In this article, we discuss published literature on the management of pediatric patients with acute limb ischemia and also present our center’s experience.
Results:
Literature review suggests that in the absence of imminent risk of limb loss, noninterventional management with anticoagulants and systemic thrombolysis is preferable and associated with better clinical outcomes than surgery such as reduced per operative morbidity and mortality. In selected more severe cases, surgery may be required. We propose an algorithm for improved clinical outcomes based on the published literature and the American College of Chest Physicians’ recommendations for antithrombotic management in the pediatric population.
Conclusion:
Literature review suggests an inverse relationship between age and surgical success, particularly in preschool pediatric population. Conservative management as a preliminary strategy seems most beneficial. It is hoped that the proposed intercalated algorithm of medical and surgical management of these patients can further improve clinical outcomes.
StangerPHeymannMATarnoffHHoffmanJIRudolphAM. Complications of cardiac catheterization of neonates, infants, and children. A three-year study. Circulation. 1974;50(3):595–608.
2.
KayssiAShaikhFRoche-NagleGRubinBBrandaoLRWilliamsSA. Management of acute limb ischemia in the pediatric population. J Vasc Surg. 2013;57(5):34S.
3.
VeldmanANoldMFMichel-BehnkeI. Thrombosis in the critically ill neonate: incidence, diagnosis, and management. Vasc Health Risk Manag. 2008;4(6):1337–1348.
4.
MonaglePChanAKGoldenbergNA. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl): e737S–e801S.
5.
WiggerHJBransilverBRBlancWA. Thromboses due to catheterization in infants and children. J Pediatr. 1970;76(1):1–11.
6.
MortenssonWHallbookTLundstromNR. Percutaneous catheterization of the femoral vessels in children. II. Thrombotic occlusion of the catheterized artery: frequency and causes. Pediatr Radiol. 1975;4(1):1–9.
7.
MortenssonW. Angiography of the femoral artery following percutaneous catheterization in infants and children. Acta Radiol Diagn (Stockh). 1976;17(5A):581–593.
8.
OskiFANaimanJL. Polycythemia and Hyperviscosity in the Neonatal Period: Hematologic Problems in the Newborn. Philadelphia, PA: Saunders; 1982.
9.
PiagnerelliMBoudjeltiaKZVanhaeverbeekMVincentJL. Red blood cell rheology in sepsis. Intensive Care Med. 2003;29(7):1052–1061.
10.
YodicePCAstizMEKurianBMLinRYRackowEC. Neutrophil rheologic changes in septic shock. Am J Respir Crit Care Med. 1997;155(1):38–42.
11.
KirschenbaumLAAzizMAstizMESahaDCRackowEC. Influence of rheologic changes and platelet-neutrophil interactions on cell filtration in sepsis. Am J Respir Crit Care Med. 2000;161(5):1602–1607.
12.
MortenssonWHallbookTLundstromNR. Percutaneous catheterization of the femoral vessels in children. I. Influence on arterial peak flow and venous emptying rate in the calves. Pediatr Radiol. 1975;3(4):195–200.
13.
CoombsCJRichardsonPWDowlingGJJohnstoneBRMonagleP. Brachial artery thrombosis in infants: an algorithm for limb salvage. Plast Reconstr Surg. 2006;117(5):1481–1488.
14.
FrankenEAJrGirodDSequeiraFWSmithWLHurwitzRSmithJA. Femoral artery spasm in children: catheter size is the principal cause. AJR Am J Roentgenol. 1982;138(2):295–298.
15.
LinPHDodsonTFBushRL. Surgical intervention for complications caused by femoral artery catheterization in pediatric patients. J Vasc Surg. 2001;34(6):1071–1078.
16.
MansfieldPBGazzanigaABLitwinSB. Management of arterial injuries related to cardiac catheterization in children and young adults. Circulation. 1970;42(3):501–507.
17.
LuriePRArmerRMKlatteEC. Percutaneous guide wire catheterization--diagnosis and therapy. Am J Dis Child. 1963;106:189–196.
18.
FreedMDKeaneJFRosenthalA. The use of heparinization to prevent arterial thrombosis after percutaneous cardiac catheterization in children. Circulation. 1974;50(3):565–569.
19.
KatzSGlobermanAAvitzourMDolfinT. The ankle-brachial index in normal neonates and infants is significantly lower than in older children and adults. J Pediatr Surg. 1997;32(2):269–271.
20.
KnirschWKellenbergerCDittrichS. Femoral arterial thrombosis after cardiac catheterization in infancy: impact of Doppler ultrasound for diagnosis. Pediatr Cardiol. 2013;34(3):530–535.
21.
SahnDJGoldbergSJAllenHD. A new technique for noninvasive evaluation of femoral arterial and venous anatomy before and after percutaneous cardiac catheterization in children and infants. Am J Cardiol. 1982;49(2):349–355.
22.
SheikhKHAdamsDBMcCannRLyerlyHKSabistonDCKissloJ. Utility of Doppler color flow imaging for identification of femoral arterial complications of cardiac catheterization. Am Heart J. 1989;117(3):623–628.
23.
DillonPWFoxPSBergCJCardellaJFKrummelTM. Recombinant tissue plasminogen activator for neonatal and pediatric vascular thrombolytic therapy. J Pediatr Surg. 1993;28(10):1264–1268; discussion 1268-1269.
24.
Nowak-GottlUBidlingmaierCKrumpelAGottlLKenetG. Pharmacokinetics, efficacy, and safety of LMWHs in venous thrombosis and stroke in neonates, infants and children. Br J Pharmacol. 2008;153(6):1120–1127.
25.
GuptaAALeakerMAndrewM. Safety and outcomes of thrombolysis with tissue plasminogen activator for treatment of intravascular thrombosis in children. J Pediatr. 2001;139(5):682–688.
26.
ZenzWArltFSodiaSBergholdA. Intracerebral hemorrhage during fibrinolytic therapy in children: a review of the literature of the last thirty years. Semin Thromb Hemost. 1997;23(3):321–332.
27.
FlaniganDPKeiferTJSchulerJJRyanTJCastronuovoJJ. Experience with latrogenic pediatric vascular injuries. Incidence, etiology, management, and results. Ann Surg. 1983;198(4):430–442.
28.
Ade-AjayiNHallNJLiesnerR. Acute neonatal arterial occlusion: is thrombolysis safe and effective?J Pediatr Surg. 2008;43(10):1827–1832.
29.
WhitehouseWMCoranAGStanleyJCKuhnsLRWeintraubWHFryWJ. Pediatric vascular trauma. Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment. Arch Surg. 1976;111(11):1269–1275.
30.
RichardsonJDFallatMNagarajHSGroffDBFlintLM. Arterial injuries in children. Arch Surg. 1981;116(5):685–690.
31.
LazaridesMKGeorgiadisGSPapasTTGardikisSMaltezosC. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities. J Vasc Surg. 2006;43(1):72–76; discussion 76.
ChaikofELDodsonTFSalamAALumsdenABSmithRB3rd. Acute arterial thrombosis in the very young. J Vasc Surg. 1992;16(3):428–435.
34.
KleinMDCoranAGWhitehouseWMJrStanleyJCWesleyJRLebowitzEA. Management of iatrogenic arterial injuries in infants and children. J Pediatr Surg. 1982;17(6):933–939.
35.
DowneyCAliuONemirS. An algorithmic approach to the management of limb ischemia in infants and young children. Plast Reconstr Surg. 2013;131(3):573–581.
