Surgical treatment of abdominal aortic aneurysms in infancy and early childhood

Open Emergency Repair of a Thoracoabdominal Aortic Aneurysm on a 12-Year-Old Boy With Tuberous Sclerosis

Tuberous sclerosis complex is a neurocutaneous syndrome caused by an autosomal dominant genetic disorder. This condition can lead to the expression of many vascular anomalies especially, in the pediatric population. Likewise, it has been linked with aortic aneurysm development. We report a case of a 12-year-old boy who presented a 97 × 70 mm Crawford type IV thoracoabdominal aortic aneurysm. Satisfactory open surgical repair was performed with an 18-mm multibranched dacron tube graft. Clinical and imaging findings revealed a de novo tuberous sclerosis diagnosis. The patient was discharged uneventfully during a 1-month follow-up.

Recurrent symptomatic aortic aneurysm in a young girl with tuberous sclerosis complex and review of the literature

An abdominal aortic aneurysm is a rare occurrence in pediatric populations. When present, it is usually associated with an underlying etiology such as a connective tissue disorder, inflammatory process, or noninflammatory medial degeneration. In the present report, we describe the case of a girl with tuberous sclerosis complex who underwent successful emergency open repair of a symptomatic infrarenal abdominal aortic aneurysm and recurrent type IV thoracoabdominal aortic aneurysm.

Acquired Saccular Abdominal Aortic Aneurysm in a 10-Year-Old Child: A Case Report and Literature Review

An abdominal aortic aneurysm (AAA) is a confined dilatation involving the abdominal aorta. The incidence is rare and the etiology is unknown. Cases associated with conditions like Kawasaki, connective tissue, Behcet's diseases, and vasculitis are considered acquired. Our patient had a clinical criterion of Behcet's disease. Management involves a surgical approach. Endovascular intervention is not an option here, as the aneurysm is close to the bifurcation evident in computed tomography angiogram scans. Usually, they have good long-term outcomes. In our paper, we aim to describe the clinical presentation, management approach, and the outcome of our patient with an acquired AAA.

Multiple Interventions to Thoracoabdominal Aortic Aneurysm in a Child With Tuberous Sclerosis

Thoracoabdominal aortic aneurysms in toddlers are extremely rare. However, we experienced an extent III thoracoabdominal aortic aneurysm in a boy with tuberous sclerosis who underwent 3 open repairs and 1 endovascular aortic repair between the ages of 4 years and 18 years. This case highlights the potential for severe recurrent vascular aneurysms in the thoracic and abdominal aorta as a complication of tuberous sclerosis in children. Although aortic aneurysms in children are rare, it is vital to recognize these cases to prevent death due to rupture.

Popliteal artery aneurysm in a 14-year-old boy with tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is rarely associated with aneurysms. We have described a patient with a popliteal artery aneurysm that was associated with TSC and occlusion of the right posterior tibial artery. The patient underwent aneurysm resection and vein graft replacement, with an uneventful postoperative course and no recurrence at 11 months of follow-up. Patients with TSC could have aneurysms in areas that will not be recognized on abdominal imaging. Physical examination of the lower extremities should be performed owing to the possibility of a popliteal artery aneurysm, and imaging studies should be performed if an aneurysm is suspected.

A single center experience on the management of pediatric blunt aortic injury

OBJECTIVE

Blunt abdominal aortic injury in pediatrics is a rare clinical entity with which most vascular surgeons have minimal experience. Evidence for management recommendations is limited. Herein we report a single institution's experience in the care of pediatric abdominal aortic injuries.

METHODS

This is a retrospective review of consecutive pediatric patients diagnosed with blunt traumatic abdominal aortic injury at our institution between 2008 and 2019.

RESULTS

Sixteen pediatric patients (50% male) were identified, ranging in age between 4-17 years. All were involved in motor vehicle collisions and were restrained passengers with a seatbelt sign. Five patients (31%) were hypotensive en route or upon arrival. Seven patients (44%) were transferred from another hospital. The median Injury Severity Score (ISS) was 34 (Interquartile range, IQR 19-35). The infrarenal aortic injuries were stratified according to the aortic injury grading classification: n=5/2/7/2 (grades 1-4, respectively). Concurrent non-aortic injuries included solid organ (63%, n=10), hollow viscus (88%, n=14), brain (25%, n=4), hemo/pneumothorax (25%, n=4), spine fractures (81%, n=13), and non-spine fractures (75%, n=12). In total, 56% of patients (n=9/16) required aortic repair: three needed immediate revascularization for distal ischemia. The remaining six patients (38%) underwent a delayed repair with a median time to repair of 52 days (range 2-916 days). Half of delayed repairs occurred during the index hospitalization. On repeat axial imaging, the three delayed-repair patients were found to have enlarging pseudoaneurysms or flow-limiting dissections and subsequently underwent repair during index hospitalization. Only one patient underwent endovascular repair. No deaths occurred, and the median follow-up length was 7 months (IQR 3-28 months) in this study population. All postoperative patients demonstrated stable imaging without requiring further intervention. Seven patients, whose injury grades ranged between 1 and 3, were observed. Their repeat imaging demonstrated either stability or resolution of their aortic injury. Remarkably, half of patients were lost to follow up after discharge or following their first postoperative clinic visit.

