Reliability of the Mangled Extremity Severity Score in the Management of Peripheral Vascular Injuries in Children: A Retrospective ReviewFunding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
This study was aimed to evaluate different management modalities for peripheral vascular trauma in children, with the aid of the Mangled Extremity Severity Score (MESS). A single-center retrospective analysis took place between 2010 and 2017 at University Hospitals, having emergencies and critical care centers. Different types of vascular repair were adopted by skillful vascular experts and highly trained pediatric surgeons. Patients were divided into three different age groups. Group I included those children between 5 and 10 years; group II involved pediatrics between 11 and 15 years; while children between 16 and 21 years participated in group III. We recruited 183 children with peripheral vascular injuries. They were 87% males and 13% females, with the mean age of 14.72 ± 04. Arteriorrhaphy was performed in 32%; end-to-end anastomosis and natural vein graft were adopted in 18% and 29% respectively. On the other hand, 20% underwent bypass surgery. The age groups I and II are highly susceptible to penetrating trauma (p = 0.001), while patients with an extreme age (i.e., group III) are more susceptible to blunt injury (p = 0.001). The MESS has a significant correlation to both age groups I and II (p = 0.001). Vein patch angioplasty and end-to-end primary repair should be adopted as the main treatment options for the repair of extremity vascular injuries in children. Moreover, other treatment modalities, such as repair with autologous vein graft/bypass surgery, may be adopted whenever possible. They are cost-effective, reliable, and simple techniques with fewer postoperative complication, especially in poor/limited resources.
Keywordspediatric extremity vascular injuries - end-to-end vascular anastomosis - interposition reversed saphenous vein graft - bypass surgery - compartment syndrome - above-knee amputation
The study was approved by the research board ethical committee of the Department of Vascular Surgery of the University Hospitals, Al-Azhar Faculty of Medicine for Males, and recorded under registration number: (25/08–01/2019).
All procedures performed in study involving human participants were in accordance with the ethical standards of the institutional/national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
A.M., O.M.Z., and L.A.A. made a substantial contribution to the concept or design of the work or acquisition, analysis, or interpretation of data.
A.M., O.M.Z., M.A.E., L.A.A., and H.A. drafted the article or revised it critically for important intellectual content.
A.M., O.M.Z., M.A.E., L.A.A., and H.A. approved the version to be published.
A.M. O.M.Z., M.A.E., L.A.A., and H.A. each author have participated sufficiently in the work to take public responsibility for appropriate portions of the content.
All authors read, revised, and approved the manuscript carefully for final publication.
Received: 21 January 2020
Accepted: 17 September 2020
26 November 2020 (online)
© 2020. International College of Angiology. This article is published by Thieme.
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- 1 Barmparas G, Inaba K, Talving P. et al. Pediatric vs adult vascular trauma: a National Trauma Databank review. J Pediatr Surg 2010; 45 (07) 1404-1412
- 2 Whitehouse WM, Coran AG, Stanley JC, Kuhns LR, Weintraub WH, Fry WJ. Pediatric vascular trauma. Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment. Arch Surg 1976; 111 (11) 1269-1275
- 3 Heinzerling NP, Sato TT. Pediatric vascular injuries. In: Dua A, Desai SS, Holcomb JB, Burgess AR, Freischlag JA. eds. Clinical Review of Vascular Trauma. Switzerland: Springer-Nature; 2014: 331-341
- 4 Cannon JW, Peck MA. Vascular injuries in the young. Perspect Vasc Surg Endovasc Ther 2011; 23 (02) 100-110
- 5 Tshifularo N, Moore SW. Surgical intervention in vascular trauma in children. Pediatr Surg Int 2012; 28 (04) 375-378
- 6 Hoover JD, Almond PS. Isolated pediatric peripheral vascular injury caused by blunt trauma: a new occurrence. J Trauma 2004; 56 (01) 198-200
- 7 Lazarides MK, Georgiadis GS, Papas TT, Gardikis S, Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities. J Vasc Surg 2006; 43 (01) 72-76 , discussion 76
- 8 Strong DP, Edwards AT. Vascular Trauma. Trauma 2002; 4: 39-63
- 9 Vertrees A, Fox CJ, Quan RW, Cox MW, Adams ED, Gillespie DL. The use of prosthetic grafts in complex military vascular trauma: a limb salvage strategy for patients with severely limited autologous conduit. J Trauma 2009; 66 (04) 980-983
