Pediatric Vascular Injury

Vascular injuries in children are relatively rare but potentially devastating. Most reported pediatric vascular injuries are iatrogenic, although larger series of noniatrogenic and combat-related pediatric vascular trauma have appeared more recently. The small caliber of the pediatric vascular tree complicates the diagnosis and management of vascular injuries in this population. Differentiating a true injury from vasospasm can be challenging as diagnostic studies including arteriography carry risks of vascular injury, contrast exposure, and radiation exposure. On the other hand, a delayed or missed diagnosis can result in vascular thrombosis leading to limb-length discrepancies or even to amputation. The biology of pediatric vessels has not been well studied from a basic science standpoint, and the clinical literature in this area consists almost entirely of case series that offer the pediatric and adult surgical subspecialists involved in the management of these challenging injuries little insight into their natural history, the appropriate diagnostic workup, and the optimal management of a particular injury. Nonetheless, recent advances in medications, operative techniques, and equipment have increased the management options for vascular injuries in young patients. In this chapter, we review both iatrogenic and traumatic vascular injuries in children and describe the traditional approaches of observation, ligation, or heparinization along with the current trend toward surgical exploration with repair of vascular injuries using open and endovascular approaches. The need for both basic and clinical research in this area is also discussed to encourage future multiinstitutional research collaborations aimed at better definition of the optimal approach to this difficult problem.