European Journal of Cardiovascular Medicine

Vascular injuries in children are relatively rare but potentially devastating. Owing to the paucity of available literature and infrequent nature, there is no clear consensus on how to manage these.¹ Trauma remains the leading cause of paediatric vascular injury followed by iatrogenic injury. The small calibre of the paediatric 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.² We present a rare case of inadvertent radial artery injury during simple dressing of wound in a child on steroid medication.

A 9 year old male patient was admitted in medical ward of our institute for treatment of pancytopenia. Child was administered methyl prednisolone for 20 days at another hospital, which was stopped once he developed fever. He had fever, cough ,weakness since 15 days and swelling of cubital fossa  since 5 days for which incision and drainage was done and child was being followed up for daily dressings. On one such routine visit, while doing dressing there appeared sudden fresh  bleeding from wound site. There was no attempt to debride the wound and the bleeding was spontaneous on removal of the covering gauge. Urgent compression dressing was done and patient was planned for emergency exploration of right arm. Routine investigation revealed severe anaemia and thrombocytopenia and child was taken for procedure under blood products cover. There was linear laceration over radial artery arising below the bifurcation of brachial artery. 2 cm segment of artery had tear and discarded. Anastomosis was done between proximal and distal ends. Heparin dose was given following anastomosis but not continued postoperatively owing to very low platelet counts and bleeding tendency. In postoperative follow-up, child was able to retain full function of hand and forearm. Doppler ultrasound in follow-up show thrombosed radial artery, but ulnar artery was patent so no functional morbidity developed and the child was discharged from surgical care.

Vascular injury in paediatric population is rare with only a few handful of cases reported. In western literature, trauma appears to be most common cause with firearm injury being accounted for major cases.³ Severe morbidity in form of limb loss to mortality related to exsanguination has been attributed to vascular injuries. Other causes especially from Indian population have been reported as crush injuries with vascular injuries which have high incidence of limb loss.⁴ bony fractures with bones impinging on vessels or causing vascular trauma and thrombus have also been reported. In newer era, therapeutic vascular interventions have emerged as a major cause of vascular injury although not prevalent in paediatric population.⁵ 

Owing to rarity of condition, general consensus is not available on how to manage these and which department to primarily oversee these patients. In many centres vascular department is available who manage these patients, while in other hospitals paediatric or general surgeons may oversee these patient. In infants and neonates with thrombosed limb arteries, the long-term morbidity is uncertain. Rapid collateral circulation development in these age groups suggests considering conservative treatment with heparin instead of open repair. The choice between medical and surgical approaches depends on the lesion type. Open repair is recommended for arterial lesions causing bleeding, false aneurysms, and arteriovenous fistulae. However, if distal ischemia is the sole issue, many surgeons prefer heparin or thrombolytic agents, closely monitoring the situation to avoid open repair unless limb viability is at risk.⁶ Postoperative heparin therapy and duration are largely dependent on individual protocols.

We report a rare case of iatrogenic radial artery injury in form of vascular tear while regular surgical dressing. As major debridement was not done, arterial wall got avulsed with gauze pieces itself pointing to weakened vascular walls. Weakening of vascular wall with steroids have been described in literature especially with chronic use.⁷ In our case, steroid was given for only 20 days before the event, so underlying sick condition with pancytopenia may play a part. We present this case to raise awareness about potential catastrophic complication that can be associated with a procedure as simple as surgical dressing. This emphasises the need to be vigilant in even minor procedures in a sick child with multiple morbidities. We could not give heparin in postoperative period owing to severe thrombocytopenia and bleeding tendency in the child. Postoperative heparin infusion may play a key role in preventing thrombosis in repaired vessel. Another point of discussion is the repair technique. We could approximate distal and proximal ends with minimal tension and carry out anastomoses. In case of large gaps between vessel edges or loss of major length of vessel, graft from saphenous vein can also be taken to bridge the gap.⁸

Vascular injury is rare in paediatric population and needs expedient management to prevent limb loss, morbidity and mortality. Routine procedures in immunocompromised patients or patients on steroids should be done with extra vigilance to prevent complications

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