Ann Thorac Surg 2000;69:1582-1584
© 2000 The Society of Thoracic Surgeons
Case reports
Management of retroperitoneal arterial injury after heart catheterization in children
Frank A. Pigula, MDa,b,
Percival Buenaventura, MDa,b,
Jose A. Ettedgui, MDa,b,
Ralph D. Siewers, MDa,b
a Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
b Department of Pediatric Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Address reprint requests to Dr Pigula, Pediatric Cardiothoracic Surgery, Children’s Hospital of Pittsburgh, Room 2820, 2 Main, Pittsburgh, PA 15213
e-mail: pigulaf{at}heart.chp.edu
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Abstract
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With the expansion of interventional cardiology into the pediatric population, vascular complications related to cardiac catheterization can be expected to occur. Cardiac surgeons must be prepared to treat these life-threatening injuries. We present a case and detail the technique of the surgical management of retroperitoneal arterial injury after interventional cardiac catheterization in a 6-month-old boy.
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Introduction
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Interventional cardiology, propelled by the advent of intravascular procedures (coiling, ballooning, and stenting), has transformed cardiac catheterization from an anatomic and hemodynamic investigation to a new treatment modality. Balloon dilatation of restenosis after aortic operation in children is one such treatment. We present a case resulting in a retroperitoneal injury of the external iliac artery in a 6-month-old boy and describe a surgical technique of rapid vascular control of this injury.
After neonatal repair of interrupted aortic arch (type B) an infant developed an anastomotic stenosis at the age of 6 months. The child underwent successful balloon dilatation of the stenosis through the right femoral artery. Approximately 1 hour later the child was noted to be pale, bradycardic, and hypotensive. The catheterization site was hemostatic and echocardiogram revealed no pericardial or pleural effusions. Palpation of the abdomen revealed the presence of a new mass in the right lower quadrant. The child was quickly transported to the operating room where a retroperitoneal approach to the iliac arteries was accomplished with rapid control and repair of an external iliac artery injury. The child made an uneventful recovery and was discharged on postoperative day 7, and daily aspirin therapy was discontinued after 6 months. The child continues to do well 16 months later, demonstrating a 10 mm Hg blood pressure gradient between the upper and lower extremities.
Regarding the surgical technique, the patient should be positioned with a small hip roll such that the involved side is elevated 20 to 30 degrees. A generous curvilinear incision above the inguinal ligament, paralleling the iliac crest, is performed (Fig 1, top). Electrocautery is used to separate the lateral oblique and transversalis musculature of the abdominal wall. Once separated, the surgeon will be faced with a large retroperitoneal hematoma contained by the loose areolar tissue of the retroperitoneum. Direct finger dissection along the iliac fossa will relieve this hematoma in a dramatic fashion. Further finger dissection will develop the retroperitoneal plane superiorly, inferiorly, and medially. This dissection will reflect the peritoneal sac anteriorly, along with the ureter, to fully expose the common, internal, and external iliac arteries (Fig 1, bottom). The bleeding point will now be readily apparent and can be controlled with digital pressure while volume resuscitation continues. If necessary, the dissection may be extended to expose the distal aorta. Once hemodynamic stability is assured, deliberate repair may be performed. In this case a near transection of the external iliac artery was identified and repaired.
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Fig 1. (Top) The child is positioned with a hip roll under the involved side and elevated 20 to 30 degrees. In this way access to the retroperitoneal vascular structures is optimized. (Bottom) A generous incision above the inguinal ligament and paralleling the iliac crest is made. With division of the oblique and transversalis muscles, finger dissection will reflect the peritoneal sac and ureter anteriorly, away from the injury. The retroperitoneal vasculature is now well exposed for control and repair of the injury. If necessary, further dissection will also expose the distal aorta.
