|Year : 2019 | Volume
| Issue : 1 | Page : 19-22
Iatrogenic vascular injuries: An institutional experience
C Shanmugavelayutham1, P Ilayakumar2, K Elancheralathan1, B Velladurachi2, J Amalorpavanathan3, M Rajkumar4
1 Department of Vascular Surgery, Stanley Medical College, Chennai, Tamil Nadu, India
2 Department of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu, India
3 Department of Vascular Surgery, Apollo Hospital, Chennai, Tamil Nadu, India
4 Department of Vascular Surgery, Vijaya Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||8-Mar-2019|
Dr. C Shanmugavelayutham
Department of Vascular Surgery, Stanley Medical College, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Iatrogenic vascular injuries are emergency referrals to the vascular surgeon. They can lead to prolonged hospitalization, higher cost, limb loss, mortality, and litigation. Aim: The aim of this study is to analyze the referral patterns and outcomes of iatrogenic vascular injuries managed in our institution from 2008 to 2013. Materials and Methods: Patients with iatrogenic vascular injuries referred to the vascular surgery department of our institution from July 2008 to Sep 2013 were included in this study. Those with isolated injury to superficial venous system were excluded from the study. Data were collected from a prospectively maintained database and analyzed with respect to patient characteristics, mode and type of vascular injury, intervention, and outcomes. Results: The incidence of iatrogenic vascular injuries was progressively on the rise year on year during the study period. The incidence was most common in the age group of 31–45 years contributing about 30%. The incidence was more in males (65%). A significant number of iatrogenic vascular injuries occurred in pediatric population (25%). The most common mode of iatrogenic vascular injuries in children was due to intravascular injections and it accounted for 50% of amputations. There was no difference in the incidence among medical and surgical specialties. Conclusion: Iatrogenic vascular injuries appear to progress day by day. Early and proper management can be a limb or life-saving. Late referral ended up in limb or life loss. Thorough knowledge of anatomy and image-guided interventions can be a preventive measure of iatrogenic vascular injuries.
Keywords: Iatrogenic, fasciotomy, hemorrhage, pseudoaneurysm
|How to cite this article:|
Shanmugavelayutham C, Ilayakumar P, Elancheralathan K, Velladurachi B, Amalorpavanathan J, Rajkumar M. Iatrogenic vascular injuries: An institutional experience. Indian J Vasc Endovasc Surg 2019;6:19-22
|How to cite this URL:|
Shanmugavelayutham C, Ilayakumar P, Elancheralathan K, Velladurachi B, Amalorpavanathan J, Rajkumar M. Iatrogenic vascular injuries: An institutional experience. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Aug 18];6:19-22. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/19/253735
| Introduction|| |
Iatrogenic vascular injuries are emergency referrals to the vascular surgeon. It leads to limb loss, prolonged hospitalization, higher cost, even death, and at times litigation.With the improvement of critical care and the interventional procedures such as cardiac catheterizations, endovascular interventions, central venous pressure monitoring, total parenteral nutrition, invasive blood pressure monitoring, and minimally invasive procedures for the treatment of congenital cardiac anomalies, the incidence of iatrogenic vascular injuries is on the rise.
| Materials and Methods|| |
Patients referred to the vascular surgery department from July 2008 to September 2013 were included in this study. Patients with isolated injury to superficial venous system were excluded from the study. Patients treated for iatrogenic vascular surgeries were identified and reviewed retrospectively from prospectively maintained registries from July 2008 to July 2012, and those from August 2012 to September 2013 were prospectively studied.
Clinical records were reviewed for presentation, type of injury, anatomic site, management, outcome, and observation.
| Results and Discussion|| |
There were 40 cases of iatrogenic vascular injuries during the period of study. The incidence is equally distributed in both medical and surgical specialties 20 each. Orthopedics (45%) being the major contribution as a whole and among the surgical specialties. General surgery (35%) contributes next among the surgical specialties. Among the medical specialties, incidence is equal among general medicine (20%), pediatrics (20%), and cardiology (20%). Above three specialties contributed to 60% of iatrogenic vascular injuries. Anesthesiology and critical care contribute to about 15% of the medical specialty incidence [Table 1] and [Figure 1]. The most common site being involved is the extremities equally in the upper and lower limbs 35% each. Vascular injuries involving abdominal vessels contribute 15% and those of neck and thorax contribute 7.5% each.
