Brachial artery thrombosis in infants: an algorithm for limb salvage.
BACKGROUND
Arterial occlusion in infants, although uncommon, is usually an iatrogenic event associated with arterial vascular access. Most common in the upper limb, the consequences of iatrogenic arterial occlusion may be gangrene and limb loss. Even if there is adequate collateral flow and limb loss is avoided, long-term growth disturbances may be seen. There are few published data to guide the management of arterial occlusion in premature or sick infants. In general, there is agreement regarding the importance of early diagnosis and the reestablishment of limb perfusion with the fewest risks, but the optimal choice and timing of treatment modalities remain unknown.


METHODS
This article examines the authors' experiences at the Royal Children's Hospital, Melbourne, and provides their algorithm for the management of this complex iatrogenic disease.


RESULTS
The management algorithm has successfully treated 11 limbs in 11 patients with arterial vascular access-associated thrombosis over the period 1995 to 2003, with no instances of limb loss. Five of these patients required surgical intervention.


CONCLUSIONS
The authors recommend a multidisciplinary approach involving plastic surgeons and hematologists for all cases of suspected or confirmed arterial thrombosis. A consensus algorithm that determines the role of heparin, thrombolysis, and acute surgical interventions, and the sequence of such interventions, is useful in providing the framework of therapy. The early recognition of the limb at risk is a key factor in obtaining a successful outcome.
Coombs
Christopher J
CJ
Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Australia. chris@southernplasticsurgery.com.au
Richardson
Phillip W
PW
Dowling
Guy J
GJ
Johnstone
Bruce R
BR
Monagle
Paul
P
D000465:Algorithms; D001132:Arm / Q000098:blood supply*; D001916:Brachial Artery; D002408:Catheters, Indwelling; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006400:Hematocrit; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D007049:Iatrogenic Disease; D007223:Infant; D007231:Infant, Newborn; D007511:Ischemia / Q000628:therapy*; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008866:Microsurgery; D011677:Punctures; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D013927:Thrombosis / Q000188:drug therapy / Q000209:etiology / Q000628:therapy*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
D005343:Fibrinolytic Agents; D006493:Heparin; D010959:Tissue Plasminogen Activator