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Acute Pediatric Arterial Occlusion

Introduction While management of acute arterial occlusion is a core skillset of the vascular surgeon, treating a child with an acutely ischemic extremity can be especially challenging. This is an uncommon problem so few surgeons have significant experience, particularly with infants and neonates with acute limb ischemia, and local expertise will vary. Etiology and epidemiology of acute arterial occlusion in children is distinct from adults where…

Placement of Arteriovenous Dialysis Access and Central Catheters in the Pediatric Patient

Background Pediatric end-stage renal disease (ESRD) is a challenge for caregivers, nephrologists, and surgeons. The number of children and adolescents beginning ESRD care is steadily decreasing from a high of 17.5 per million in 2004 to 13.8 per million in 2016, representing a decrease of 21.1%. Despite the decreasing number of pediatric patients with ESRD, there is still a large burden of healthcare costs, accounting for…

Vascular Trauma in the Pediatric Population

Introduction Pediatric trauma is the leading cause of death in children older than one year in the United States. Although vascular injuries are infrequent, occurring in 0.6% to 1% of trauma patients, , they constitute an important cause of mortality after trauma. Efforts to curb death and morbidity after automobile accidents, such as wearing seat belts and using car seats, may have mitigated the mortality due…

Pediatric Vascular Tumors

Introduction Vascular tumors are different from malformations in that they have proliferative endothelium, while malformations occur from abnormal tissue growth as the child grows and has quiescent endothelium. Both primary vascular tumors and vascular malformations may look similar, raised or flat lesions, blue, red or purple in hue. Growth and/or expansion of such may risk clinical complications like disfigurement, chronic pain, recurrent infections, systemic manifestations like…

Aortic and Arterial Aneurysms in the Pediatric Population

Pediatric arterial aneurysms include many rare and heterogeneic diseases. Etiologies vary widely among the different types of aneurysms, with important differences in the aneurysm’s character and clinical relevance often dependent on the specific vessel affected ( Table 186.1 ). Aneurysms in children, with few exceptions, should be considered dangerous. Although optimal management strategies and established criteria for operative treatment remain ill defined, rupture and thrombosis are…

Special Techniques in Pediatric Vascular Surgery

Introduction Although conditions afflicting the extracardiac vascular system during infancy and childhood have been described for well over two centuries, a comprehensive literature dedicated to the management of pediatric vascular surgery patients remains lacking. Despite the presence of a number of textbooks devoted to the focused topic of pediatric cardiac surgery, a unified resource collating common themes and describing surgical techniques and principles does not exist…

Conditions Arising from Repetitive Trauma and Occupational Vascular Problems

Upper extremity work-related injuries are a major societal problem, resulting in significant disability, cost, and loss of productivity. Occupational injuries affecting the shoulders, arms, and hands have been recognized for hundreds of years and are generally categorized into injuries caused either from accidents, or from injuries resulting from long-standing repetitive tasks. Injuries in the latter category are collectively known as cumulative trauma disorders, which are the…

Vascular Trauma: Extremity

General Considerations Injury Characteristics Although vascular injuries are present in a small percentage of injured patients, they are responsible for an outsized share of morbidity, mortality, and resource utilization. , The major vessels of the extremities account for 20% to 50% of all vascular injuries ( Table 183. 1 ). Extremity arterial injuries result from blunt and penetrating mechanisms with nearly equal frequency although blunt mechanisms…

Vascular Trauma: Abdominal

Abdominal vascular injuries are the most common cause of death after penetrating abdominal trauma. Accurate diagnosis, rapid surgical exposure and control, and the definitive management of these injuries may challenge the skills and judgment of even the most experienced surgeons. These can be made even more complex by any associated intraabdominal injuries. Rapid transportation to a trauma center, early recognition of the injuries, early surgical intervention,…

Thoracic Vascular Trauma

Introduction Thoracic injuries are common sequelae of both blunt and penetrating trauma, with blunt thoracic injuries proving responsible for approximately 8% of all trauma admissions in the United States, with motor vehicle crashes being the most common (>70%) mechanism. Penetrating injuries are also commonly encountered, with one report from a high-volume, urban trauma center identifying penetrating chest trauma among 7% of all trauma admissions and 16%…