Mode of injury injuries may be due to trauma during surgery/procedure and intravascular injections. In case of artery, trauma is the leading cause. However, in vein, both contribute equally. Intravascular injections can result in vascular injury [Table 4] and [Figure 2]. They have equal incidence in both pediatric and adult age group.
|Figure 2: Pseudoaneurysm of carotid artery (postfine-needle aspiration cytology thyroid)|
Click here to view
The most common type of vascular injury was nonischemic in nature (65%). The most common presentations were hemorrhage and pseudoaneurysm [Figure 3]. In pediatric age group, ischemic and nonischemic injuries have equal incidence [Table 2].
Arterial versus venous
Orthopedic-related surgeries were most commonly associated with pseudoaneurysm. The most common site being the lower limbs. They were usually managed by repair, ligation, and ultrasonogram compression depending on the site and vessel involved [Table 3].
Injuries to major veins were repaired by lateral venorrhaphy in stable patients and ligation of the vein in unstable patients. Injuries to nonaxial arteries were managed by ligature. Injuries to axial arteries were primarily sutured in case of partial injury or defect <50% of the circumference [Figure 4]. Injuries involving >50%of the circumference or complete transection were managed by reverse saphenous vein interposition bypass [Figure 5].
Eighty percent of the vascular injuries required intervention and 20% were managed conservatively.
Of the total patients, 15% resulted in amputations. Among the amputations, 50% were major and 50% were minor. Amputations resulting from intravascular injections were minor, whereas resulting from trauma were almost major. The mortality was 7.5% [Figure 6] and [Figure 7].
In a study conducted in Sweden, of the total vascular injuries, 48% (888 cases) were due to iatrogenic injuries. Of the 888 cases, 768 were arterial, 80 were venous, and 40 were graft injuries [Table 5]. In our study of the total of 40 cases, 27 were arterial injuries, 11 venous, and 2 with both artery and vein injury.
Sexwise distribution was almost equal in the Swedish study (men-49%). In our study, 65% (26) were males and 35% (14) were females. Regarding the site of injury, in Swedish study, a maximum of 58% involved the lower extremity. In our study, both upper and lower extremities had equal contribution of 35% each.
Regarding the procedures resulting in injuries, in a study by Mills et al., around 62% were due to cardiac catheterizations and 14% due to endovascular procedures. In the University of Texas Health Science Center study, out of 46 patients, diagnostic procedures led to 24 injuries, while therapeutic procedures were responsible for 22 vascular injuries. In our study, 82.5% of vascular injuries were due to therapeutic procedures (open surgeries and endovascular interventions) and 7 (17.5%) due to diagnostic procedures [Figure 8].
In a study done in Oregon Health and Science University, of the total 85 patients, 3 (3.5%) patients had permanent morbidity and the mortality was 7.1% (6). In the Swedish study, the mortality was 4.9%. In another study of the total 71 patients, 1 patient had limb loss and 2 resulted in death though not resulted from the injury itself. In our study, 15% (6) resulted in permanent morbidity and 7.5% (3) resulted in mortality.
- Intravenous (IV) cannulations and administration of IV injections by specially trained nurses/doctors in children
- Use of appropriate small IV cannulas and infusion sets in pediatric age group
- Image-guided intervention whenever possible
- Refreshing the anatomy/surgical steps by the operating surgeon before major cases
- Seeking the help of a vascular surgeon in the planning stage-in complicated cases, where vascular structures are infiltrated/invaded.
| Conclusion|| |
Iatrogenic vascular injuries appear to be increasing day by day. Early and proper management can be a limb or life-saving. Late intervention ended up in limb or life loss. Thorough knowledge of anatomy and image-guided interventions can be a preventive measure of iatrogenic vascular injuries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rudström H, Bergqvist D, Ogren M, Björck M. Iatrogenic vascular injuries in Sweden. A nationwide study 1987-2005. Eur J Vasc Endovasc Surg 2008;35:131-8.
Mills JL, Wiedeman JE, Robison JG, Hallett JW Jr. Minimizing mortality and morbidity from iatrogenic arterial injuries: The need for early recognition and prompt repair. J Vasc Surg 1986;4:22-7.
Orcutt MB, Levine BA, Gaskill HV 3rd
, Sirinek KR. Iatrogenic vascular injury. A reducible problem. Arch Surg 1985;120:384-5.
Giswold ME, Landry GJ, Taylor LM, Moreta GL. Iatrogenic arterial injury is an increasingly important cause of arterial trauma. American J Surg 2004;187:590-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]