- 10 Rich NM, Leppäniemi A. Vascular trauma: a 40-year experience with extremity vascular emphasis. Scand J Surg 2002; 91 (01) 109-126
- 11 Fox N, Rajani RR, Bokhari F. et al; Eastern Association for the Surgery of Trauma. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73 (05) (Suppl. 04) S315-S320
- 12 Feliciano DV. Evaluation and treatment of vascular injuries. In: Bruce DB, Jesse B, Jupiter MA, Christian K, Paul AA. eds. Skeletal Trauma Basic Science, Management, and Reconstruction. Philadelphia, PA: Elsevier; 2020: 474-498
- 13 Nazem M, Beigi AA, Sadeghi AM, Masoudpour H. Non iatrogenic paediatric vascular trauma of the extremities and neck. Afr J Paediatr Surg 2009; 6 (01) 35-39
- 14 Halvorson JJ, Anz A, Langfitt M. et al. Vascular injury associated with extremity trauma: initial diagnosis and management. J Am Acad Orthop Surg 2011; 19 (08) 495-504
- 15 Stuebing E, Lieberman H, Vu T. et al. Shank vessel injuries: the forgotten vascular injuries. Eur J Trauma Emerg Surg 2012; 38 (04) 393-401
- 16 Mommsen P, Zeckey C, Hildebrand F. et al. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res 2010; 5: 25
- 17 Robertson PA. Prediction of amputation after severe lower limb trauma. J Bone Joint Surg Br 1991; 73 (05) 816-818
- 18 Kirkilas M, Notrica DM, Langlais CS, Muenzer JT, Zoldos J, Graziano K. Outcomes of arterial vascular extremity trauma in pediatric patients. J Pediatr Surg 2016; 51 (11) 1885-1890
- 19 Joshi SS. Peripheral arterial injuries: an Indian experience. Indian J Surg 2016; 78 (03) 187-191
- 20 Wahlgren CM, Kragsterman B. Management and outcome of pediatric vascular injuries. J Trauma Acute Care Surg 2015; 79 (04) 563-567
- 21 Khan FH, Yousuf KM, Bagwani AR. Vascular injuries of the extremities are a major challenge in a third world country. J Trauma Manag Outcomes 2015; 9: 5
- 22 Allen CJ, Straker RJ, Tashiro J. et al. Pediatric vascular injury: experience of a level 1 trauma center. J Surg Res 2015; 196 (01) 1-7
- 23 Sciarretta JD, Macedo FI, Chung EL, Otero CA, Pizano LR, Namias N. Management of lower extremity vascular injuries in pediatric trauma patients: a single Level I trauma center experience. J Trauma Acute Care Surg 2014; 76 (06) 1386-1389
- 24 Gurien LA, Maxson RT, Dassinger MS, Mehl SC, Saylors ME, Smith SD. Pediatric vascular injuries: are we preparing trainees appropriately to meet our needs?. Am J Surg 2017; 214 (02) 336-340
- 25 Klinkner DB, Arca MJ, Lewis BD, Oldham KT, Sato TT. Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Pediatr Surg 2007; 42 (01) 178-182 , discussion 182–183
- 26 Kayssi A, Metias M, Langer JC. et al. The spectrum and management of noniatrogenic vascular trauma in the pediatric population. J Pediatr Surg 2018; 53 (04) 771-774
- 27 Saunders BE, Adams ZW. Epidemiology of traumatic experiences in childhood. Child Adolesc Psychiatr Clin N Am 2014; 23 (02) 167-184 , vii
- 28 Hogan AR, Lineen EB, Perez EA, Neville HL, Thompson WR, Sola JE. Value of computed tomographic angiography in neck and extremity pediatric vascular trauma. J Pediatr Surg 2009; 44 (06) 1236-1241 , discussion 1241
- 29 Ali MK, Bullard KM, Beckles GL. et al. Household income and cardiovascular disease risks in U.S. children and young adults: analyses from NHANES 1999-2008. Diabetes Care 2011; 34 (09) 1998-2004
- 30 Corneille MG, Gallup TM, Villa C. et al. Pediatric vascular injuries: acute management and early outcomes. J Trauma 2011; 70 (04) 823-828
- 31 Villamaria CY, Morrison JJ, Fitzpatrick CM, Cannon JW, Rasmussen TE. Wartime vascular injuries in the pediatric population of Iraq and Afghanistan: 2002-2011. J Pediatr Surg 2014; 49 (03) 428-432
- 32 Johansen K, Daines M, Howey T, Helfet D, Hansen Jr ST. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990; 30 (05) 568-572 , discussion 572–573
- 33 Pasquale MD, Frykberg ER, Tinkoff GH. ACS Committee on Trauma, Ad Hoc Committee on Outcomes. Management of complex extremity trauma. Bull Am Coll Surg 2006; 91 (06) 36-38
- 34 Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled extremity severity score. Clin Orthop Relat Res 1990; (256) 80-86
- 35 Mousa A, Zakaria OM, Hanbal I. et al. Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: an experience from a resource challenged setting. Asian J Surg 2019; 42 (07) 761-767
- 36 Mavrogenis AF, Panagopoulos GN, Kokkalis ZT. et al. Vascular Injury in Orthopedic Trauma. Orthopedics 2016; 39 (04) 249-259
- 37 Jaipuria J, Sagar S, Singhal M. et al. Paediatric extremity vascular injuries - experience from a large urban trauma centre in India. Injury 2014; 45 (01) 176-182
- 38 Harris LM, Hordines J. Major vascular injuries in the pediatric population. Ann Vasc Surg 2003; 17 (03) 266-269