Evidence for nonoperative management of acute limb ischemia in infants
2011; Elsevier BV; Volume: 55; Issue: 4 Linguagem: Inglês
10.1016/j.jvs.2011.09.092
ISSN1097-6809
AutoresJesus M. Matos, Andres Fajardo, Michael C. Dalsing, Raghu L. Motaganahalli, George Akingba, Michael P. Murphy,
Tópico(s)Vascular Procedures and Complications
ResumoAcute limb ischemia (ALI) in infants is a catastrophic event. We performed a query of our database to determine those with ALI. Twelve patients were identified. The most frequent presentation was cyanotic limbs. Eleven patients were treated nonoperatively with anticoagulation. One patient was treated surgically with Fogarty balloon thrombectomy. There were three deaths all due to associated comorbidities. All had viable limbs on follow-up examination. There were three complications in the patients managed conservatively. Our recommendation for infants presenting with ALI is conservative observation with anticoagulation and intervention only for cases with tissue loss. Acute limb ischemia (ALI) in infants is a catastrophic event. We performed a query of our database to determine those with ALI. Twelve patients were identified. The most frequent presentation was cyanotic limbs. Eleven patients were treated nonoperatively with anticoagulation. One patient was treated surgically with Fogarty balloon thrombectomy. There were three deaths all due to associated comorbidities. All had viable limbs on follow-up examination. There were three complications in the patients managed conservatively. Our recommendation for infants presenting with ALI is conservative observation with anticoagulation and intervention only for cases with tissue loss. Acute limb ischemia (ALI) is a catastrophic event that portends a significant probability of limb loss. ALI in the infant population (≤1 year old) is an exceedingly rare clinical event, and consequently, consensus management guidelines do not exist.1Whitehouse W.M. Coran A.G. Stanley J.C. Kuhns L.R. Weintraub W.H. Fry W.J. Pediatric vascular trauma Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment.Arch Surg. 1976; 111: 1269-1275Crossref PubMed Scopus (77) Google Scholar, 2Gamba P. Tchaprassian Z. Verlato F. Verlato G. Orzali A. Zanon G.F. Iatrogenic vascular lesions in extremely low birth weight and low birth weight neonates.J Vasc Surg. 1997; 26: 643-646Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Over the past decade, there have been several successful reports of limb salvage in children over a wide range of ages with anticoagulation and/or thrombolytic therapy but no series focusing specifically on the infant population with ALI.3Lazarides M.K. Georgiadis G.S. Papas T.T. Gardikis S. Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities.J Vasc Surg. 2006; 43 (Discussion:6): 72-76Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 4Kothari S.S. Varma S. Wasir H.S. Thrombolytic therapy in infants and children.Am Heart J. 1994; 127: 651-657Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 5Perry M.O. Iatrogenic injuries of arteries in infants.Surg Gynecol Obstet. 1983; 157: 415-418PubMed Google Scholar, 6Dillon P.W. Fox P.S. Berg C.J. Cardella J.F. Krummel T.M. Recombinant tissue plasminogen activator for neonatal and pediatric vascular thrombolytic therapy.J Pediatr Surg. 1993; 28 (Discussion:8-9): 1264-1268Abstract Full Text PDF PubMed Scopus (69) Google Scholar In this report, we provide a review of our experience in the management of ALI in the infant population, demonstrating efficacy in limb salvage with conservative management consisting of anticoagulation and close monitoring of limb viability. The Indiana University School of Medicine Vascular Surgery Section maintains a database of all vascular interventions and consultations performed by our staff at the Clarian Hospital System (Methodist, University, and Riley). The protocol of this study was approved by institutional review board review. Query of this database for all patients with acute limb ischemia in infants (defined as less than 1 year of age) from 2004 to 2010 was conducted. Data collected and analyzed included age, gender, medical comorbidities, affected extremity, mechanism of occlusion, presenting symptoms, diagnostic studies, treatment, and follow-up data. Between November 21, 2004 and April 12, 2010 there were 12 patients identified with ALI7Norgren L. Hiatt W.R. Dormandy J.A. Nehler M.R. Harris K.A. Fowkes F.G. et al.Inter-Society Consensus for the Management of peripheral Arterial Disease (TASC II).J Vasc Surg. 2007; 45: S5-S67Abstract Full Text Full Text PDF PubMed Scopus (4327) Google Scholar (Fig 1) . Injuries were more common in male patients (n = 9; 75%) with an average age of 3 months (range, 10 days-8 months). At presentation, seven (59%) patients had absent pulses by examination, and nine (75%) had limb cyanosis (Fig 2) . A color-flow duplex ultrasound (DUS) was initially obtained on all patients that provided sufficient information to confirm the diagnosis, mitigating the need for additional imaging studies. Comorbidities included congenital cardiac disease (n = 5; 42%), pulmonary failure requiring mechanical ventilation (n = 4; 33%), prematurity (n = 1; 8%), sepsis (n = 1; 8%), and intermittent methemoglobinemia (n = 1; 8%).Fig 2Infant with cyanotic limb at time of presentation.