David Biko, MD, MAJ, USAF

Assistant Professor of Radiology

Uniformed Services University of the Health Sciences

Thank you to Monica Epelman, MD for her

contribution to this presentation

Disclaimer

The views expressed in this presentation are those of the authors

and do not necessarily reflect the official policy or position of the

Department of the Navy, Army, Air Force, Department of Defense,

nor the U.S. Government.

We certify that all individuals who qualify as authors have been

listed; each has participated in the conception and design of this

work, the writing of this presentation, and the approval of the

submission of this version; that this presentation represents valid

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Background

Traumatic injury is the leading cause of death

in children older than 1 year

Vascular injury well studied in adult population,

but not in children

Uncommon (0.6% all pediatric trauma patients)

Management of most pediatric injuries

often similar to adult strategies

Background

Differences between adults and children

Children less severely injured than adults

Significant injuries more difficult to detect

○ Asymptomatic

○ Associated with spasm

○ Other more severe injuries take priority

Small vessel size

○ Technical challenges in diagnosis and treatment

Imaging Evaluation

Clinical presentation varies depending

anatomic location and type of injury

Hard Signs

Soft Signs

Imaging Evaluation

Prompt diagnosis important

Good outcome

○ *64/66 (97%) with initial correct diagnosis

○ *19/23 (83%) with delayed diagnosis

Poor results most likely in arteries adjacent to

elbow and knee

*Evans WE, King DR, Hayes JP. Ann Vasc Surg 1988;3:268-2270.

Consider liberal use of angiography in

child with involvement of elbow or knee

Imaging Evaluation –

Which Modality?

Duplex Ultrasound

Noninvasive, no radiation burden, portable

Limited evaluation of many structures

CT angiography (CTA) or Conventional

Angiography (CA)

Both have potential risks of radiation exposure

and contrast reactions

Although CA still the gold standard, CTA is

largely replacing it for vascular injuries

CT Angiogram vs. Conventional

Angiography in Pediatric Population

• Noninvasive, widely available, rapidly obtained

• Limited studies diagnostic in pediatric population

• Neck and Extremity -95% sensitive; 97% specific*

CTA

• Gold standard

• Invasive but safe

• Low complication rate in pediatric population**

• May perform thrombolysis or embolization

CA

*Hogan et al. J Ped Surg 2009;44:1236-1241.

**Puapong et al. J Ped Surg 2006; 41: 1859-1863

Vascular Injuries in Children

Iatrogenic Vascular Injuries

Most etiologies of pediatric vascular injury

Extremity Vascular Injuries

High incidence of isolated upper extremity

injuries

Truncal Vascular Injuries

Additional major injuries common

○ Most commonly with abdominal trauma

Iatrogenic Vascular Injuries

Significant proportion of pediatric vascular

trauma (33-100%)

Diagnostic catheterization

Cannulation for ECMO or cardiopulmonary

bypass

Placement of Arterial Lines

Arterial puncture/Venopuncture

Postoperative

Extremity Vascular Injuries

Non-iatrogenic injury increases with age

½ - ¾ penetrating injury

Children more likely to develop collaterals

Amputation rate still up to 50% after major vascular

compromise

Extremity Vascular Injuries-

Management

Soft Signs Arterial Pressure Index (API) with

Doppler

API > 0.90

99% NPV*

API < 0.90

95% Sensitivity for Major Arterial Injury*

Hard Signs

(absence of distal pulses, active external hemorrhage, signs of ischemia, pulsatile

bruit or thrill)

Intervention

*Johansen K, Lynch K. J Trauma 1991;31:515-522.

