Pediatric vascular trauma in Manaus , Amazon – Brazil

Objective: to assess the incidence of pediatric vascular injuries in patients treated at the Emergency Room of the Eastern Children’s Hospital, in Manaus. Methods: we conducted a retrospective study of pediatric patients who suffered vascular injuries treated between February 2001 to February 2012. Results: we studied 71 patients, predominantly male (78.87%), with a mean age of 7.63 years. The predominant mechanism of injury was stab wound in 27 patients (38.03%). The average hospital stay was 10.18 days; 16 patients required care in intensive care unit, with average stay of 8.81 days. The main injuries occurred in the extremities, the upper limb being the most affected, with lesions of the ulnar artery in 13 (15.66%) and radial in 10 (12.04%). The mostly applied procedure was vascular exploration 35 (32.4%). Complications occurred in nine patients (12.68%). Mortality was 1.4%, in one patient with a lesion of the common iliac vein and the inferior vena cava due fall from height. Conclusion: pediatric vascular injury occurred predominantly in the extremities. The dimensions of the injured vessels made surgical correction more complex and increased complication rates, particularly amputations.


INTRODUCTION
I n Brazil, as in most developing countries, violence is the leading cause of trauma, reaping many lives in the productive phase and generating billions of reais in expenses for hospitalization, temporary or permanent incapacitation and rehabilitation 1,2 .
Trauma sequelae incapacitate an even greater number of people, not counting the psychological and emotional aspects, which in children can lead to a regressive behavior in the presence of stress related to the event 1 .In the pediatric population, in which multisystem injuries are more frequent, mainly due to the greater absorption of energy per unit area generated by the lower body mass, trauma is a major cause of death and disability 1,[3][4][5][6][7] .Vascular injury is a segment with unique features and difficult to analyze, mainly due to the small number of reported cases and technical challenges involved 3,4,[8][9][10] .
The knowledge on vascular trauma evolved mainly by the accumulated military experience in the first and second world wars, the Korean War and Vietnam one.It is right to say that among the different age groups affected by vascular lesions, the adult population was the most benefitted from this accumulated knowledge, ie, vascular lesions in adult patients have been well documented [11][12][13][14] .Contemporary conflicts, such as in Iraq and Afghanistan, have contributed to increase the knowledge of vascular trauma in children also 15 .
Severe vascular lesions occur with relatively low incidence in the pediatric population, but are associated with significant mortality and severe complications.They can be caused by penetrating wounds, closed ones or iatrogenic trauma.Vascular injury in this age group have been described in five major series totaling 204 cases, with an average of 3.3 cases per year 5,13,14,16,17 .
In adults, vascular lesions are adequately treated by surgeons, with their diagnosis and surgical indication well established.However, in children, the small caliber of the blood vessels, intense vasospasm and the inability of some very young patients reporting symptoms to the medical staff, in addition to factors related to the

RESULTS
Of the 71 pediatric patients who suffered vascular trauma, the majority (78.87%) were male.The mean age was 7.63 years, ranging from one month to 14  In total, there were 36 different injured blood vessels, with a predominance of venous lesions (52.77%) in relation to arterial ones (47.23%).Vascular lesions occurred mainly in the ulnar (15.66%), radial (12.04%) and brachial (12.04%) arteries of the total of 83 recorded vascular lesions (Table 2).
Regarding the diagnosis method, clinical examination was used in 71 patients for identification of vascular injury.In 13 cases (18.3%), clinical examination was associated with another diagnostic method, such as arteriography (Figure 1) and ultrasound to confirm the vascular trauma.The main clinical presentation verified at the time of admission was bleeding at the site of injury (56.33%), followed by hypovolemic shock (7.04%).
The most common surgical procedure was vascular exploration (Figure 2) in 32.4% of cases, followed by vessel ligation (23.14%) and end-to-end anastomosis (16.66%).Postoperatively, there were complications in nine patients (12.68%); of these, in five (55.55%) amputation of the affected limb was necessary due to the vascular lesion (Table 3).
The average length of stay of patients was 10.18 days, ranging from one day to 55, with the longer time related to one patient victim of trampling and presenting lesions in the femoral and external iliac arteries.In 16 cases (22.53%), admission to the intensive care unit (ICU) was required, with an average length of stay of 8.81 days.There was one death (1.4%) among the 71 patients attended.

