PEDIATRIC VASCULAR INJURIES

Pearls

- Intervention should be avoided in those less than 10 years old given propensity for spasm.
- Ligation is more well tolerated in infants and toddlers given ability to recruit collaterals.
- Perform interrupted suture lines (6-0 Prolene) to allow expansion with growth of child.

Although rare, deployed surgeons can expect to see young patients with vascular injury. Intervention of any type, including angiography, should be avoided in those less than 5 years even if an extremity appears ischemic (i.e. without Doppler signal). The small size of arteries in children and their propensity for vasospasm makes it more likely that an intervention will do harm or confuse the clinical scenario rather than improve the situation. Because of the ability of children to tolerate relative limb ischemia and to develop collateral circulation, ligation of bleeding vessels alone is recommended with warming of the extremity and resuscitation. In rare cases, in children older than 8, reconstruction of larger proximal arteries can be accomplished using reversed saphenous vein. In such instances, the anastomosis should be performed using interrupted suture allowing expansion as the child grows.1

ENDOVASCULAR CAPABILITY & INFERIOR VENA CAVA FILTERS

(See Trauma-Specific Endovascular Inventory Tables) 2

Pearls

- Techniques should be used in a small subset of injuries and directed by a trauma surgeon.
- Indications for vena cava filter include inability to initiate chemoprophylaxis within 48 hours of injury and the occurrence of pulmonary embolus while on chemoprophylaxis.

The emergence of catheter based endovascular technology to manage injury in the civilian setting has been expanded to the wartime setting. Although advantageous in a small set of combat injuries, endovascular capability in austere settings is in its early stages and its application should be directed by appropriately trained surgeons or interventional radiologists. Injury patterns and procedures which lend themselves to endovascular techniques include central injuries of the thoracic aorta and brachiocephalic vessels (subclavian and carotid) and select patterns of solid organ and pelvic injury amenable to coil embolization. Placement of vena cava filters to reduce the risk of pulmonary thromboembolic events is indicated in patients who cannot receive chemoprophylaxis or therapy with heparin. A trauma specific endovascular inventory for in-theater capability is listed in Trauma-Specific Endovascular Inventory Tables on the next page.

Indications for placement of an inferior vena cava filter include an inability to initiate chemoprophylaxis with low molecular weight heparin or unfractionated heparin due to contraindications, proximal deep vein thrombosis and contraindications for full anticoagulation, failed trial of anticoagulation for DVT or pulmonary embolism (progression or bleeding). Examples of contraindications to chemoprophylaxis include significant traumatic brain, solid organ, or pelvic injuries with bleeding (refer to JTS Prevention of Venous Thromboembolism CPG). The Günther-Tulip (Cook Medical, Inc.) filter is currently recommended because of its established record of success and its ability to be removed in certain circumstances. (See tables on the next page.)