CONCLUSIONS

Delayed aortic intervention can be safely performed in the majority of pediatric patients with blunt abdominal aortic injuries with preserved distal perfusion to the lower extremities. This suggests that transfer to a tertiary center with vascular expertise is a safe and feasible management strategy. However, progression of aortic injuries was seen as early as within 48 hours and as late as 30 months post injury, underscoring the importance of long-term surveillance. Unfortunately, in this cohort, 50% of the children were lost to follow up, highlighting the need for a more structured surveillance strategy.

Endovascular Repair of a Descending Thoracic Aortic Aneurysm in a Pediatric Patient with Tuberous Sclerosis: A Case Report and Review of the Literature

Aortic aneurysm in children is rare, but has been described in the tuberous sclerosis complex (TSC) population. While surgical repair has been utilized as the primary means of intervention, we present the first known case reporting exclusion of a descending thoracic aortic aneurysm with percutaneous covered stent implantation in a pediatric patient with TSC. A review of the literature is also included herein.

Resolving the biological paradox of aneurysm formation in children with tuberous sclerosis complex

Aortic aneurysms are rare manifestations in children with tuberous sclerosis complex (TSC) with life threating implications. Although an association between TSC, aortic and other aneurysms has been recognized, mechanistic insights explaining the pathophysiology behind aneurysm development and genetic aberrations in TSC have so far been lacking. Here, we summarize existing knowledge on aneurysms in TSC and present a case of a 2-year-old boy with an infrarenal aortic aneurysm, successfully treated with open aortic reconstruction. Histologic examination of the excised aneurysm wall showed distortion of vessel wall structure with loss of elastin and a pathologic accumulation of smooth muscle cells. Until now, these pathologic features have puzzled researchers as proliferating smooth muscle cells would rather be expected to preserve vessel wall integrity. Recent reports exploring the biological consequences of the dysregulated intracellular signaling pathways in patients with TSC provide plausible explanations to this paradox, which may support the development of future therapeutic strategies.

Low-Back Pain Revealing an Abdominal Aortic Aneurysm in a 15-Year-Old Girl: A Case Report

CASE

An abdominal aortic aneurysm is rarely seen in children. We report the case of a 15-year-old girl who presented with lower back pain in a subfebrile setting with moderate biological inflammatory syndrome. Imaging assessment, including a spinal magnetic resonance imaging, had shown no evidence of spondylodiscitis or other spinal or renal pathology. Ten days later, she presented in hemorrhagic shock and was found to have a ruptured infected aneurysm of the abdominal aorta.

CONCLUSIONS

This case reminds us to include an aneurysm in the differential diagnosis of lower back pain, even in children.

Management of Seat Belt-type Blunt Abdominal Aortic Trauma and Associated Injuries in Pediatric Patients

BACKGROUND

"Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may concentrate forces in a band-like pattern across the abdomen, resulting in the triad of hollow viscus perforation, spine fracture, and aortoiliac injury. We report 4 cases of pediatric seat belt-type aortic trauma and review management strategies for the aortic disruption and the associated constellation of injuries.

METHODS

-approved, retrospective review of all pediatric patients requiring surgical intervention for seat belt-type constellation of abdominal aortic/iliac and associated injuries over a 5-year period. Blunt thoracic aortic injuries were excluded.

RESULTS

We identified 4 patients, ranging from 2 to 17 years of age, who required surgical correction of seat belt-type aortoiliac trauma and associated injuries: 3 abdominal aortas and 1 left common iliac artery. The majority (3/4 patients) were hemodynamically unstable at emergency room presentation, and all underwent computed tomography angiography of the chest/abdomen/pelvis during initial resuscitation. Injuries of the suprarenal and proximal infrarenal aorta were accompanied by unilateral renal artery avulsion requiring nephrectomy. Presumed or proven spinal instability mandated supine positioning and midline laparotomy, with medial visceral rotation utilized for proximal injuries. Aortoiliac injuries requiring repair were accompanied by significant distal intraluminal prolapse of dissected intima, with varying degrees of obstruction. Conduit selection was dictated by the presence of enteric contamination and the rapid availability of an autologous conduit. The sole neurologic deficit was irreparable at presentation.