DISCUSSION
Pediatric vascular injuries have complex management problems mainly due to the limited experience with vascular injuries in this age group, controversy surrounding conservative treatment, particular anatomy and physiology, requiring meticulous surgical technique and specialized pediatric follow-up after surgical treatment 6,14,16,17 .
The different topographies of vascular lesions generate different characteristics to trauma.Central vascular trauma is uncommon and is associated with high mortality.
Vascular neck injuries usually result from penetrating trauma and are related to favorable survival rates.At the extremities, vascular trauma is associated with vasospasm, complicating both diagnosis and treatment.There is in these cases an immediate concern for the viability of the body extremity affected by the vascular trauma, since it is necessary to occur restoration of blood flow and adequate circulation for the future musculoskeletal development of the affected limb, differing from the elderly in whom collateral circulation is already present 3,8,9,10,21,23 .
Children whose age is equal to or less than five years old suffer from vascular trauma related to iatrogenic injuries 2,8,9,[19][20][21]24,25 . Many f these injuries could be avoided by correct use of invasive techniques, such as insertion catheters for venous access 20,25,26 .In children older   Intra-abdominal or cervical arterial lesions may be diagnosed by ultrasound examinations and treated by early exploratory laparotomy and cervicotomy, respectively 16 .
Even in the absence of signs and symptoms that confirm the possibility of vascular injury, physical examination should be repeated several times as it has been documented that the presence of signals such as distal pulses does not exclude the possibility of arterial injury and thus the symptoms of the vascular trauma can change 13 .
Vascular ultrasound through the duplex scan with color flow mapping of the arteries and veins is an important diagnostic method for suspected vascular trauma.The use of anatomic and hemodynamic information of the Duplex Scan, with the image in real time, makes this a versatile examination and of reasonable accuracy when there is suspicion of pediatric vascular trauma.
Preoperative arteriography remains the gold standard as a supplementary examination in cases of vascular injury in childhood, favoring the early diagnosis of injury or even excluding its possibility 5,13,14,16,17 .It is important to know that the arterial vasospasm during angiography and artery manipulation is more common in pediatric patients than in adults.
The definitive treatment of a vascular injury depends on several factors.The most important are related to the type of vessel injury, the condition of the patient, the presence of materials and adequate facilities for the treatment and also the existence or not of hemorrhage 13,16 .Immediate surgery should be performed in situations such as the presence of persistent bleeding, pulsatile hematoma, open fracture, acute arterial insufficiency after reduction of a closed fracture, absence of pulses distal to the wound, in the upper and lower limbs or in the case of a significant amount of devitalized tissue 13 .Delaying the surgical treatment in order to improve collateral circulation and combat pathogens adjacent to the lesion 14 is a little defined measure, because the proper development of collateral circulation to maintain tissue viability does not ensure normal growth of the extremity 14,16 .
When surgery is indicated, conventional surgery is still considered as the first option in treating these injuries, with the proximal and distal control of the lesion, vascular repair through direct arteriorrhaphy, use of "patch" or grafting 16,28 .Procedures such as appropriate debridement of the injury, clot removal with preservation of collateral circulation, anastomosis or local artery angioplasty are measures used in all age groups 5,13,14,16 .
Endovascular surgery has several benefits as a treatment option for vascular trauma, such as remote approach of vascular lesions of difficult access, less invasiveness and minor intervention times.It also allows a temporary vascular control for definitive surgical repair, contributing to the stabilization of critically ill patients 16,28 .
Where ligation of the vessel or anastomosis cannot be made, grafts with autogenous veins, such as the saphenous, are a good option 14,23 .The use of synthetic prostheses in children should be the exception, as these components do not follow the vessel's longitudinal and circular growths, their diameters are generally inadequate and the permeability rate is low due to lack of endothelium 5,14,16,23 .
