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Iatrogenic Vascular Lesion Surgery

Background

The term iatrogenic derives from the Greek words iatros (“physician”) and gennan (“to produce”); thus, the term refers to the consequences of medical action. In general, an iatrogenic injury is secondary to one or more of the following:

Performance of a high-risk procedure when a lower-risk option is available

Lack of medical knowledge, negligence, careless practice, or omission

Lack of honesty or medical ethics

Iatrogenic injuries represent a significant proportion (50%) of pediatric vascular trauma. The proportion inversely varies with age, being highest in neonates (80%) and declining to 50% in the 2- to 6-year-old group and to 33% in older children.

Arterial injuries in infants are rare and, in most cases, iatrogenic as a consequence of catheterization, venipuncture, or arterial blood sampling. These lesions require an accurate, noninvasive clinical diagnosis and prompt exploration and reconstruction with microvascular techniques to restore perfusion and avoid morbidity and even mortality. In this age group, any suspected vascular injury calls for immediate clinical and diagnostic assessment to avoid potential life-threatening complications. Surgery is mandatory in the case of extensive arterial injuries, inadequate distal blood supply, or progressive worsening of ischemic clinical findings.

The widespread use of percutaneous vascular access in children and invasive neonatal resuscitation techniques has led to an increased incidence of vascular complications in the pediatric population. The thrombosis rate in children with vascular access ranges from 1% to 25%.

The risk of iatrogenic vascular injuries secondary to catheterization, cannulation for extracorporeal membrane oxygenation (ECMO), cardiopulmonary bypass, repeated venipuncture, or arterial blood sampling has increased. In particular, transfemoral catheterization, transfemoral arteriography, and umbilical artery catheterization used for diagnostic and monitoring purposes have been associated with thromboembolism in the lower extremities.

Although management of these injuries has evolved over time, it is not yet standardized in children. Treatment of these injuries in infants and small children is distinctly different from that in adults. Historically, injured vessels were ligated, or the child was given systemic heparin without repair, however, this expectant therapy resulted in poor limb outcomes, involving high amputation rates and diminished limb growth. Currently, aggressive surgical management yields better results, making early diagnosis and definitive repair the approach of choice at present.

In children, the small size of the vessels, severe arterial vasospasm, and the consequences of diminished blood flow on limb growth must be considered. Moreover, the need for future growth of blood vessels and long-term duration of the repair must be accounted for.

Follow-up studies to demonstrate protection of the limb by medical and surgical treatment of iatrogenic vascular injuries are needed. With the advent of newer technology and the clinical possibilities that it offers, the management of pediatric vascular injuries will continue to evolve. There is no doubt that the use minimally invasive techniques will continue to expand.

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