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Intra-arterial catheterizations for diagnostic or monitoring purposes were the cause of ALI in 11 (92%) patients. Vessels of the lower extremity were more commonly injured (n = 9; 75%), and arteries that were injured were the common femoral artery (n = 7; 58%), superficial femoral artery (n = 2; 17%), radial artery (n = 2; 17%), and brachial artery (n = 1; 8%). Six of the patients had dopamine running during evaluation of the ischemic event. Twelve patients were anticoagulated with unfractionated heparin (n = 10) or subcutaneous (SQ) enoxaparin.2Gamba P. Tchaprassian Z. Verlato F. Verlato G. Orzali A. Zanon G.F. Iatrogenic vascular lesions in extremely low birth weight and low birth weight neonates.J Vasc Surg. 1997; 26: 643-646Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Unfractionated heparin was administered as an initial bolus of 100 units/kg followed by continuous infusion of 20 units/kg/hr to achieve an activated partial thromboplastin time (APTT) of 2 to 2.5 times normal. DUS was performed serially during the critical period of initiating anticoagulation. All patients were transitioned from heparin to SQ enoxaparin. Patients continued for 3 to 4 weeks with follow-up DUS. There was one failure of anticoagulation with heparin manifesting as ulceration and gangrene 48 hours after initiation of therapy. The patient underwent common femoral artery thrombectomy with a #3 Fogarty balloon catheter and four compartment fasciotomies with restoration of distal pulses. There were two deaths (18%) in the anticoagulation group during treatment for ALI. One patient died 2 days and the second patient died 9 days after vascular surgery evaluation due to heart failure. Out of the remaining nine patients, we had follow-up data on seven. On follow-up visits, every patient had repeat DUS. Three patients experienced complications felt to be related to limb ischemia: One was found to have a size discrepancy of 1 cm of the foot on the fully functional index limb, a second patient required skin debridement and grafting due to skin necrosis, and the third patient lost a fingernail. One patient had a follow-up DUS 24 days after treatment with enoxaparin that documented persistent occlusion of the common femoral artery with notable development of a collateral branch perfusing the superficial femoral artery (Fig 3) . The one patient that was managed with surgical thrombectomy died 30 days after surgery from septic shock unrelated to the surgery or complications of limb ischemia. Infant vascular injuries are rare and account for <1% of patients with acute limb ischemia seen by vascular surgeons.8Dalsing M.C. Cikrit D.F. Sawchuk A.S. Open surgical repair of children less than 13 years old with lower extremity vascular injury.J Vasc Surg. 2005; 41: 983-987Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Iatrogenic vascular injuries are more common in the infant population, while older children and adolescent will experience penetrating injuries.9Smith C. Green R.M. Pediatric vascular injuries.Surgery. 1981; 90: 20-31PubMed Google Scholar, 10Navarre J.R. Cardillo P.J. Gorman J.F. Clark P.M. Martinez B.D. Vascular trauma in children and adolescents.Am J Surg. 1982; 143: 229-231Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 11Flanigan D.P. Keifer T.J. Schuler J.J. Ryan T.J. Castronuovo J.J. Experience with iatrogenic pediatric vascular injuries Incidence, etiology, management, and results.Ann Surg. 1983; 198: 430-442Crossref PubMed Scopus (93) Google Scholar Common causes for infant vascular injuries are cardiac catheterizations and arterial blood pressure monitoring devices.11Flanigan D.P. Keifer T.J. Schuler J.J. Ryan T.J. Castronuovo J.J. Experience with iatrogenic pediatric vascular injuries Incidence, etiology, management, and results.Ann Surg. 1983; 198: 430-442Crossref PubMed Scopus (93) Google Scholar “Soft signs” of vascular injury are difficult to evaluate on this population age due to lack of verbalization of pain and diminished or absent sensation.8Dalsing M.C. Cikrit D.F. Sawchuk A.S. Open surgical repair of children less than 13 years old with lower extremity vascular injury.J Vasc Surg. 2005; 41: 983-987Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar In the infant population, active