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Comment
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Vascular complications are an uncommon but acknowledged risk of cardiac catheterization in children. In a study of 4,952 pediatric cardiac catheterizations, Vitiello and colleagues [1] have shown this risk of vascular complications to be 3.8%. Subset analysis showed age less than 1 year and interventional procedure to be independent risk factors for major complications. Although retroperitoneal hemorrhage after cardiac catheterization can be a diagnostic dilemma, prompt recognition and rapid control of retroperitoneal arterial injuries can be life saving. This is particularly true among pediatric patients, in whom a relatively small volume of hemorrhage can be life threatening.
With improvements in instrumentation and greater experience, the number of children considered for interventional procedures will increase. New interventional procedures such as transcatheter closure of atrial and ventricular septal defects are being trialed in many centers [2, 3]. Thus, with the expanding role that transcatheter procedures are assuming in the treatment of congenital heart disease, it is imperative that congenital heart surgeons be familiar with the surgical approaches to retroperitoneal vascular injuries.
Once such an injury is recognized, the only effective treatment is rapid and direct surgical control. Rapid control of the injury must be stressed because as demonstrated in our case, a hemodynamically stable infant may quickly decompensate. We recommend the retroperitoneal approach to these injuries compared with the transabdominal approach for several reasons. First, the iliac artery is a retroperitoneal structure that courses within the hollow of the iliac fossa, and as such is not easily accessible from a transabdominal approach. Second, by reflecting the peritoneal sac and ureter anteriorly, the risk of injury to the abdominal viscera, vasculature, and ureter is reduced. Finally, and most importantly, control of the injury may be accomplished very quickly with few instruments. With a knife, digital dissection, and hand retraction, vascular control may be obtained quickly—at the bedside if need be. The potential disadvantage of the retroperitoneal approach, disruption of retroperitoneal lymphatics, has not been identified as a clinical problem. We do, however, leave a small silicone elastomer Blake drain in the retroperitoneum.
Even though originally developed by vascular surgeons, this retroperitoneal approach to the iliac arteries has been popularized by transplant surgeons to the point that it is often referred to as the "kidney transplant incision" [4]. It is accepted by many as the approach of choice for adults undergoing vascular operations involving the iliac vessels [5]. Although such exposure is seldom required in pediatric patients, the expansion and application of interventional cardiology to younger patients make retroperitoneal arterial injuries more likely.
The surgical alternative, the transabdominal, transperitoneal approach, has serious drawbacks. Exposure, obscured by the retroperitoneal hematoma that is invariably present in these injuries, is suboptimal. This may result in prolonged surgical dissection in a hemodynamically unstable patient, and risks iatrogenic injury to the visceral vasculature and to the ureter.
In summary, hemodynamic instability in a pediatric patient after cardiac catheterization should prompt a thorough evaluation (including the chest, abdomen, and percutaneous sites). In the presence of hypovolemic shock, palpation of a mass in the abdomen is diagnostic of a retroperitoneal arterial injury. When identified, we recommend the retroperitoneal approach for rapid control and safe repair of these life-threatening vascular injuries in children.
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Acknowledgments
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We acknowledge Mr Randy Mckenzie for the illustrations.
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References
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Vitiello R., McCrindle B.W., Nykanen D., Freedom R.M., Benson L.N. Complications associated with pediatric cardiac catheterization. J Am Coll Cardiol 1998;32:1433-1440.[Abstract/Free Full Text]
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Thanopoulos B.D., Tsaousis G.S., Konstadopoulou G.N., Zaraylyan A.G. Transcatheter closure of muscular septal defects with the Amplatzer ventricular defect occluder. J Am Coll Cardiol 1999;33:1395-1399.[Abstract/Free Full Text]
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Latson L.A. Per-catheter ASD closure. Pediatr Cardiol 1998;19:86-93.[Medline]
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Rutherford R.B. Vascular exposures. In: Rutherford R.B., ed. Atlas of vascular surgery. Philadelphia: WB Saunders, 1993:184.
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Chang B.B., Paty P.S., Shah D.M., Leather R.P., Kaufman J.L., McClellan W.R. The right retroperitoneal approach for abdominal aortic surgery. Am J Surg 1989;158:156-158.[Medline]
Accepted for publication September 27, 1999.
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Abstract
Introduction
