Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center

Abstract

Objectives:

Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes.

Methods:

In total, 506 patients presented with lower extremity vascular injury (LEVI) between January 1, 2009, and January 1, 2021, to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, GA. Thirty-two of the 506 patients were younger than 18 years of age and were evaluated for a total of 47 LEVIs. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications.

Results:

The median (IQR) age was 16 (2) years [range, 3–17 years], and the majority were male (n=29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n=28, 87.5%), and of these all but two were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by non-pediatric surgeons; 11 by trauma surgeons, 13 by vascular surgeons, two by orthopedic surgeons, and one by an interventional radiologist. Two patients required amputation: one during the index admission, and one delayed at 3 months. Overall survival was 96.9%.

Conclusions:

Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.

INTRODUCTION

Trauma is the leading cause of death in children.¹ The morbidity and mortality of trauma has garnered significant attention as many investigators seek to innovate prevention strategies and improve the quality of care. Vascular trauma, in particular, carries a significant risk of morbidity and mortality; however, the incidence is relatively infrequent and therefore difficult to study. According to the National Trauma Database, the incidence of pediatric peripheral vascular trauma is 0.4–0.6%.^{2, 3} While complications such as amputations are rare, granular data regarding management and detailed outcomes are sparse.

Previous studies have recognized that multiple mechanisms are associated with peripheral vascular injuries, both blunt and penetrating, including fractures, contusions, and crush injuries.⁴ The morbidity from these multi-system extremity injuries includes chronic pain, soft tissue and bone defects, motor loss, and loss of limb in extreme cases, necessitating prompt, multidisciplinary management of these injuries to achieve acceptable outcomes.

In the acute trauma setting, management of peripheral vascular injuries, including lower extremity vascular injuries (LEVIs), adheres to several core tenets. These principles dictate that outcomes directly correlate with mechanism of injury, presence of concomitant venous or orthopedic injuries, severity of soft tissue destruction, nerve injury, and time to revascularization. Given this, the initial attempt to preserve limbs usually comes in the form of surgical revascularization. In the pediatric population, there are several additional challenges to approaching LEVIs, but management of pediatric lower extremity vascular trauma has largely been guided by small single center retrospective reviews and application of adult principles.^{5, 6, 7, 8} Given the rarity of pediatric vascular trauma, pediatric surgeons may not be as familiar with repair techniques as surgeons treating the adult population, potentially leading to delays in care and disparate outcomes. One major difference in clinical presentation is that pediatric patients may present with different physiologic changes compared to adults. In pediatric LEVI, blood loss and hypovolemic shock may present abruptly with hypotension after a period of relatively minimal physiologic derangement, leading to delays in recognition and therefore intervention. Additionally, the pediatric population has the additional consideration of requiring blood flow to the affected extremity to prevent interrupted growth of the limb, as an interruption of sufficient magnitude can lead to lifelong disability.^{9, 10} Lastly, the pediatric patient may have a smaller diameter vessel, which may make the vascular repair or reconstruction more challenging to the surgeon.

The majority of pediatric LEVIs are treated at adult trauma centers by surgeons not trained specifically in pediatric surgery.¹¹ We will describe our experience with pediatric LEVIs at an urban, high-volume, adult level I trauma center, focusing on epidemiology, initial management, surgical approach, outcomes including complications, and potential future considerations.

METHODS

2.1. Study design

The trauma registry was queried for all patients 17 years or less who were treated for a traumatic LEVIs during a 12-year period between January 2009 to December 2021 following Institutional Review Board approval from Emory University School of Medicine. This was a single center retrospective cohort study conducted at Grady Memorial Hospital in Atlanta, Georgia, an American College of Surgeons (ACS)-verified Level 1 adult trauma center. A lower extremity vascular injury was defined as injuries to vessels that occurred below the inguinal ligament and identified by the trauma registry with International Classification of Diseases (ICD) 9 and 10 codes: 904.0, 904.1, 904.40, 904.41, 904.42, 904.51, 904.53, 904.7, S75.009A, S75.002A, S75.109A, S85.009A, S85.509A, S85.139A, S85.169A, 585.209A. Exclusion criteria included patients greater than 17 years of age, those pronounced dead on arrival, vascular repairs completed from transferring facilities, and those with iatrogenic injuries.

2.2. Data collection

The trauma registry and electronic medical record was reviewed for patient demographics, mechanism of injury, Injury Severity Score (ISS), physiologic vital signs, diagnostic imaging, location and type of vessel injury, revascularization technique, concomitant injuries, and additional operative interventions. In addition, hospital complications, short-term 30-day outcomes, discharge disposition and overall mortality were reviewed. If applicable, revascularization patency was assumed if a palpable pulse was documented upon discharge and on follow up.