bleeding is the absolute indication for operation.12Dalsing M.C. Cikrit D.F. Sawchuk A.P. Open surgical repair of children less than 13 years old with lower extremity vascular injury.J Vasc Surg. 2005; 41: 983-987Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar There is limited literature when it comes to management of infants with ALI. Surgical management of these injuries represents a technical challenge; not only the small vessel size but also the problem of arterial spasms can cause difficulties. Our institution previously published how open surgical repair in older children with blunt vascular injuries allowed limb salvage in the absence of diagnostic delay.12Dalsing M.C. Cikrit D.F. Sawchuk A.P. Open surgical repair of children less than 13 years old with lower extremity vascular injury.J Vasc Surg. 2005; 41: 983-987Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar There are multiple series that report surgical intervention of pediatric patients1Whitehouse W.M. Coran A.G. Stanley J.C. Kuhns L.R. Weintraub W.H. Fry W.J. Pediatric vascular trauma Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment.Arch Surg. 1976; 111: 1269-1275Crossref PubMed Scopus (77) Google Scholar, 12Dalsing M.C. Cikrit D.F. Sawchuk A.P. Open surgical repair of children less than 13 years old with lower extremity vascular injury.J Vasc Surg. 2005; 41: 983-987Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 13Lin P.H. Dodson T.F. Bush R.L. Weiss V.J. Conklin B.S. Chen C. et al.Surgical intervention for complications caused by femoral artery catheterization in pediatric patients.J Vasc Surg. 2001; 34: 1071-1078Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 14Aspalter M. Domenig C.M. Haumer M. Kitzmüller E. Kretschmer G. Hölzenbein T.J. Management of iatrogenic common femoral artery injuries in pediatric patients using primary vein patch angioplasty.J Pediatr Surg. 2007; 42: 1898-1902Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 15Shah S.R. Wearden P.D. Gaines B.A. Pediatric peripheral vascular injuries: a review of our experience.J Surg Res. 2009; 153: 162-166Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar and infants2Gamba P. Tchaprassian Z. Verlato F. Verlato G. Orzali A. Zanon G.F. Iatrogenic vascular lesions in extremely low birth weight and low birth weight neonates.J Vasc Surg. 1997; 26: 643-646Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 16Friedman J. Fabre J. Netscher D. Jaksic T. Treatment of acute neonatal vascular injuries–the utility of multiple interventions.J Pediatr Surg. 1999; 34: 940-945Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 17Chaikof E.L. Dodson T.F. Salam A.A. Lumsden A.B. Smith 3rd, R.B. Acute arterial thrombosis in the very young.J Vasc Surg. 1992; 16: 428-435Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar with ALI, but according to Lin et al15Shah S.R. Wearden P.D. Gaines B.A. Pediatric peripheral vascular injuries: a review of our experience.J Surg Res. 2009; 153: 162-166Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar operative results in children younger than 2 years leads to less satisfactory outcomes when compared with older children.5Perry M.O. Iatrogenic injuries of arteries in infants.Surg Gynecol Obstet. 1983; 157: 415-418PubMed Google Scholar, 9Smith C. Green R.M. Pediatric vascular injuries.Surgery. 1981; 90: 20-31PubMed Google Scholar Lazarides et al conducted a review of the literature describing outcomes of surgically managed patients in children ≤2.5 years of age and found only 48% of patients were able to regain palpable pulses, and limb discrepancy was detected in as many as 15% of patients.3Lazarides M.K. Georgiadis G.S. Papas T.T. Gardikis S. Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities.J Vasc Surg. 2006; 43 (Discussion:6): 72-76Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar In terms of a more conservative approach, there are several management guidelines that have been proposed.2Gamba P. Tchaprassian Z. Verlato F. Verlato G. Orzali A. Zanon G.F. Iatrogenic vascular lesions in extremely low birth weight and low birth weight neonates.J Vasc Surg. 1997; 26: 643-646Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 3Lazarides M.K. Georgiadis G.S. Papas T.T. Gardikis S. Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities.J Vasc Surg. 2006; 43 (Discussion:6): 72-76Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 18Saxena A. Gupta R. Kumar R.K. Kothari S.S. Wasir H.S. Predictors of arterial thrombosis after diagnostic cardiac catheterization in infants and children randomized to two heparin dosages.Cathet Cardiovasc Diagn. 1997; 41: 400-403Crossref PubMed Scopus (61) Google Scholar, 19Weiner G.M. Castle V.P. DiPietro M.A. Faix R.G. Successful treatment of neonatal arterial thromboses with recombinant tissue plasminogen activator.J Pediatr. 