Department of Surgery, Loyola University Medical Center, Maywood, Ill; One to MAP Section of Surgical Analytics, Department of Surgery, Loyola University Medical Center, Maywood, Ill.
Department of Surgery, Loyola University Medical Center, Maywood, Ill.
J Vasc Surg. 2018 Jul;68(1):182-188. doi: 10.1016/j.jvs.2017.11.064. Epub 2018 Mar 1.
Acute limb ischemia (ALI) in a pediatric patient is a rare condition but may result in lifelong disability. A paucity of evidence exists to derive treatment guidelines; some surgeons advocate conservative management over invasive measures. The purpose of this study was to evaluate the role of surgical revascularization in the pediatric population and outcomes of conservative vs surgical management.
The Healthcare Cost and Utilization Project State Inpatient Database (California, Iowa, and New York) between 2007 and 2013 was queried using International Classification of Diseases, Ninth Revision codes. Patients were stratified into two cohorts: conservative management and surgical management. Each group was further subdivided into three age groups: infant (<24 months), child (<12 years), and adolescent (<18 years). Outcome variables included mortality, amputation status, length of hospital stay, and hospital charge.
A total of 1576 pediatric patients with ALI were identified among 6,122,535 pediatric admissions (26 per 100,000 admissions). Average age was 9.9 ± 7.1 years. There were 263 patients who underwent surgical revascularization. The conservative management group was younger (5.8 ± 6.2 vs 9.2 ± 6.1 years; P < .01). Otherwise, baseline characteristics were similar between the two groups. Overall, the amputation rate was low (<2%; n = 28), especially in the upper extremities (<0.2%). Outcomes of conservative management and surgical revascularization were similar for mortality (5.0% vs 3.4%; P = .34), amputation (1.9% vs 1.1%; P = .46), length of hospital stay (15.4 vs 12.9 days; P = .07), and hospital charge ($281,794 vs $288,507; P = .28). In subgroup analysis, infants had less concomitant orthopedic injury than other age groups. Children demonstrated a higher likelihood of associated upper extremity injury and operative revascularization (P < .01) than infants or adolescents. In infants, mortality was higher and surgical intervention was associated with longer hospital stay (29.5 ± 34.4 days vs 45.6 ± 31.6 days; P = .02) and larger health care expenditure ($467,885 ± $638,653 vs $1,099,343 ± $695,872; P < .01).
Pediatric ALI is a rare entity and is associated with low amputation and mortality rates. Among the pediatric age cohorts, infants with ALI are at higher risk of in-hospital mortality than older age groups are. Surgical intervention is not associated with improved limb salvage or mortality. Nonoperative management may be considered an initial treatment modality, but further research is needed to elucidate which important subset of pediatric patients benefit from open or endovascular operative intervention.
儿科患者急性肢体缺血（ALI）较为罕见，但可能导致终身残疾。目前证据有限，难以制定治疗指南；一些外科医生主张采用保守治疗而非侵入性治疗。本研究旨在评估手术血运重建在儿科人群中的作用以及保守治疗与手术治疗的结果。
使用国际疾病分类第 9 版代码，检索 2007 年至 2013 年加利福尼亚州、爱荷华州和纽约州的医疗保健成本和利用项目州际住院数据库。患者分为保守治疗组和手术治疗组。每个组进一步分为三个年龄组：婴儿（<24 个月）、儿童（<12 岁）和青少年（<18 岁）。主要结局变量包括死亡率、截肢状态、住院时间和住院费用。
在 6122535 例儿科住院患者中，共发现 1576 例 ALI 患儿（26/100000 例）。平均年龄为 9.9±7.1 岁。有 263 例患者接受了手术血运重建。保守治疗组的年龄更小（5.8±6.2 岁比 9.2±6.1 岁；P<0.01）。其他基线特征两组相似。总体而言，截肢率较低（<2%；n=28），尤其是在上肢（<0.2%）。保守治疗和手术血运重建的死亡率（5.0%比 3.4%；P=0.34）、截肢率（1.9%比 1.1%；P=0.46）、住院时间（15.4 天比 12.9 天；P=0.07）和住院费用（281794 美元比 288507 美元；P=0.28）相似。亚组分析显示，婴儿合并骨科损伤的比例低于其他年龄组。与婴儿或青少年相比，儿童更有可能合并上肢损伤和手术血运重建（P<0.01）。在婴儿中，死亡率较高，手术干预与更长的住院时间（29.5±34.4 天比 45.6±31.6 天；P=0.02）和更高的医疗费用（467885 美元±638653 美元比 1099343 美元±695872 美元；P<0.01）相关。
儿科 ALI 较为罕见，其截肢和死亡率较低。在儿科年龄组中，与其他年龄组相比，婴儿发生院内死亡的风险更高。手术干预并不能改善肢体存活率或死亡率。非手术治疗可能是初始治疗方法，但需要进一步研究阐明哪些重要的儿科患者亚组受益于开放或血管内手术干预。