Vascular Trauma: Head and Neck

Cervical vascular injuries are notoriously difficult to evaluate and to manage, mostly secondary to complex anatomy confined to a relatively narrow and layered anatomic space. The initial evaluation of these patients is often obscured by associated injuries to the head, chest, or abdomen. In addition, signs of cerebral ischemia, cranial nerve deficits, or cervical nerve compression may not be present on initial evaluation. The evaluation and…

Vascular Trauma: Epidemiology and Natural History

Introduction Vascular injury is a major cause of death and disability in society, with trauma being the principle etiology. Despite the establishment of mature trauma systems to improve delivery of prompt and effective treatment, as well as innumerable technological advances with improved clinical outcomes and expanded application of data collection systems, the burden of traumatic injuries continues to increase in society. In the US, trauma is…

Hemodialysis Access: Nonthrombotic Complications

The National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (KDOQI) has updated guidelines for 2019. Recognized complications are: bleeding, infection, aneurysm/pseudoaneurysm, seroma, access-related hand ischemia (ARHI) or steal syndrome, venous hypertension, neuropathy, and cardiopulmonary complications. Bleeding The most frequent bleeding complications are prolonged access-site bleeding and easy bruising. Needle dislodgement is extremely rare. End-stage renal disease (ESRD) is associated with increased gastrointestinal bleeding, spontaneous retroperitoneal bleeding,…

Hemodialysis Access: Failing and Thrombosed

The maintenance of arteriovenous (AV) hemodialysis accesses in patients with end-stage kidney disease (ESKD) requires as much thought and consideration as their initial creation in order to individualize patient care and preserve future access options. The ESKD Life-Plan, a key concept detailed in the 2019 KDOQI Guidelines for Vascular Access, recommends the development of a written short- and long-term access plan with the patient and interdisciplinary…

Hemodialysis Access: Dialysis Catheters

Central venous catheters play an important role in the treatment of patients with end-stage renal disease. Despite initiatives to improve fistula creation, more than 80% of patients initiated hemodialysis with a catheter, a number that has changed little over the past 15 years. Central venous catheters for hemodialysis are categorized by their intended duration as either acute or chronic. Both acute and chronic hemodialysis catheters can…

Hemodialysis Access: Complex

Over the past decade, significant improvements have been made in quality of care and life expectancy for patients on hemodialysis. Consequently, it is not uncommon for the surgeon to be confronted with patients who have “outlived” their arteriovenous (AV) access options in the upper extremities. In one study, nearly 7% of access placements were located at a site other than the upper extremity. For many of…

Hemodialysis Access: General Considerations and Strategies to Optimize Access Placement

As the population ages and the incidence of diabetes rises, chronic kidney disease (CKD) and end-stage renal disease (ESRD) are increasingly common diagnoses in the United States. In 2017, data from the United States Renal Data System (USRDS) showed that 124,500 new patients began therapy for ESRD, whereas the prevalent dialysis population reached 746,557. Of note, after a sharp rise in the incidence of ESRD patients…

Acquired Arteriovenous Fistulas

The earliest description of an acquired arteriovenous fistula (AVF), the abnormal communication between an artery and vein, is attributed to William Hunter, who in 1761 reported two cases of brachial AVFs following attempted phlebotomy. He also described the adaptive dilation of the artery and veins proximal to the AVF, as well as the associated tremulous motion, (“thrill”) and hissing noise (“bruit”). , AVFs were infrequently identified…

Congenital Vascular Malformations: Endovascular Management

Introduction Vascular anomalies comprise a collection of disorders characterized by abnormal, non-neoplastic blood vessel growth. The need for accurate characterization of these lesions has led to the development of a classification system based on biologic behavior which is approved by the International Society for the Study of Vascular Anomalies (ISSVA). , This classification system was most recently updated in 2018. It broadly divides vascular anomalies into…

Congenital Vascular Malformations: Surgical Management

Introduction The proper diagnosis and treatment of vascular anomalies has long been impeded by misused terminology. Advances in our understanding of these disorders led to the creation of a biological classification system, formally adopted by the International Society for the Study of Vascular Anomalies in 1996 and updated in 2018. This classification scheme divides these anomalies into vascular tumors and vascular malformations based on physical characteristics,…