Acute vascular problems of children

Blunt femoropopliteal trauma in a child: Is stenting a good option?

Vascular injuries resulting from blunt trauma are uncommon in the pediatric age. In children, there are particular factors that should be taken into account when vascular traumatic lesions are treated: small vessel size or vessel spasm, a higher risk of infection, a tendency for restenosis, and rapid body growth. The endovascular procedure is a minimally invasive, quick technique that restores blood flow immediately. The stent's fate is the Achille's heel of this technique; this is the reason why a careful follow-up and further studies are required.

Candida sepsis following infected iliocaval thrombosis: a case report

The authors report the case of a patient who developed a thrombosis of the right iliac vein involving also the inferior vena cava (IVC), in association with Candida sepsis. Despite adequate and prolonged antimycotic treatment, the patient recovered from the fungal sepsis only following the surgical removal of the infected thrombus.

Efficacy and durability of autogenous saphenous vein conduits for lower extremity arterial reconstructions in preadolescent children

OBJECTIVE

Limb length discrepancies (LLDs) in growing children may accompany extremity arterial occlusions. Revascularization with vein grafts has been questioned because of degenerative graft changes observed at other sites. This study was undertaken to define vein graft durability and efficacy in lower extremity revascularizations in preadolescent children.

STUDY DESIGN

Fourteen children (10 boys, 4 girls) with a mean age of 7.3 years (range, 2-11 years) who underwent 16 lower extremity revascularizations with greater saphenous vein grafts were subjected to follow-up with graft ultrasonography, ankle/brachial indices (ABIs) with and without exercise, and limb length determinations. A mean of 5.7 years elapsed between the onset of ischemia and operation. Arterial occlusions resulted from cardiac catheterizations (11), arteritis (1), dialysis cannulation (1), and penetrating trauma (1). Indications for operation included LLD (6), claudication (4), both LLD and claudication (3), markedly diminished ABIs with a potential for LLD (2), and a traumatic transection with hemorrhage (1). The reconstructions with 15 reversed and one in situ vein grafts included iliofemoral (11), femorofemoral (1), aortofemoral (1), femoropopliteal (1), popliteal-popliteal (1), and popliteal-posterior tibial (1) arterial bypass grafts.

RESULTS

Among patent grafts available for follow-up, 36% (5 of 14) remained unchanged, 50% (7 of 14) developed nonaneurysmal dilatation, and 14% (2 of 14) exhibited nonprogressive aneurysmal expansion. One graft became occluded, and one graft was lost to follow-up. Collectively, the grafts manifest an 11.2% expansion at an average of 10.7 years postoperatively. ABIs increased from 0.75 preoperatively to 0.97, at an average of 11.0 years postoperatively. LLDs were reduced from 1.66 to 1.24 cm, at an average of 11.4 years postoperatively.

CONCLUSION

Vein graft reconstructions of lower extremity arteries in preadolescent children are durable. They provide an efficacious means of restoring normal blood flow, and in 70% of children their preexisting LLDs were reduced.

Caval thrombectomy for severe staphylococcal osteomyelitis

Two children are presented in whom thrombosis of the inferior vena cava developed in association with an acute staphylococcal osteomyelitis. One case involved the left femur and the other the left ileum. Both children had diffuse bilateral staphylococcal pneumonia from presumed septic embolization. There were close similarities between their illness and management, except that the child who survived underwent a caval thrombectomy in the acute phase of her illness. It is hypothesized that the thrombectomy played an important role in her recovery.

Giant cell vasculitis with extravascular granulomas in an adolescent

We describe an 18-year-old white male who developed lower extremity ischemia requiring amputation. He presented at 14 with pulmonary infiltrates, hepatosplenomegaly, fever, rash, adenopathy, uveitis, and arthralgias; clinical and laboratory findings were consistent with Mycoplasma pneumoniae infection. Despite adequate treatment with antibiotics, he developed chronic arthralgias and fevers, with rash and pericardial effusion. Criteria for the diagnosis of systemic lupus erythematosus were not met; juvenile rheumatoid arthritis was diagnosed presumptively. Over the subsequent 4 years he developed lymphadenopathy with biopsy-proven nonnecrotizing granulomas, chronic leg ulceration with granulomatous histology, and acute-onset impending gangrene of the left foot. A biopsy of the posterior tibial artery demonstrated giant cell arteritis. Although the histologic features were consistent with Takayasu's arteritis, complete aortic arteriography was normal. Examination of the amputated leg showed multifocal segmental giant cell arteritis. Clinicopathologic features suggested, but were not fully consistent with, juvenile systemic granulomatosis. His disease may represent a separate sarcoid-like entity in the broad spectrum of vasculitis.

Superficial thrombophlebitis. II. Secondary hypercoagulable states

Secondary hypercoagulable states are complex clinical conditions associated with an increased risk of thrombosis in which the exact pathophysiology is poorly understood. Secondary causes of superficial thrombophlebitis include malignancy, pregnancy, use of oral contraceptives, infusion of prothrombin complex concentrates, Behçet's disease, Buerger's disease, Mondor's disease, infectious agents, conditions that promote venous stasis, intravenous catheters and intravenous drug use. Conditions that may stimulate superficial thrombophlebitis include dermatophyte cellulitis at saphenous phlebectomy sites, sarcoidal granulomas, cutaneous polyarteritis nodosa, and hyperalgesic pseudothrombophlebitis in patients who test positive for human immunodeficiency virus. The distinguishing features, clinical evaluation, treatment, and histologic characteristics of the various disorders are reviewed.

Giant hydronephrosis presenting as unilateral iliofemoral vein thrombosis

We report a case of left iliofemoral vein thrombosis with extension to the inferior vena cava associated with giant right hydronephrosis secondary to ureteropelvic junction obstruction. Surgery revealed marked infrarenal vena caval compression and deviation to the left side caused by the dilated right renal pelvis, with resultant kinking of the origin of the left iliac vein. It is postulated that the reduction in blood flow caused by this compression and distortion predisposed this patient to venous thrombosis.

Spontaneous deep vein thrombosis in childhood and adolescence

Deep vein thrombophlebitis (DVT), unrelated to intravenous catheters, is unusual in children. During the period between 1970 to 1984, 15 cases of spontaneous DVT were seen at The Montreal Children's Hospital. The female to male ratio was 2:1. Age ranged from 10 to 17 years. Venogram was positive in the 14 patients in whom it was done. Significant factors were related to the DVT in 12 patients: oral contraceptives, pelvic fracture, Ewing's sarcoma and chemotherapy, brain tumor, nephrotic syndrome, and ulcerative colitis (2, one of whom developed the DVT 3 months before the onset of gastrointestinal symptoms). The sites of thrombophlebitis encountered were left iliofemoral vein, right iliofemoral, right tibial, and left subclavian. Three patients developed pulmonary emboli, which were recurrent in two and required iliac vein ligation or inferior vena cava clipping. Treatment usually consisted of intravenous heparin followed by oral anticoagulants for 3 to 6 months. Two patients received streptokinase with good results. All the patients recovered. With a limited follow-up (6 months to 5 years), we have not seen any postphlebitic sequelae.