Results of nonoperative management of acute limb ischemia in infants

Abstract

Objective: Acute limb ischemia (ALI) in infants poses a challenge to the clinician secondary to poor operative outcomes, limb loss risk, and lifelong morbidity. This retrospective study reviewed a 10-year institutional experience with the nonoperative management of ALI in infants.

Methods: Infants (aged ≤12 months) diagnosed with ALI by duplex ultrasound and treated with initial nonoperative management at a tertiary care children's hospital were identified through vascular laboratory arterial duplex ultrasound records and International Classification of Diseases and Current Procedural Terminology codes associated with ALI. Demographics of the patients, injury characteristics, treatment administered, and outcomes were abstracted by chart review and presented using descriptive statistics.

Results: During the study period, a total of 25 (28% female) infant patients were diagnosed with ALI. The average age for this cohort was 3.5 ± 3.2 months (standard deviation). Most cases were secondary to iatrogenic injury (88%) from arterial cannulation. Injury sites were more concentrated to the lower extremities (84%) compared with the upper. Absence of Doppler signals was noted in 64% of infants, whereas limb cyanosis was observed in 60% at the time of presentation. Infants were initially treated with anticoagulation (80%) when possible. Two patients failed to respond to nonoperative management and required thrombolysis secondary to progression of thrombus burden while anticoagulated. There were no major (above-ankle) amputations at 30 days. Three deaths occurred within 30 days; all were unrelated to limb ischemia. In the 30-day survivors, overall duration of follow-up was 53.5 ± 38.5 months. One infant required above-knee amputation 6 weeks after diagnosis, resulting in an overall limb salvage rate of 96% on follow-up. Long-term morbidity included two patients with a chronic wound of the affected limb and one patient with limb length discrepancy. No subjects reported claudication at the latest follow-up appointment. In addition, all patients were independently ambulatory except for one adolescent girl who was using a walker with leg braces.

Conclusions: In contrast to the adult population, ALI in infants can be managed with anticoagulation alone with good results. Long-term follow-up continues to demonstrate excellent functional results and minimal disability.