Iatrogenic Vascular Injury: Arteriovenous Fistula in NICU Neonates

Abstract

Purpose: Invasive treatments have increased the risks of iatrogenic vascular injuries in neonates. Acute complications, such as thrombosis, rupture and pseudoaneurysm, require accurate diagnosis and prompt correction. In arteriovenous fistulas (AVFs) identified in time, some resolve spontaneously whereas others progress and cause major problems; potential growth disturbances and limb discrepancies. The paper is to evaluate the timing of surgery based on considerations of operation risk and expected clinical course in AVF neonates.Methods: We reviewed the charts of 2776 neonates admitted to the neonatal intensive care unit of the Department of Pediatrics of GMC over the 7-year period (Jan 2010-2017).Results: Eight (4 males, 4 females) had vascular lesions (0.29%). Mean gestational age was 196.4 days (range, 179-218 days), mean birth weight 985 g (range, 690-1340 g), mean gestational age at operation 352 days (range, 95-679 days), mean weight at operation 1825 g (range, 1230-2700 g), and mean time between diagnosis of fistula and operation 308 days (range, 41-646 days). Definite limb size discrepancy on simple radiographs was identified in 3 patients operated upon more than 1 year after being diagnosed with AVF. In 2 neonates aged between 6 months and 1 year, leg edema was evident and resolved postoperatively. In 3 neonates with simultaneous fistulas in both thighs, surgical correction was preferred for ipsilateral lesions with intense bruit on auscultation. Contralateral small fistulas resolved spontaneously in these 3 neonates within 6 months of initial AVF diagnosis.Conclusion: Early surgery should not be considered mandatory in all AVF neonates, based on considerations of long-term sequelae, the potential for iatrogenic injury to normal vascular structures and the wide-spectrum of clinical courses. Modulation of operative timing within the 6 months following diagnosis is reasonable as it does not increase risks of permanent impairment or sequela and can avoid unnecessary surgery.