Primary descriptive outcomes included rates of amputation and mortality. Secondary outcomes included length of hospital and intensive care unit (ICU) stay and need for subsequent procedures, including revascularization revision, thrombo-embolectomy and four-compartment lower extremity fasciotomies. Categorical patient characteristics are presented using frequencies and percentages, while continuous measures are summarized using means with standard deviations (SDs) or medians with interquartile ranges (IQR) where appropriate.

RESULTS

During the 12-year period, there were 32 patients who met inclusion criteria for a total of 47 LEVIs. The median (IQR) age were 16 (2) years [range, 3–17 years], the majority of the patients were males (n=29, 90.6%) and Black (n=30, 93.7%). Many of the injuries resulted from gunshot wounds (n=26, 81.3%). Two additional penetrating injuries occurred from an impalement, one from glass and another from a bicycle collision. The remaining four patients resulted from blunt trauma (12.5%; three motor vehicle collisions and one fall from heights). The overall median ISS was 10 (8.25) [range, 4–41]. Table 1 summarizes additional patient demographics and injury data

TABLE 1:

Admission and Outcome Data

Table 1 - Admission data (n=32)
	Number	Percentage
Sex
Male	29	90.6%
Female	3	9.4%
Race
Black	30	93.8%
White	2	6.3%
Mechanism
Penetrating	28	87.5%
GSW	26	81.3%
Blunt	4	12.5%
MVC	3	9.4%
Initial imaging modality
CT angiogram	12	37.5%
Diagnostic angiogram	2	6.3%
None	18	56.3%
	Median (IQR)	Range
Age	16 (2)	3–17
Overall ISS	10 (8.25)	4–41
Blunt ISS	24 (22)	9–41
Penetrating ISS	9 (11)	4–33
Hospital days	7 (14)	1–54
ICU days	2(3.5)	0–27
Ventilator days	0 (0)	0–25

Data related to demographics, injury mechanism, initial imaging modality, and length of stay outcomes are tabulated. GSW, gunshot wound; MVC, motor vehicle collision; CT, computed tomography; ISS, injury severity scale; ICU, intensive care unit.

3.1. Injury details

On presentation, six patients, all greater than 15 years of age, presented in hemorrhagic shock (systolic blood pressure < 90 mmHg) with one arriving in cardiac arrest who did not survive past operative intervention. Their average hemoglobin was 9.8 g/dL. In total, four patients (12.5%) were transferred from an outside facility with a mean ischemic time of 4.2 hours. Prehospital tourniquets were utilized in only seven patients (21.9%). Twenty-three (66%) patients had absent pulses on physical exam (consistent with Rutherford 2b classification), six (19%) had pedal signals on Doppler only, and five (16%) patients had palpable pedal pulses. All patients with absent pulses or signals proceeded directly to the operating room except for one, who received a CTA prior to operation due to equivocal exam findings. Fourteen patients received imaging prior to definitive management: 12 underwent computed tomography angiogram (CTA), and two received traditional angiograms intraoperatively, which defined the location of the vascular injury. The remaining 18 vascular injuries that did not receive imaging were identified by direct surgical exposure in the operating room. Associated orthopedic injuries were noted in 16 patients (50%), including two pelvic fractures, six femur fractures, seven tibia or fibula fractures, one tibial tendon tear, and one knee arthrotomy. All of the vascular injuries resulting from blunt trauma had an associated long-bone or bony pelvis injury.

In total, there were 28 arterial injuries and 19 venous injuries, 14 of which were combined arterial-venous injuries. Vessel injury patterns are described in Table 2. The superficial femoral artery and vein were the most injured vessels (42.5%), followed by the popliteal vessels (23.4%). Most of the vessel injuries in our cohort were observed to have partial luminal disruptions (n=24, 51.1%). Sixteen complete luminal disruptions were noted, two intimal disruptions, and seven contusions with associated non-occlusive thrombus requiring thrombectomy and repair. Some vessels had multiple injuries.

