Iatrogenic and Pediatric Vascular Trauma

67.1Definition and presentation

Iatrogenic vascular injury. Access procedures and closure-device failure can produce hemorrhage, pseudoaneurysm, dissection or occlusion. Larsen, Hörer and colleagues reported covered-stent treatment of 20 selected iliofemoral access injuries: technical success was 19/20. Reported patency was 100% among the 15 assessed cases at 30 days and 11 at one year, not among all 20 at both time points. This uncontrolled series supports feasibility in selected cases, not superiority over open repair Endovascular management 2025.

Pediatric vascular trauma epidemiology depends heavily on patient age and mechanism:

• Arterial thrombosis can complicate catheterization in neonates and children CHEST 2012.
• Older children and adolescents present primarily following penetrating mechanisms, road traffic accidents, and falls South India Pediatric Trauma 2025 · Pediatric Trauma Aetiology 2020.

Extremity ischemia in children is frequently one component of a polytrauma pattern, where concurrent hemorrhage, fractures, and head injury drive overall mortality Tanzania Registry 2022 · South India Pediatric Trauma 2025. Older adults with vascular trauma. Assess frailty, pre-injury function, comorbidities and medications alongside injury anatomy. Beta-blockade can mask tachycardia, and apparently acceptable blood pressure can coexist with important hypoperfusion; identify anticoagulant and antiplatelet exposure early. WSES recommends frailty assessment in elderly trauma patients (1B) and a lower threshold for trauma activation (1B). Age alone does not justify withholding hemorrhage control or attempted salvage WSES 2023. Coordinate geriatric assessment, rehabilitation and the patient’s care goals with the trauma and vascular teams ACS 2023.

67.2Anatomy and injury prevention

Ultrasound guidance improves the technical performance of femoral access, but clinical outcome evidence is not uniform. FAUST found fewer vascular complications with ultrasound than fluoroscopic guidance (1.4% versus 3.4%), with better first-pass success and fewer venipunctures FAUST 2010. UNIVERSAL also improved access performance, but its 30-day bleeding/major vascular complication composite was not significantly reduced (12.9% versus 16.1%; OR 0.77, 95% CI 0.49–1.20) UNIVERSAL 2022. These femoral-access results do not establish separate reductions in every pseudoaneurysm, fistula or hematoma outcome for radial access.

Displaced supracondylar humeral fractures in children can compromise the brachial artery. Assess and document limb perfusion and nerve function before treatment, after reduction and during postoperative observation BOASt 2020.

67.3Diagnosis and resuscitation

Pediatric traumatic hemorrhagic shock requires an age- and weight-appropriate resuscitation pathway. The Pediatric Traumatic Hemorrhagic Shock Consensus Conference suggests balanced component resuscitation targeting plasma-to-red-cell and weight-based platelet-to-red-cell ratios near 1:1. These are consensus recommendations supported by limited pediatric evidence, rather than a universal adult-derived protocol Pediatric Traumatic 2023.

Duplex ultrasound is the initial test described in the ACC summary for a suspected femoral postcatheterization pseudoaneurysm ACC 2019. Kelm's femoral arteriovenous-fistula cohort also used duplex for diagnosis AVF 2002.

Pediatric lower-extremity vascular imaging must be interpreted in the context of perfusion and physiology. Lyons and colleagues describe selective CT angiography in hemodynamically stable patients with concerning findings; their study does not support choosing CT angiography because a child is unstable Management lower 2023.

67.4Adult iatrogenic trauma management

The pathways below concern selected postcatheterization femoral pseudoaneurysms and arteriovenous fistulas; they do not constitute a complete emergency algorithm for hemorrhage, arterial occlusion or dissection. Confirm a suspected pseudoaneurysm with duplex ultrasound before choosing treatment. The 2019 ACC review summary describes observation with duplex surveillance for selected stable pseudoaneurysms smaller than 2 cm. Enlargement, significant pain or a continuing need for anticoagulation favors active treatment; size alone does not select a procedure. Rapid expansion, infection, skin necrosis or compression causing ischemia or neuropathy may require surgery ACC 2019.

A femoral arteriovenous fistula does not invariably require immediate repair. In a prospective cardiac-catheterization cohort, some fistulas closed during follow-up and no cardiac volume overload or limb damage was observed in patients with persistent fistulas. This supports considering surveillance in selected patients; it does not establish safety for every symptomatic or high-flow lesion AVF 2002.

