Femoral artery and vein injuries in a child due to firecracker explosion: a case report

Introduction

Vascular trauma in the pediatric population is uncommon, occurring in only 0.6% of all pediatric trauma patients. Although less frequent than adults, a significant proportion was due to penetrating injury (1). Penetrating injuries are more common and extremities are frequently affected (2). Unlike the adults, vascular injuries in the pediatric population are uniquely characterized because children are more prone to vasospasm, have smaller diameters, and need to grow (3,4). Due to its low incidence, there are no clear guidelines for its diagnosis and treatment, and most of the experience in diagnosis and treatment is gained from adult cases. In the event of an injury to a major blood vessel, an experienced surgeon is needed to make a quick diagnosis and provide a plan for repair. Prompt diagnosis is important, with a 97% rate of recovery for patients correctly diagnosed (5). We present this case in accordance with the CARE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-23-553/rc).

Case presentation

A 9-year-old male child was admitted to Shandong Provincial Hospital with a firecracker injury to the left perineum, with blood spurting from the wound. The location of the wound can be seen in Figure 1A. The child became unconscious 20 minutes after the accident and was admitted to the local hospital for intensive care, blood transfusion and pressure dressing. He was transferred to our hospital for further treatment. The child is currently unconscious, with a red blood cell of 3.19×10¹²/L, hemoglobin of 91 g/L, platelets of 105×10⁹/L, stable blood pressure, and a heart rate of about 120 beats per minute. The patient exhibited inadequate blood flow to the left lower extremity, presenting with cold skin temperature, terminal toes with pale nail beds and absence of palpable dorsalis pedis arterial pulsation. Further specialized investigations were impeded by the patient’s inability to cooperate. A computed tomography (CT) scan of the abdomen showed signs of left lower anterior abdominal wall – left inguinal region – left thigh soft tissue injury (Figure 1B,1C). This patient was suspected of having an injury to a vital blood vessel, and admitted to the hospital and surgery was urgently scheduled.

Figure 1 Images of wound appearance and CT: (A) patient left perineal trauma; (B,C) axial and coronal CT images of lower abdomen. CT, computed tomography.

Intraoperative exploration revealed that the wound was located in the superficial projection of the spermatic cord. However, it injured the left femoral artery and femoral vein, as shown schematically in Figure 2A. The left femoral artery was mostly dissected along a 3-cm long section with a disfigured wall, and the left femoral vein was partially dissected with its anterior wall partially disrupted and missing. A comparison of the vascular condition before and after repair is shown in Figure 2B,2C. Two segments of the autologous saphenous vein from the affected limb were taken. A longitudinal dissection is performed, followed by a spiral technique for resuturing to enlarge the lumen to match the caliber of the femoral artery (Figure 3). A reverse saphenous vein graft technique was employed, where the distal vein was anastomosed to the proximal artery, and the proximal vein was anastomosed to the distal artery. The left femoral vein was sutured with a patch of autologous saphenous vein to repair the broken and damaged area. The vessels were closed with continuous 5-0 noninvasive vascular sutures. Then the femoral artery was checked again for good pulsation, no bleeding from the anastomosis, and usual blood flow in the femoral vein. Adequate hemostasis was performed, and the spermatic cord and adjacent vessels were explored without obvious injury. A drain was left in place. Intraoperative bleeding was about 400 mL. To correct anemia, 4 U of A-type Rhesus (+) de-whitened suspended erythrocytes were given intraoperatively, and the patient was transferred to the pediatric intensive care unit (PICU) for custodial treatment after the operation. Anti-infection, anti-shock, anti-coagulation, rehydration and other nutritional support therapies were given. The changes of anemia index and infection index were closely monitored. Prompt postoperative injection of tetanus human immunoglobulin at 250 iu. Initial antibiotic treatment was performed using ceftriaxone sodium for injection at 2 g and teicoplanin at 0.35 g for 10 days. The treatment regimen was subsequently adjusted to include cefoperazone sodium and sulbactam sodium for injection at 1.5 g for 6 days. Four days before discharge, the patient’s medication was transitioned to oral faropenem, with a dosage of 0.175 g three times a day. Anticoagulation was initiated on the first postoperative day with 0.6 mL of heparin sodium administered via micro pump for 17 days. Subsequently, upon ultrasound detection of femoral vein thrombosis, the patient was discharged with a daily dose of 1.2 mL of heparin sodium via micro pump for 8 days. Following hospital discharge, he maintained oral anticoagulant therapy with a daily dose of 10 mg rivaroxaban. Erythrocytes and hemoglobin gradually increased after a 3-day postoperative decline, and hemorrhagic shock was eventually corrected (Figure 4A,4B).