CONCLUSIONS

Seat belt aortoiliac injuries in pediatric patients require prompt multidisciplinary evaluation. Evidence of contained aortoiliac transection, major branch vessel avulsion, and bowel perforation mandates immediate exploration, which generally precedes spinal interventions. Lesser degrees of aortoiliac injuries have been managed with surveillance, but long-term follow-up is needed to fully validate this approach.

Arterial reconstructions for pediatric splanchnic artery occlusive disease

OBJECTIVE

Pediatric splanchnic arterial occlusive disease is uncommon and a rare cause of clinically relevant intestinal ischemia. This study was undertaken to better define the clinical manifestations and appropriate treatment of celiac artery (CA) and superior mesenteric artery (SMA) occlusive disease in children.

METHODS

Clinical courses of 30 consecutive children undergoing operations for splanchnic arterial occlusive disease at the University of Michigan from 1992 to 2017 were retrospectively analyzed.

RESULTS

Vascular reconstructions were performed for splanchnic arterial disease in 18 boys and 12 girls, 1.5 to 16 years of age (mean, 7.5 ± 4.1 years). Isolated splanchnic arterial disease was uncommon (2 children), being more often associated with abdominal aortic coarctations (19 children) or ostial renal artery stenoses (25 children). Primary splanchnic arterial reconstructions (30) included aortic reimplantation of SMAs (15) or celiacomesenteric arteries (2), aortoceliac and aortomesenteric bypasses (7), reimplantation of the CA as a patch over the stenotic SMA orifice (3), and patch angioplasty of the CA (2) or SMA (1). There was no perioperative mortality. Two groups (I and II) were identified for study. Group I children (14) experienced symptomatic intestinal ischemia, manifested by various combinations of chronic postprandial abdominal discomfort (14), ischemia-related intestinal bleeding (2), or failure to thrive (4). Four children in group I became symptomatic after known CA and SMA occlusive disease was left untreated at the time they underwent earlier interventions for renovascular hypertension. Seven secondary redo interventions were undertaken for recurrent symptoms in six group I children. Only one major periprocedural complication occurred: segmental colon infarction. The assisted patency rate of reconstructed arteries in group I children was 93%, and intestinal ischemic symptoms resolved in every child. Group I follow-up from the most recent splanchnic arterial reconstruction averaged 4.3 years. Group II children (16) without manifestations of intestinal ischemia underwent prophylactic splanchnic arterial reconstructions in concert with combined aortic and renal artery procedures (11), isolated abdominal aortic reconstructions (3), or renal artery reconstructions alone (2). Group II children experienced no major perioperative morbidity and remained asymptomatic postoperatively, and none required secondary splanchnic artery interventions. Group II follow-up averaged 7.4 years.

CONCLUSIONS

Pediatric splanchnic artery occlusive lesions are often associated with developmental aortic and renal artery occlusive disease. Carefully conducted therapeutic and prophylactic reconstructive procedures are appropriate in children having splanchnic arterial occlusive disease.

Ligation of the aorta for a mycotic abdominal aortic aneurysm in an infant

Mycotic aortic aneurysms are exceedingly uncommon in infants and they have a high risk of rupture. Their surgical management is extremely challenging. We report a case of a 22-month-old girl who presented with abdominal pain and fever revealing a ruptured mycotic aneurysm of the infrarenal aorta. The surgical treatment consisted of a ligature of the proximal and distal ends of the aneurysm. Postoperative course was significant for hypertension. A year and a half follow-up showed no other complications. Limited data are available concerning our chosen technique, but the reported cases showed a good short-term outcome.

Ruptured abdominal aortic aneurysm repair in pediatric Marfan syndrome patient

Marfan syndrome is a well-described autosomal dominant connective tissue disorder with a constellation of anatomic characteristics including aortic degeneration as a result of the spontaneous mutation of the fibrillin gene, FBN1. Whereas life-threatening dissection and ascending aneurysmal rupture have been thoroughly documented in the literature, aneurysms of the abdominal aorta and those present in the pediatric population have only rarely been reported. In this case report, we describe presentation, successful open surgical repair, and recovery of a pediatric Marfan syndrome patient with a ruptured abdominal aortic aneurysm.

Pediatric Vascular Surgery Review with a 30-Year-Experience in a Tertiary Referral Center

Pediatric vascular disease is rare, and remains a big challenge to vascular surgeons. In contrast to adults, surgery for pediatric vascular disease is complicated by issues related to small size, future growth, and availability of suitable vascular conduit. During the last 30 years, 131 major vascular operations were performed in a tertiary referral center, Seoul National University Hospital, including aortoiliac aneurysm, acute or chronic arterial occlusion, renovascular hypertension, portal venous hypertension, trauma, tumor invasion to major abdominal vessels, and others. Herein we review on the important pediatric vascular diseases and share our clinical experiences on these rare diseases.