Ultrasound-guided thrombin injection is an option for a selected postcatheterization pseudoaneurysm. In Krueger’s historical prospective 240-patient series, primary success was 93.8% and secondary success 99.6%, with two thromboembolic events and one allergic reaction Krueger 2005. This is not a universal current dose protocol. The historical bovine-thrombin technique must not be converted into a current THROMBIN-JMI injection instruction: its US label specifies topical use and states not to inject. Product selection, lesion suitability and the off-label protocol therefore require explicit specialist and pharmacy review; topical concentration instructions must not be copied as an injection prescription THROMBIN-JMI 2026.

Covered-stent repair is an option for selected iliofemoral access injuries, with planned surveillance. The cited small uncontrolled series supports feasibility, without establishing superiority over open repair Endovascular management 2025.

67.5Pediatric vascular trauma management

Reconstruction must account for vessel size, available conduit and future growth. A 2024 single-center pediatric lower-extremity trauma cohort used both saphenous vein and synthetic grafts. The authors favor suitable autologous conduit, while noting that availability, caliber and associated injuries may limit its use. This predominantly adolescent cohort does not establish a universal conduit rule for infants or long-term growth outcomes Management lower 2023.

After reduction and stabilization of a displaced supracondylar humeral fracture, the need for brachial exploration depends on perfusion rather than the radial pulse alone. BOA's October 2020 standard does not require exploration solely for an absent pulse when there is no clinical ischemia. Persistent ischemia after reduction requires exploration by a surgeon competent in small-vessel repair. Document pulse, digital capillary refill and individual nerve function. Continue postoperative neurovascular monitoring until the treating surgeon considers vascular compromise and compartment syndrome no longer a concern. Deterioration requires immediate reassessment and intervention when indicated BOASt 2020.

Catheter-associated arterial thrombosis. CHEST's 2012 guidance separates acute femoral artery thrombosis from peripheral indwelling arterial catheter-related thromboembolism in neonates and children. For acute femoral thrombosis, it recommends initial therapeutic intravenous unfractionated heparin (UFH), then suggests continued UFH or conversion to low-molecular-weight heparin to complete 5–7 days of therapeutic anticoagulation. For femoral thrombosis threatening a limb, or an organ through proximal extension, despite initial UFH, CHEST recommends thrombolysis when there are no known contraindications. It recommends surgery when thrombolysis is contraindicated and limb or organ loss is imminent. For peripheral arterial catheter-related thromboembolism it suggests immediate catheter removal; symptomatic cases receive UFH with or without thrombolysis, or thrombectomy and microvascular repair followed by heparin. These dated recommendations require specialist pediatric assessment and do not provide a complete current dosing or monitoring protocol CHEST 2012.

67.6Surveillance and follow-up

For selected small, stable femoral pseudoaneurysms managed conservatively, the 2019 ACC summary describes weekly duplex surveillance until thrombosis ACC 2019. Pediatric reconstruction follow-up should assess perfusion and growth. Reliable long-term estimates remain limited: the 2024 lower-extremity cohort could not accurately assess growth or bypass occlusion because vascular-specific follow-up was incomplete Management lower 2023.

Krueger’s historical thrombin series documented reperfusion after initial success, supporting follow-up assessment of sustained thrombosis. Its study-specific schedule should not be treated as a universal current protocol Krueger 2005.

67.7Areas of controversy

Pediatric deployment of resuscitative endovascular balloon occlusion of the aorta (REBOA) remains constrained by a lack of pediatric-specific trials, limits in equipment sizing for young children, and uncertainty regarding selection criteria. Current utilization is primarily extrapolated from adult paradigms and is heavily concentrated in adolescent cohorts treated at major pediatric trauma centers with adult-trauma collaboration Kuo 2024 · Pediatric REBOA Barriers · 2024.

Intra-pericardial thrombin injection has been reported as a bailout strategy for iatrogenic pericardial tamponade complicating cardiac interventions. Its evidentiary status remains limited to salvage case-series experience, and it is not a standard vascular therapy Intrapericardial Thrombin 2023.

Further reading

• The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children. (2008). Pediatric pulseless supracondylar-fracture vascular complications; historical review requiring modern pathway context. Griffin 2008