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The impact of choice of bypass method and outcomes after pediatric lower extremity arterial trauma
Hilary Ragin Jessup
1, Alexandra Mao
2, Adriana Gutierrez Yllu
3, Justin Sobrino
4, Jason D. Sciarretta
5, Manuel Garcia-Toca
6, Yazan Duwayri
6, Olamide Alabi
6 1Department of Surgery, Emory University School of Medicine, Atlanta, GA;
2Emory University School of Medicine, Atlanta, GA;
3Rollins School of Public Health, Emory University, Atlanta, GA;
4Emory University Department of Surgery, Division of Pediatric Surgery; Children's Healthcare of Atlanta, Atlanta, GA;
5Division of Trauma/Surgical Critical Care, Grady Memorial Hospital, Department of Surgery, Emory University School of Medicine, Atlanta, GA;
6Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
Background: Pediatric vascular injury is rare, and there is some debate regarding which revascularization method, standard end-to-side bypass or interposition bypass grafts, should be employed for optimal management of pediatric lower extremity arterial injuries. We sought to understand the relationship between arterial revascularization method (interposition vs. bypass) and outcomes of interest.
Methods: An analysis of pediatric trauma registry examining all lower extremity arterial trauma managed with bypass at two, level-1 trauma centers (one pediatric, one adult) between 2008 and 2023 was performed. Revascularization method, standard bypass graft (SBG) versus interposition graft (IG), was the exposure variable of interest. Demographic (race/ethnicity, mechanism of injury, insurance payor status, child opportunity index) and injury-related factors were compared. A multivariate analysis was performed to determine the association between arterial revascularization method and several outcomes of interest - delayed fasciotomy, graft stenosis/thrombosis, subsequent reintervention, and need for major amputation.
Results: Among 41 patients with traumatic arterial injuries below the groin who underwent bypass (24.4% SBG; 75.6% IG) the median age was 15.39[IQR:12.88-16.85]. Compared to those who underwent IG, those with SBG were more likely to have sustained blunt traumatic injury (80.0% vs 19.4%, p=.001) and identify as White (40.0% vs 6.45%, p=0.015). Patients who underwent IG were more likely to identify as Black (83.87% vs 40.0%, p=0.015), have public insurance (83.8% vs 60.0%) or no insurance (9.68% vs 0.0%). The distribution of arterial injury among SBG was 80% popliteal artery and among IG was 45.2% superficial femoral and 45.2% popliteal artery (p=0.1). There was no difference between groups in the proportion of vein (p=0.2), nerve (p=0.6), or bony (p=0.1) injury. In cases where preoperative imaging was obtained, there was no difference between groups in length of arterial injury (p=0.72). All SBG were performed with autologous vein whereas 93.5% of IG used an autologous conduit. While trauma surgeons did not perform SBG, 19.4% of IG were performed by trauma surgeons. On multivariate analysis, compared to SBG, IG was associated with increased risk for delayed fasciotomy (OR, 10.4; 95% CI: 1.28 - ∞, p=0.026). There were no significant differences between SBG and IG in graft stenosis/thrombosis, reintervention, or major amputation. Results are summarized in Table 1.
Conclusion: In our study involving two urban level-I trauma centers treating pediatric patients, IG method is associated with delayed fasciotomy. More liberal use of intraoperative fasciotomies in pediatric lower extremity arterial injury, with particular consideration in the setting of interposition bypass, may be warranted. Prospective pediatric trauma registries, such as the upcoming Pedi-PROOVIT, should pay particular attention to this finding.
Table 1. Patient characteristics stratified by arterial revascularization method
| | | Interposition Graft (n=31) | | Standard Bypass Graft (n=10) | | p value |
| Age (median, IQR) | | 15 (12 - 16) | | 14.5 (13 - 16) | | 0.671 |
| Male | | 28 (90.32%) | | 8/10 (80.00%) | | 0.386 |
| Race and Ethnicity | | | | | | |
| White, non-Hispanic | | 2 (6.45%) | | 4/10 (40.00%) | | 0.015 |
| Black, non-Hispanic | | 26 (83.87%) | | 4/10 (40.00%) |
| Hispanic | | 3 (9.68%) | | 2/10 (20.00%) |
| Insurance | | | | | | |
| Private | | 2 (6.45%) | | 4/10 (40.00%) | | 0.026 |
| Public | | 26 (83.87%) | | 6/10 (60.00%) |
| None | | 3 (9.68%) | | 0/10 (0.00%) |
| Social Work Consult | | 28 (90.32%) | | 10/10 (100.00%) | | 0.307 |
| DFCS referral | | 9/31 (29.03%) | | 1/10 (10.00%) | | 0.223 |
| Mechanism of Injury | | | | | | |
| Blunt | | 6 (19.35%) | | 8/10 (80.00%) | | 0.001 |
| Penetrating | | 25 (80.65%) | | 2/10 (20.00%) |
| Injured Artery | | | | | | |
| Common femoral | | 2 (6.5%) | | 0 (0%) | | 0.132 |
| Superficial femoral | | 14 (45.2%) | | 1 (10%) |
| Popliteal | | 14 (45.2%) | | 8 (80%) |
| Tibial | | 1 (3.2%) | | 1 (10%) |
| Length of arterial injury (mm), median (IQR) | | 21 (13-55) | | 35 (20-40) | | 0.72 |
| Service performing bypass | | | | | | |
| Vascular Surgery | | 25 (80.7%) | | 10 (100%) | | 0.13 |
| Trauma Surgery | | 6 (19.3%) | | 0 (0%) |
| Bypass Conduit | | | | | | |
| Ipsilateral vein | | 9 (29.0%) | | 3 (30.0%) | | 0.71 |
| Contralateral vein | | 20 (64.5%) | | 7 (70.0%) |
| PTFE | | 2 (6.5%) | | 0 (0%) |
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