TABLE 2:

Vascular Injury Pattern

Table 2 - Vascular Injury Pattern	Number	Percentage
Total Vessel Injuries	47	-
Artery	28	59.6
Vein	19	40.4
Vessels
Common femoral
artery	2	4.3
vein	1	2.1
Superficial femoral
artery	11	23.4
vein	9	19.1
Deep femoral
artery	1	2.1
vein	1	2.1
Popliteal
artery	6	12.8
vein	5	10.6
Anterior tibial
artery	2	4.3
vein	1	2.1
Posterior tibial
artery	3	6.4
vein	2	4.3
Peroneal
artery	3	6.4
Patients with concomitant arterial-venous injuries	14	29.8
Injury types
Complete luminal disruption	16	34.0
Partial luminal disruption	24	51.1
Intimal disruption	2	4.3
Thrombosis	7	14.9

All vascular injuries in this cohort are tabulated. Percentages refer to the proportion of specific injuries over the total number of injuries. Fasciotomy percentage used the total number of patients as the denominator. PTFE, polytetrafluoroethylene.

All but four patients underwent definitive surgical management in the operating room. Of these four patients, three patients had infrapopliteal vessel injuries with reconstitution on imaging, and one patient regained pulses after orthopedic reduction. Surgical interventions for the LEVIs are described in Table 3. Fourteen interposition grafts were performed for arterial injuries, of which 13 were with autogenous reverse saphenous vein grafting, with seven to superficial femoral artery, four to popliteal artery, and two to common femoral artery. One patient received a 6 mm polytetrafluoroethylene (PTFE) graft to the superficial femoral artery, as the patient was found to have a saphenous vein of inadequate diameter for grafting. The contralateral greater saphenous vein (GSV) was used as the bypass conduit in the majority (n=10, 76.977%) of these cases. Patients who underwent arterial grafting or thrombectomy both had an average age of 16 years. PTFE grafts were used in three venous repairs: 10 mm and 8 mm PTFE grafts for two popliteal vein injuries, and one 8 mm PTFE graft for a superficial femoral vein injury. A PTFE graft was used instead of autologous vein graft for these venous repairs based on our own institutional study demonstrated that early patency rates of venous repairs is irrespective of type of repair.¹² Primary repair by end-to-end anastomosis was performed on five arteries and three veins, and 11 vessels (artery or vein) were ligated or embolized. The single arterial ligation was a small branch of the superficial femoral artery (SFA). Almost half (47.4%) of venous injuries were ligated, specifically the superficial femoral vein (three times due to the extent of the injury), the common femoral vein (once to obtain better control of the concomitantly injured common femoral artery, twice due to the extent of injury, once as a side branch off the common femoral vein), and the popliteal vein (twice due to the extent of injury). One patient sustained a pelvic fracture with associated injury of the ascending branch of the profunda femoris artery, and so underwent coil embolization with interventional radiology (IR), the only patient without an open approach. Four shunts were placed, prior to definitive repair in three patients and prior to amputation in one patient. Fourteen patients required fasciotomy during the index procedure, and two patients required delayed fasciotomy after developing compartment syndrome. Of the 28 procedures performed, various subspecialists performed the definitive procedure: trauma surgery (n=12), vascular surgery (n=13), orthopedic surgery (n=2), and interventional radiology (n=1).

TABLE 3:

Surgical Repair Techniques

Table 3 - Surgical intervention
Surgical Procedure	Counts and percentages of total injury type
	Artery	(%)	Vein	(%)
Primary repair	5	17.9%	3	15.8%
Interposition grafting
Autogenous saphenous vein grafting	13	46.4%	0	0.0%
PTFE grafting	1	3.6%	3	15.8%
Ligation	2	7.1%	9	47.4%
Temporary Shunt	4	14.3%	0	0.0%
Coil Embolization	1	3.6%	0	0.0%
Catheter Embolectomy	7	25.0%	0	0.0%
Fasciotomy	N=14		43.8%

All surgical procedures used for repair of primary vascular injuries in this cohort are tabulated. Percentages refer to the proportion of repairs per each injury type (out of 28 total arterial injuries for “Artery” and 19 total venous injuries for “vein”). Fasciotomy percentage used the total number of patients as the denominator. PTFE, polytetrafluoroethylene.

While most of our study group patients were among ages 14 to 17, there was one three-year-old male patient who sustained a gunshot wound (GSW) to the left thigh with active arterial hemorrhage and hemorrhagic shock. He was taken to the operating room (OR) emergently and found to have a complete transection of the left proximal SFA and superficial femoral vein. The vein was ligated, and the SFA was debrided to healthy edges then repaired primarily using 7–0 Prolene sutures; a parachute technique was used to close the back wall, and simple interrupted sutures used for the anterior wall. Following the repair, there was pulsatile flow throughout the limb.

