interventions in pediatric cardiology

1. VASCULAR COMPLICATIONS IN SMALL
CHILDREN: HOW TO DEAL WITH
DR. HEMANT KUMAR NAYAK
H.O.D. PEDIATRIC CARDIOLOGY
THE MISSION HOSPITAL, DURGAPUR.

2. OVERVIEW
• The reported incidence of vascular complication is between 1% - 40%.
• Permanent arterial occlusion: 5-20%
• These complications include:
• Groin hematoma,
• Vessel disruption/rupture
• Vessel thrombosis/spasm,
• Retroperitoneal hematoma,
• Pseudoaneurysm
• Arteriovenous fistula
• Limb loss

3. GROIN HEMATOMA

4. PSEUDO-ANEURYSM
Courtesy: Dr Amitabha Chattopadhay

5. RETROPERITONEAL HEMATOMA

6. EXT IL. A PERFORATION
Courtesy: Dr Amitabha Chattopadhay

7. RFA BALLOON ANGIOPLASTY

8. VASCULAR SPASM

9. HOW TO DEAL WITH IT?

10. Qureshi and Kumar: Vascular access in pediatric interventions, APC, January-March 2020

14. AXILLARY ARTERY ANATOMY

15. USG GUIDED VASCULAR ACCESS

16. AXILLARY ARTERY ACCESS

17. PSEUDOANEURYSM IN AXILLARY ARTERY

18. POST SURGICAL REPAIR

19. FEMORAL VEIN ACCESS

20. FEMORAL VEIN ACCESS

22. VASCULAR COMPLICATION POST BPV

23. STUCK RUPTURED BALLOON IN FEMORAL VEIN
• 9 MO FEMALE, 6 KG
• SEVERE VALVAR PS

26. • After surgical repair the femoral venous doppler was normal

27. MX OF PULSE LOSS
• In the case of diminished or absent pulses
• Starting a heparin infusion 2-3 hours after the procedure The initial treatment
consists of heparin 100 U/kg as a single stat dose, followed by an infusion of
20 U/kg/hr
• If the pulses have not normalized the next 24hrs. an intravenous
streptokinase infusion is started.
• In small patients (less than 12 kg), if there is no return of pulses in another 24
hours but no threat of tissue loss, no surgical intervention be undertaken
because of the difficulty of repairing these small vessels.

28. THRMBOLYSIS
• Streptokinase: Initial bolus 1000 units/kg followed by an infusion of 1000 units/kg/hr.
• rTPA Regime 1 Initial bolus of 0.7 mg/kg followed by an infusion of 0.2 mg/kg/hr.
• rTPA Regime 2 Infusion 0.1 to 0.5 mg/kg/hr (incremental increase of 0.1 mg/kg/hr).
• End Points
• Return of pulse.
• Bleeding at entry site.
• Internal bleeding e.g. haematemesis, melaena, cerebral haemorrhage,
retroperitoneal bleed.
• If no response after 6 hours or if clinical deterioration

29. • the rate of vascular complications occurring after intervention procedures has
been reported to be 3 to 6 times higher than in diagnostic procedures despite
systemic heparinization.
• However, another study found that there were no arterial complications in
children as long as the ACT was maintained above 200 seconds.
• It was also reported that the incidence of arterial complications rose from
5.2% to 12.9% in patients < 5 kg as the arterial sheath size increased from 4F
to 5F. It rose further to 42.8% when the size increased to 6F

30. SUMMARY
• Younger children, longer procedure times, and difficult access more prone thrombosis.
• Use of low profile balloon/ double balloon
• Proper training of the staffs for sheath removal
• Early institution of heparin in small infants
• Judicious use of vasodilators
• USG guided access
• Surgical back-up