Angiographic Signs of Extremity

Trauma

Active contrast extravasation

Loss of opacification or occlusion of an

arterial segment

Intraluminal filling defect

Early venous opacification

Abnormal change in vessel caliber,

course, or contour

Truncal Vascular Injuries

Includes thoracic, abdominal, and cervical

vascular injuries

Outcomes/intervention based on hemodynamic

stability of patient

Thoracic Injury - Diagnostic

Blunt injury

Thoracic aorta, innominate

artery, pulmonary veins,

vena cava

Little data on imaging

evaluation of children

Chest Radiograph

CTA/CA

TEE

Thoracic Injury

OPEN repair standard of care

Endovascular interventions common in

adults, but limited in children

Existing stent grafts too large for children

Delivery systems too large or too short

Vessel growth lead to migration

Abdominal Injury

Renal, mesenteric, iliac, aorta

Management driven by

hemodynamic stability

Penetrating trauma (90-95%

vascular injury)

Blunt trauma- more likely solid

organ injury

Abdominal Injury: Children vs. Adults

Children more prone to abdominal

solid organ injury

Abdominal organs relatively larger

Abdominal musculature less mature

Abdominal organs and wall have less fat

Compliant ribcage

Cervical Vascular Injury

Penetrating injuries less frequent than blunt

trauma

Arterial injury 25x higher with penetrating injury

Morbidity mostly related to stroke

Mechanisms of Injury

Penetrating vascular trauma

Along the injury tract

○ Direct contact with vessel wall

○ Energy imparted to the vessel by projectile

Blunt vascular trauma (carotid artery)

Direct blow to the anterior neck

Blow to the side of the head with stretching of vessel

Fracture of the skull base

Intra-oral

○ Falling on toothbrush or lollipop in mouth

Management of Cervical

Vascular Injury

Immediate exploration

Hemodynamically unstable

Hard Signs

○ Rapidly expanding hematoma

○ Pulsatile bleeding

○ Air bubbles in the wound

Imaging for all others

Most often CT angiography

Conclusion

Pediatric vascular trauma is rare

Most injuries iatrogenic or isolated extremity

Diagnostic evaluation and management

based on adult strategies

But remember that children have unique

anatomic and physiologic consideration so

adult management should be approached

with caution

Conclusion

Conventional angiography remains the gold

standard to evaluate vascular trauma, but

CT angiography is often replacing it

Noninvasive, widely available, rapidly

obtained

Although studies limited, CTA has been

successful in the evaluation of pediatric

vascular injury

References 1. Corneille MG et al. Pediatric Vascular Injuries: Acute Management

and Early Outcomes. J Trauma 2011;70: 823-828.

2. Barmpras G et al. Pediatric vs adult vascular trauma: a National Trauma Databank review. J Ped Surg 2010;45:1404-1412.

3. Cannon JW, Peck MA. Vascular Injuries in the Young. Perspect Vasc Surg Endovasc Ther 2011 doi: 10.1177/1531003511408439.

4. Evans WE, King DR, Hayes JP. Arterial Trauma in Children: Diagnosis and Management. Ann Vasc Surg 1988;3:268-2270.

5. Lineen EB et al. Computed tomographic angiography in pediatric blunt vascular injury, J Ped Surg 2008; 43:549-554.

6. Hogan AR et al. Value of computed angiography in neck and extremity pediatric vascular trauma. J Ped Surg 2009; 44:1236-1241.

7. Wallin D et al. Computed Tomographic Angiography as the Primary Diagnostic Modality in Penetrating Lower Extremity Vascular Injuries: A Level I Trauma Experience. Ann Vasc Surg 2011;25:620-623.

References

8. Puapong D et al. Angiography and the pediatric trauma patient: 10- year review. J Ped Surg 2006; 41:1859-1863.

9. Johansen K, Lynch K. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities J Trauma 1991;31:515-522.

10. Gakhal MS, Sartip KA. CT Angiography Signs of Lower Extremity Vascular Trauma. AJR 2009;193:W49-W57.

11. Allison ND et al. Outcomes of truncal vascular injuries in children. J Ped Surg 2009; 44: 1957-1964

12. Wang NE, Blankenburg RL. Pediatric Abdominal Trauma. Trauma Reports 2007;.8:1-12.

13. Schroeder JW, Baskaran V, Aygun N. Imaging of traumatic arterial injuries in the neck with an emophasis on CTA. Emerg Radiol