There were no deaths attributed to the vascular repair, although one patient arrived in traumatic arrest secondary to hemorrhage from a GSW to a femoral vessel and did not survive past initial operative course after achieving ROSC with resuscitative thoracotomy. Two patients required amputation postoperatively. One patient presented to our institution as a transfer from an outside hospital with a Mangled Extremity Severity Score of 10, secondary to severe crush injuries to the bilateral lower extremities after a high-speed motor vehicle collision (requiring prolonged extrication at the scene). This patient’s lower extremity musculature was noted to be nonviable intraoperatively, and although three attempts at revascularization were made, the patient ultimately failed limb salvage and required bilateral above knee amputations during the index admission. The second patient developed compartment syndrome with subsequent graft occlusion on post-operative day (POD) three requiring graft revision; subsequent sequential foot amputations were required until the patient finally received a below knee amputation due to necrotic tissue. Overall, there were six patients who required subsequent surgical procedures related to their vascular injuries (return to OR). Two were the above-mentioned patients who required amputations. In terms of surgical revision of grafts, one patient required a PTFE graft revision with a PTFE graft replacement on POD two after formation of a hematoma associated with the 6 mm PTFE graft of his SFA. One patient required an open thrombectomy on POD 12 after receiving a reverse saphenous vein interposition graft of the femoral artery; this patient had a change in his pulse exam prompting return to the OR, which was found to be secondary to thrombosis of the SFA distal to the interposition graft anastomosis with clot in the graft. One patient required delayed removal of a foreign body (bullet) after developing an abscess within the calf. One patient required delayed fasciotomies for compartment syndrome; she had an injured popliteal vein that was repaired with a PTFE graft, without accompanying arterial injury, and later developed lower extremity pain, edema, and elevated CPK, necessitating four-compartment fasciotomy of the right calf and lateral thigh. We did not experience any complications of venous thromboembolism or surgical site and graft infections in this group. There was one death within the cohort.

The median (IQR) hospital length of stay of was 7 (14) [range 1–54] days, intensive care unit (ICU) stay was 2 (3.5) [range 0–27] days. Two patients, ages 3 and 14, were transferred to the nearest children’s trauma center after emergent surgical revascularization for further care. The majority of patients were suitable for discharge home (n=27, 84.3%), one was discharged to a rehabilitation facility, one was discharged to jail, and one died. Sixteen patients were discharged on antiplatelet therapy, 15 patients on aspirin, and one on clopidogrel. Three patients were discharged on anticoagulation therapy, two of which had PTFE interpositions which were considered high risk for graft thrombosis. All patients who were discharged alive had palpable peripheral pulses at the time of discharge. Five patients were lost to follow-up, but the remainder had palpable pulses at their one-month post-operative clinic appointments.

When observing long-term follow up, it was found that four patients (12.5%) from our cohort presented at a later time to Grady Memorial Hospital with violence-related injuries, two of whom had suffered a GSW.

DISCUSSION

Pediatric patients experiencing LEVI are commonly triaged to adult trauma centers due to the relatively limited availability of pediatric trauma centers and the considerable risk to life and limb. LEVIs are relatively rare in pediatric trauma, however, adult trauma and vascular surgeons are often tasked in managing these injuries. Standard management guidelines can be a challenge at adult centers with overall treatment dictated by experiences observed in the adult population. This single-institution review is one of the largest series of pediatric LEVIs at an adult center. Our study results indicate that pediatric LEVIs can be safely managed utilizing the same core surgical principles and operative techniques used in adult vascular trauma by non-pediatric surgeons at a level 1 trauma center. Patients with hard signs of vascular injury (most commonly absent pulse in our cohort) or imaging findings consistent with vascular trauma should undergo prompt surgical revascularization; in our study, this resulted in limb salvage of 93.8%. Successful management of pediatric LEVI vascular injuries requires expeditious prehospital transport, prompt evaluation, diagnosis, and revascularization.

In this cohort, all but one procedure was performed via an open surgical technique, allowing prompt evaluation of associated injuries and early revascularization of the ischemic limb. As in adults, primary repair is preferred when feasible; otherwise, an autogenous reverse saphenous vein graft is often used to bridge the defect. Use of synthetic grafts in pediatric trauma is associated with higher rates of thrombosis and worse long-term patency, particularly small-diameter grafts.^{7, 13} In our cohort, autologous grafts were most commonly used for arterial repair with good short-term results, though long-term patency rates and complications were not investigated and remain a challenge. One 6 mm PTFE graft was used to repair the superficial femoral artery given the size discrepancy of the autogenous vein. Unfortunately, this patient later developed graft occlusion requiring subsequent graft revision. Given the predictably smaller size of the saphenous veins in children, this may be an opportunity to further study PTFE use in pediatric peripheral vascular injuries.