1998; 133: 133-136Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar One includes the use of thrombolytic agents as the first-choice therapy for 48 hours followed by microsurgery if no improvement was seen.2Gamba P. Tchaprassian Z. Verlato F. Verlato G. Orzali A. Zanon G.F. Iatrogenic vascular lesions in extremely low birth weight and low birth weight neonates.J Vasc Surg. 1997; 26: 643-646Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Lazarides et al recommended only operating on infants with definite threat of limb loss and doing systemic heparinization or thrombolytic therapy, knowing that limb length discrepancies will be inevitable.3Lazarides M.K. Georgiadis G.S. Papas T.T. Gardikis S. Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities.J Vasc Surg. 2006; 43 (Discussion:6): 72-76Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar The recommended conservative method is the administration of heparin as an initial bolus of 75 to 100 units/kilogram with an infusion depending on age: for the <2 month old, 28 units/kilogram/hour, while older infants require only 20 units/kilogram/hour.8Dalsing M.C. Cikrit D.F. Sawchuk A.S. Open surgical repair of children less than 13 years old with lower extremity vascular injury.J Vasc Surg. 2005; 41: 983-987Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 20Monagle P. Chan A. Massicotte P. Chalmers E. Michelson A.D. Antithrombotic therapy in children: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.Chest. 2004; 126: 645S-687SCrossref PubMed Scopus (386) Google Scholar Other groups recommend the use of thrombolytic agents in a selective group of patients who do not respond to systemic heparin anticoagulation.19Weiner G.M. Castle V.P. DiPietro M.A. Faix R.G. Successful treatment of neonatal arterial thromboses with recombinant tissue plasminogen activator.J Pediatr. 1998; 133: 133-136Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 20Monagle P. Chan A. Massicotte P. Chalmers E. Michelson A.D. Antithrombotic therapy in children: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.Chest. 2004; 126: 645S-687SCrossref PubMed Scopus (386) Google Scholar Criticism of conservative management includes the possibility of developing compartment syndrome and limb length discrepancies.3Lazarides M.K. Georgiadis G.S. Papas T.T. Gardikis S. Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities.J Vasc Surg. 2006; 43 (Discussion:6): 72-76Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 9Smith C. Green R.M. Pediatric vascular injuries.Surgery. 1981; 90: 20-31PubMed Google Scholar, 11Flanigan D.P. Keifer T.J. Schuler J.J. Ryan T.J. Castronuovo J.J. Experience with iatrogenic pediatric vascular injuries Incidence, etiology, management, and results.Ann Surg. 1983; 198: 430-442Crossref PubMed Scopus (93) Google Scholar In the infant population, supportive care and the use of systemic anticoagulation with heparin is the best management for most patients. Limb viability was 100% in this series of infants with ALI managed nonoperatively, and we propose that favorable remodeling in parallel collateral vessels occurs due to changes in flow dynamics with acute occlusion. Our recommendation for infants presenting with ALI is physical examination followed by DUS and systemic anticoagulation with heparin and transitioned to SQ lovenox. Patients should undergo serial examinations to assess changes in perfusion of the index limb and a repeat DUS in 3 to 4 weeks. We further recommend that if adequate perfusion of the limb is established by examination and DUS, then anticoagulation should be stopped. During the observational period, it is important for the vascular surgeon to establish expectations with the family. It is important to warn the family that the child could suffer limb discrepancies. If DUS depicts restoration of flow with collateral formation, anticoagulation can be stopped. Surgical intervention is indicated in patients with tissue loss, active bleeding, or lack of response to systemic anticoagulation. DiscussionJournal of Vascular SurgeryVol. 55Issue 4PreviewDr George Hamilton (London, United Kingdom). Congratulations on your results; we have a similar experience. What you haven't mentioned is thrombolysis. As a tertiary referral center, a lot of our children get to us late, having been treated at other hospitals. Our protocol is to start with anticoagulation absolutely monitored with APTT for a period of 6 hours or so. If that doesn't improve perfusion, systemic thrombolysis is then used. There is a risk, particularly in preterm infants, of cerebral hemorrhage, but that risk actually is worth taking because the results of thrombolysis are universally good except in irreversible ischemia. Full-Text PDF Open Archive
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