. Nine percent of patients eventually developed signs or symptoms of chronic limb ischemia, such as limb length discrepancy, abnormal gait, or claudication symptoms. Symptomatic patients presented on average about 2.5 years after the injury (range 3 months to 6 years, and all underwent revascularization often with interposition graft with greater saphenous vein or patch angioplasty. This study highlights the need both for ongoing active surveillance for patients with iatrogenic vascular injury to identify signs and symptoms of chronic limb ischemia and prevent more significant sequelae. Additionally, the relative frequency of the need for intervention reinforces the need for a vascular surgery “pediatric champion” who collaboratively manages these children with the pediatric surgical team.

Ultrasound-Guided Femoral Arterial Cannulation in Neonates Undergoing Cardiac Surgery or Catheterization: Comparison of 0.014-Inch Floppy Versus 0.019-Inch Straight Guidewire. [4]Polat TB et al., Pediatr Crit Care Med. 2019 Jul;20(7):608-613. PMID: 31013264

Vascular access, particularly in small infants, can be technically quite challenging. Multiple access attempts is associated with a higher rate of cannulation failure and potential thrombosis leading to acute limb ischemia.

This study demonstrates that even in low birth weight/ premature infants, use of a smaller diameter floppy tipped wire was associated with a higher success rate at the first attempt and lower rates of subsequent acute limb ischemia. This approach should be considered when performing vascular access on neonates to reduce access complications.

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