Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 19-22

Iatrogenic vascular injuries: An institutional experience


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 Publication8-Mar-2019

Correspondence Address:
Dr. C Shanmugavelayutham
Department of Vascular Surgery, Stanley Medical College, Chennai, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_46_18

Rights and Permissions
  Abstract 


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 Mar 21];6:19-22. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/19/253735




  Introduction Top


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.[1]


  Materials and Methods Top


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 Top


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.
Table 1: Specialitywise distribution

Click here to view
Figure 1: Departmentwise distribution

Click here to view


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].
Figure 3: Type of presentation

Click here to view
Table 2: Type of presentation

Click here to view


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].
Table 3: Pseudoaneurysm managment

Click here to view
Table 4: Type of vessel injury

Click here to view


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].
Figure 4: External iliac artery injury – graft nephrectomy

Click here to view
Figure 5: Postlaminectomy iliac arteriovenous fistula

Click here to view


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].
Figure 6: Management of intraarterial injection injuries

Click here to view
Figure 7: Amputations

Click here to view


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].[1] In our study of the total of 40 cases, 27 were arterial injuries, 11 venous, and 2 with both artery and vein injury.
Table 5: Comparison of studies

Click here to view


Sexwise distribution was almost equal in the Swedish study (men-49%).[1] 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.[1] 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.[2] 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.[3] 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].
Figure 8: Distribution of iatrogenic vascular injuries

Click here to view


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).[4] In the Swedish study, the mortality was 4.9%.[1] 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.[2] In our study, 15% (6) resulted in permanent morbidity and 7.5% (3) resulted in mortality.

Preventive measures

  • 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
Orcutt MB, Levine BA, Gaskill HV 3rd, Sirinek KR. Iatrogenic vascular injury. A reducible problem. Arch Surg 1985;120:384-5.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
   Materials and Me...
   Results and Disc...
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed42    
    Printed0    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]