The most notable contrast in management from adults is that attempted repair of all major injured vessels is essential because there is a considerable risk for potential skeletal growth retardation in pediatric trauma patients.⁷ Inadequate circulation may compromise the normal growth of the affected bones and lead to limb length discrepancies and long-term disability. Additionally, primary vascular anastomosis in children is often done with interrupted sutures to accommodate future growth, which is not applicable in the adult population.

This study examined our experience with traumatic LEVIs in pediatric patients who were treated at an urban adult trauma center. Overall, we observed one death in our cohort and 93.8% limb salvage during the index admission. Other published series have demonstrated limb loss rates of 0–13% in similar groups.^{2, 13, 14, 15, 16} One factor contributing to the need for fasciotomy in our cohort included longer ischemic times from transferring facilities, a problem also reported in other published series.^{7, 14, 17} The known risk of proximal injury, especially to the common femoral artery, was a contributing factor to this case as well.¹⁸ Compartment syndrome is also a risk factor for distal ischemia and limb-loss, a finding observed in one patient who required delayed amputation.

Patients in our cohort were managed by a range of surgical subspecialties, including trauma surgeons, vascular surgeons, orthopedic surgeons, and interventional radiologists. At our busy urban trauma center, adult trauma surgeons routinely care for peripheral vascular injuries, including in pediatric patients, at times with vascular surgery consultation for complex injuries. Consistent with the literature, in our experience, vascular surgeons more often operated on pediatric patients (46.4%), though trauma surgeons did manage a large number of these cases (42.9%) with similar overall short-term outcomes.

Though there is limited data on readmissions related to firearm-associated violence in this population, in our study alone 4 patients in our initial cohort with GSW injury required re-admission for a second violence-related injury. This pattern emphasizes the importance of an injury prevention team at a trauma center to help prevent recurrent violence and injury. Additionally, one of our patients died as a result of blood loss prior to admission; this highlights the need for programs like Stop the Bleed to improve the chance of survival for time-dependent injuries like this. Furthermore, effective pre-hospital tourniquet use (only seen in seven of our cases) may prevent hemorrhage for these patients.

In combining our experience with the available literature, we present recommendations on treatment of pediatric LEVIs. In accordance with the adult literature, we believe that patients with only intimal injury may be given heparin or aspirin, as 87–95% of these injuries are expected to resolve without invasive intervention.¹⁹ As is well established in the adult literature, patients presenting with “hard” signs of vascular injury or imaging findings consistent with occlusion or extravasation from major named arteries/veins should undergo operative intervention.^{6, 20, 21} The choice of intervention will depend on the extent of injury and the size of the injured vessel, which should generally correlate with age. Wahlgren and Kragsterman report that when analyzing a nationwide database of pediatric vascular injuries in those age 15 years or younger in Sweden, patch repair was more commonly performed in younger patients (30% in those ages 2–6 years, 23% in those ages 7–12 years, and 7.8% in those older than 12 years) while interposition and bypass graft reconstruction was more common in older patients (20% in those ages 2–6 years, 29% in those ages 7–12 years, and 49% in those older than 12 years).²² Although this study was not specific to lower extremity vascular injuries, we believe that the same principle applies, with the preferential use of patch angioplasty in younger children with narrow luminal diameter. Surgeon judgement will determine whether a pediatric patient is physiologically and anatomically similar enough to an adult to benefit from operative techniques that would be employed in adult vascular trauma.

There are several limitations in this study. We recognize that our study is retrospective and includes a small sample size. The data was obtained from previously collected trauma registry information incorporated from the electronic medical record and therefore limited to only the data documented in these sources. For example, ischemic time measurements were not consistently documented, which makes us unable to comment on this important aspect of vascular injury management. Our limited data and follow up did not allow for outcomes comparison with respect to surgical repair techniques and long-term outcomes, such as permanent disability, limb length discrepancy, and vessel patency. This was a single institutional study at an adult Level 1 trauma center and did not include pediatric trauma center data; however, a future collaboration with the surrounding metropolitan pediatric centers could allow for more long-term outcomes.

The management of pediatric LEVIs, a rare entity in the trauma sphere, requires early diagnosis and often prompt surgical intervention. Clinical principles used for adult LEVIs can be safely applied to pediatric patients with acceptable short-term outcomes, specifically regarding limb salvage and mortality rates. We believe such injuries can be safely managed in an adult tertiary specialized care center with the support of a multidisciplinary team of surgeons and interventionalists.

Highlights.

• Pediatric lower extremity vascular injury is devastating and needs rapid management

• Most injuries can be managed similarly to vascular injuries seen in adults

• Using principles of vascular surgery, limb salvage rates after injury are high