Figure 2 Images of the wound location and changes before and after vascular repair: (A) the position of the incision in relation to the left spermatic cord, left femoral artery and femoral vein; (B) injury to the left femoral artery and vein; (C) repaired femoral artery and vein.

Figure 3 Spiral technique surgical procedure: (A) removed the saphenous vein; (B) longitudinally dissected saphenous vein; (C) a spiral vein graft is constructed around cylindrically shaped instrument using continuous sutures; (D) a spiral vein graft with enlarged lumen.

Figure 4 Trends in erythrocyte and hemoglobin: (A) plot of changes in erythrocyte; (B) plot of changes in hemoglobin.

A vascular ultrasound was conducted on post-operative day 15, revealing thrombosis in the left common femoral vein, and smooth blood flow in the left femoral artery. Additionally, the arterial bypass with autologous venous graft was noted to be normal, indicating the absence of stenosis, pseudoaneurysm, intimal flap and dissections. The ultrasound was repeated on post-operative day 20. The results revealed thrombosis in the left common femoral vein, with a small blood flow signal detected around the vessel in the lumen, and the flow filling in the left femoral artery remained intact. The infection indexes also decreased to the normal range, and the overall condition improved significantly. Following these findings, the patient was discharged home on post-operative day 25 and oral rivaroxaban at a daily dose of 10 mg were continued after discharge.

The ultrasound was repeated at 4 months after the operation, and the results showed that the left femoral artery had a normal internal diameter, smooth internal median membrane, and usual blood flow, while the common femoral artery had a normal internal diameter and the velocity of blood flow had increased, about 297.2 cm/s. Fortunately, the thrombosis in the left femoral vein had disappeared. Oral anticoagulants are then discontinued. The patient is currently 15 months postoperative. Examination reveals strong pulsations in the left femoral and dorsalis pedis arteries, with no abnormal sensations such as hyperalgesia, numbness, or tingling in the lower extremities. Normal activity and joint mobility were observed in the left lower limb, accompanied by normal muscle strength and tone. The current ultrasound results show that the femoral vein has a smooth inner wall with good vascular compression and smooth blood flow. The femoral artery had a normal internal diameter and blood flow.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient’s parent for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Pediatric vascular conditions are rare, resulting in limited exposure for most vascular surgeons (6). Simultaneous injury of the femoral artery and femoral vein is particularly rare. In most of the studies, patients had penetrating trauma to the arteries of the upper extremities with shattered glass, utensils, knives or tools (7-9). Firearm injuries account for 20% of vascular trauma in the United States (1). This case is characterized by injury to the left femoral artery and femoral vein due to a firecracker laceration to the perineum. Interestingly, the location of the wound was in the body projection of the spermatic cord and not in the projection area of the femoral artery and femoral vein. This reflected that the direction of travel of the explosive after penetrating the subcutaneous tissue was oblique, coincidentally resulting in injuries of the femoral artery and femoral vein.

Clear recommendations regarding indications for surgical repair, types of reconstruction, and postoperative management, particularly regarding antithrombotic therapy, are lacking (10). The tricky and difficult nature of vascular injuries in children demands that pediatric surgeons need the ability to make rapid diagnoses when faced with such patients. Pediatric extremity vascular injuries represent a rare yet serious condition that can result in severe complications, particularly if left untreated or diagnosed late (11). A clear history of trauma and physical examination reveals active bleeding with or without ischemia of the distal limb. Weakened or absent distal arterial pulsation can confirm the diagnosis of vascular injury. Arteriography is indicated only in hemodynamically stable patients and should be used as a ‘‘roadmap’’ when questions arise. The arteriographic findings may help to indicate an operation; plan the appropriate approach; or entertain alternatives of management (12). Although angiography is the gold standard for diagnosis, it is associated with significant complications in children, including radiation exposure, contrast nephropathy, acute femoral artery thrombosis, and chronic femoral artery occlusion associated with limb growth retardation. Therefore, CT angiography (CTA) with controlled radiation exposure and minimal acceptable contrast dose was proposed as a safe and reliable alternative tool of diagnosis (13). Noninvasive studies have also been applied to the diagnosis of vascular injuries, such as doppler sonography (12), B-mode ultrasonography (14), and MR angiography (15).