The advent of microsurgical techniques contributed to the treatment of low success rates vascular lesions 16 .In vascular repair, the use of absorbable sutures generates positive results in venous anastomosis compared to nonabsorbable ones.The use of atraumatic Costa Pediatric vascular trauma in Manaus, Amazon -Brazil clips, such as the "Uclips" represents a major step forward, facilitating the achievement of difficult vascular anastomoses 23 under optical magnification.
In cases where the vascular lesion is located in the upper or lower limbs, one should given due importance to the realization of fasciotomy.This procedure should be performed in patients with signs and symptoms of compartment syndrome or as prophylaxis for limbs affected by prolonged ischemia 6 .
Systemic anticoagulation with heparin sodium is an important factor in the care of acute vascular injuries, also contributing to reducing the incidence of thrombosis associated with invasive procedures such as cardiac catheterization or obtaining arterial blood gases in children 14,23 .
The increasing use of invasive procedures such as percutaneous arterial access or correction of congenital malformations in treatment centers for children and newborns makes the iatrogenic vascular trauma a subject for debate.Studies report that even with the increased number of invasive procedures, the rate of arterial lesions has not increased significantly.Some preventive measures should be taken to avoid iatrogenic vascular lesions, such as minimizing the number of arterial punctures in children, and the access should be limited to major arterial trunks, and perform pressure for several minutes at the site of catheter removal or puncture.When there is suspicion of arterial injury, such as fistula, thrombosis or pseudoaneurysm, one should initially perform Doppler ultrasound to verify arterial and venous patency, dilation or arteriovenous communication, and the flow rate of the vessel 23,24 .For this type of vascular trauma, microsurgery proves advantageous, especially avoiding vascular thrombosis 10,19,20,21,24 .
Outpatient regular monitoring aims to identify the decrease in pulses of affected extremities, lowering blood pressure, length differences of the limbs or clinical manifestations of arterial insufficiency, such as fatigue and lameness.These signs are indications for angiographic evaluation of the circulation of the limb affected by the vascular injury 14 .
The complications related to vascular trauma in childhood mainly comprise abnormalities of growth and development of the limbs affected by this type of injury, stenosis in injured vessels or complications related to the severity of the trauma.However, the incidence of complications is low 14,16 .The neurological injury associated with the vascular one contributes to the emergence of sequelae in the affected limb 5,17,23 .
The end result after the diagnostic measures and treatment of vascular injury depends on several factors, mainly related to delays in care, experience of the surgical team to treat this type of injury, type and location of the injury and infection [11][12][13] .Early recognition and prompt treatment are considered important factors for achieving good postoperative results in pediatric patients with vascular injuries 1,2,5,6,8,10,[11][12][13][14]19,29 .
The pediatric vascular trauma is a neglected public health problem.Investments in prevention, surgical staff training and acquisition of appropriate instruments are crucial to reduce morbidity and mortality.
Concluding, the pediatric vascular injury occurred predominantly in the extremities.The dimensions of the injured vessels made surgical repair more complex and increased complication rates, particularly amputations.
than five years of age, vascular lesions present an etiology similar to that observed in the adult population, that is, related to injury by firearm or stabbing wounds, falls from height, fractures, dislocations and closed trauma 2,3,9,27 .When treating a vascular lesion, the surgeon should know the pathophysiology and the main signs and symptoms of this type of injury.Diagnosis can be accomplished simply by careful physical examination.When the vascular injury is in the extremities, one must check the

Figure 1 :
Figure 1: Contrast radiograph of pediatric patient victim of gunshot wound in lower limb showing vascular lesion.Source: author's Files.

Figure 2 :
Figure 2: Femoral artery injury in pediatric patient victim of gunshot wound.Source: author's Files.

Table 1 .
Distribution of patients as to gender.age group.trauma mechanism and topography of the lesions.

Table 2 .
Distribution of vascular lesions according to the type of vessel.

Table 3 .
Distribution of patients according to surgical procedure and postoperative complications.