Once vascular injury is detected, rapid hemostatic measures should be taken. Therefore, in this reported case, the early treatment of gauze pressure hemostasis and blood transfusion at the local hospital provided a key guarantee for the opportunity to perform subsequent surgery to repair the vessel. Patients with confirmed femoral vascular injuries should be transported quickly to the operating room. Substantial venous access through the upper extremities should be secured, and hypothermia should be avoided (16). Bleeding from the femoral triangle occasionally can be challenging to control, especially with combined arterial and venous injuries. Initial repair of the injured vessel is the preferred and most common method. If initial repair is not feasible, both autografts and synthetic grafts are available. The saphenous vein is the most common autograft. Reverse saphenous vein graft for the treatment of limb arterial injuries in children and adolescents is a reliable, feasible, and more cost-effective technique with favorable results (17). Early temporary vascular shunts to bypass injured vessels as an alternative to maintaining distal arterial perfusion can help restore early perfusion to the limb (18). In the exploration of injuries to the femoral artery, femoral vein, and other major blood vessels, it is essential to employ rapid suction guidance. Attention must be given to clear anatomical levels, identify bleeding sites, and effectively control bleeding. Caution should be exercised in the use of vascular clamps to avoid damage to surrounding nerve tissue and tendons, thereby reducing the risk of complications. Vascular repair procedures, including direct repair, anastomotic patch formation, and bypass reconstruction, should be tailored to the specific nature of the vascular injury. In this case, for instance, a longitudinal tear measuring approximately 3 cm in the femoral artery wall warrants consideration of autologous vein grafting, typically employing the saphenous vein. It is imperative to perform vascular repair or anastomosis without tension to prevent luminal narrowing and thrombosis resulting from excessive vascular tension. The patient experienced postoperative thrombosis of the common femoral vein. Fortunately, following anticoagulant therapy, a follow-up ultrasound at four months post-surgery revealed a normal vessel diameter and regular blood flow.

The more pronounced vasospasm and reduced vessel size in children compared with adults may present technical difficulties that may be ameliorated by the direct use of intra-arterial vasoactive drugs. Postoperative intervention with anticoagulants and anti-spasm drugs is crucial to maintain the patency of the reconstructed vessel. In adults, papaverine are commonly employed as intraoperative vasodilators. Similarly, in pediatric patients, papaverine serve as valuable drugs that can be applied topically to blood vessel surfaces to prevent vasospasm intraoperatively and to maintain vasodilation postoperatively. Papaverine blocks calcium influx through the cell membrane of vascular smooth muscle, inhibits phosphodiesterase activity in smooth muscle, and exerts a direct, nonspecific relaxing effect on peripheral blood vessels and other smooth muscle. Sodium heparin, an anticoagulant derived from mucopolysaccharides sulfate, acts on various stages of the coagulation cascade upon administration, effectively inhibiting platelet aggregation and destruction while facilitating fibrinolysis. Additionally, it modulates blood viscosity and enhances blood flow. Postoperative antithrombotic therapy is an important consideration in the management of vascular injuries in children (10). However, there are no clear recommendations to guide how it should be used. Therefore, further determination of which medications should be used and the optimal duration of treatment warrants further exploration. Multiple surgical subspecialists are often involved in these cases (19). Both pediatric and vascular surgeons are involved in the procedure. The proposed multidisciplinary diagnostic and treatment model can provide additional safeguards for children with vascular trauma combined with hypovolemic shock. The most common immediate complication after femoral vessel injuries is early thrombosis. Other complications included associated injuries of adjacent nerves and tendons, such as impaired function, which included decreased mobility or range of motion and paresthesia (2).

Long-term follow-up enables continuous monitoring of the effectiveness of the patient’s vessel repair, assessing vessel patency. This facilitates timely identification and management of restenosis, occlusion, or other complications, thereby reducing patient risk and ensuring lasting surgical repair. Additionally, it evaluates the patient’s recovery of limb function through regular physical examination and functional assessment. This enables doctors to understand the patient’s motor ability, sensory function, and quality of life, facilitating timely adjustments to treatment plans and rehabilitation programs. Furthermore, long-term follow-up aids doctors in better understanding the patient’s medical history, providing a reference basis for future treatment and management. Long-term follow-up should be emphasized, particularly in pediatric patients undergoing growth and development.

Conclusions

Pediatric femoral arteriovenous injury is a rare and complex condition, often associated with critical complications, challenging surgical interventions, and a high risk of mortality and disability. The location of body wounds may contribute to delayed diagnosis of the condition, emphasizing the importance of timely physical examination for early diagnosis. Timely and accurate vascular repair is paramount for saving lives and minimizing the risk of limb amputation. Long-term postoperative follow-up is necessary to monitor the patency of the repaired vessels and promptly detect any complications.

Acknowledgments

Funding: The study was funded by Youth Science Foundation of Shandong First Medical University (No. 202201-066), the Shandong Provincial Natural Science Foundation (Nos. ZR2020QH263, ZR2020QH078, and ZR2022MH095), and Shandong Province Natural Science Foundation (No. ZR2020QH078).

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-23-553/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-23-553/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-23-553/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient’s parent for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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