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

Autologous and synthetic pediatric iliofemoral reconstruction: a novel technique for pediatric iliofemoral artery reconstruction

Pediatric lower extremity arterial catheterization-related injuries can result in significant long-term morbidity. Revascularization is challenging due to concerns for long-term patency and growth accommodation with synthetic grafts. We describe a novel technique for iliofemoral revascularization using common iliac artery transposition and bridging polytetrafluoroethylene grafts. We treated two children who underwent femoral catheterization resulting in lifestyle-limiting claudication. Both patients experienced immediate resolution of symptoms. Postoperative imaging demonstrated widely patent vasculature. ASPIRE (autologous and synthetic pediatric iliofemoral reconstruction) is a method of pediatric iliofemoral artery revascularization that allows for an autologous artery to span the hip joint, reducing graft thrombosis risk and accommodating patient growth.

Interposition of great saphenous vein on lymphatic venous anastomosis for infantile intractable chylothorax

Central lymphatic diseases such as intractable chylothorax can be fatal. Lymphatic venous anastomosis at the venous angle level is expected to give a direct therapeutic effect because it opens the obstructed outlet of the main lymphatic vessels. However, the original methods resulted in some important issues, such as the potential for venous reflux. In the present case, we modified the original anastomosis method by interposing a vein graft with venous valves to increase the distance and prevent venous reflux. Collecting the lymphatic flow resulted in termination of the chylothorax with preserved postoperative patency for years, without any complications, including at the graft-harvested extremity.

Review of surgical treatment of iatrogenic iliofemoral artery injury in the pediatric population after catheterization

Trauma is the leading cause of death in the pediatric population. Although vascular trauma has an incidence of 6% in civilian population, iatrogenic injuries are the leading cause, and the most frequent injured vessel is the iliofemoral sector. However, little information is available and there are no guidelines about its treatment. Therefore, this review aimed to describe the information available concerning pediatric iatrogenic arterial trauma, focusing on the iliofemoral segment and present 3 cases. We described 11 articles with 171 patients, of whom 61% underwent surgery to treat iatrogenic trauma. Mean age was 3.28 years (standard deviation of 3.5 years), and 54% were female. Most iliofemoral injuries occurred after arterial catheterization for hemodynamic monitorization and therapeutic or diagnostic cardiac catheterization (due to congenital heart diseases, including septal defects, tetralogy of Fallot, aortic coarctation, and patent ductus arteriosus). For acute complications, arterial thrombosis was the leading injury, followed by pseudoaneurysm, hematoma, dissection, transection, avulsion, eversion, and combined lesions.

Current Opinions in Open and Endovascular Treatment of Major Arterial Injuries in Pediatric Patient

Pediatric major arterial vascular injuries may belong to the same principal categories as adults, but have been poorly documented, with an estimated overall incidence of <2% of all vascular traumas. Open surgery has been the mainstay of treatment, but no clear guidelines have been developed to recommend the best practice patterns in terms of strategy or repair as well as postoperative pharmacological regimen. Herein, we report three cases and a narrative review of the available literature regarding the main aspects when dealing with pediatric arterial injuries based on the predominant series available from the most recent published literature.

Peripheral vascular bypass with cadaveric arterial allograft in a toddler with femoral mycotic aneurysm

Mycotic aneurysms are exceedingly rare in the pediatric population. The optimal surgical treatment for children with this disease is unclear as aneurysm resection and vascular reconstruction are uncommonly performed in young children. We present a unique case of a 21-month-old child with a complex cardiac history who presented with limb ischemia and was discovered to have thrombosis of the common femoral and superficial femoral artery. Groin exploration revealed a left common femoral and superficial femoral artery mycotic aneurysm that was successfully repaired with excision of the mycotic aneurysm, external iliac to profunda femoral artery vascular bypass using cryopreserved arterial allograft and femoral vein reconstruction. This case demonstrates successful vascular reconstruction can be performed in a young child with an Aspergillus mycotic aneurysm using cadaveric arterial allograft.

Aortic Injury From High-Speed Deceleration Against a Lap Belt in a 10-year-Old

Traumatic aortic injuries in children and adolescents are rare, and even more rare are blunt traumatic injury to the abdominal aorta in this population. Therefore, there are few reports discussing the presentation and repair of such injuries, especially within the pediatric population. We report the successful repair of traumatic abdominal aortic transection in a 10-year-old female after a high speed MVC. She arrived in extremis with a seatbelt sign and was taken emergently for damage control laparotomy with subsequent postoperative CT findings of aortic transection/dissection at L3 with active extravasation. She immediately underwent open thrombectomy of the bilateral iliac arteries, and repair of her aortic injury with a 12 × 7 mm Hemashield interposition graft extending just distal to the IMA and 1 cm proximal to the aortic bifurcation. There are little data regarding long-term outcomes of pediatric patients undergoing different aortic repair techniques, and further research is needed.

Lower extremity aneurysmal degeneration of great saphenous venous allograft bypass in an adolescent boy

Chronic limb-threatening ischemia in the pediatric population is a rare phenomenon. When open repair is necessitated, an autogenous conduit is preferred. However, venous grafts are prone to their own long-term complications. We have presented the case of a 10-year-old boy with chronic limb-threatening ischemia due to popliteal artery thrombosis that was treated with an ipsilateral great saphenous vein bypass. Seven years after the initial procedure, the venous graft had developed aneurysmal degeneration with acute thrombosis, necessitating bypass revision. Through the present case, we have discussed the surgical approach and highlighted the importance of long-term postoperative surveillance after open repair in the pediatric population.

Long-term outcome in pediatric surgical bypass grafting after traumatic injury and tumor resection: retrospective cohort analysis

Vascular bypass surgery in children differs significantly from adults. It is a rarely performed procedure in the setting of trauma and tumor surgery. Besides technical challenges to reconstruct the small and spastic vessels, another concern in bypass grafting is the adequate limb length growth over time. The primary aim of this study was to assess long-term outcome after pediatric bypass grafting, in a single academic center, focusing on potential effects on limb development. In this retrospective cohort analyses we included all pediatric patients undergoing vascular bypass grafting at our department between 2002 and 2017. All patients ≤ 18 years suffered a traumatic injury or underwent a tumor resection of the lower or upper limb. The youngest female patient was 0.4 years, the youngest male patient was 3.5 years. During the observation period, 33 pediatric patients underwent vascular repair, whereby 15 patients underwent bypass grafting. Median overall follow-up was 4.7 years (IQR ± 9). 8 patients (53%) had a traumatic injury (traumatic surgery group) and 7 patients had a planned orthopedic tumor resection (orthopedic surgery group). In 13/15 (87%) a great saphenous vein (GSV) graft and in 2/15 (13%) a Gore-Tex graft was used for bypassing. Both Gore-Tex grafts showed complete occlusion 12 and 16 years after implantation. No patient died in the early postoperative phase (< 30 days), however 3/7 (43%) in the orthopedic group died during follow-up. Revision surgery had to be performed in 1/15 (7%) patients. A functional use of the extremity was reported in all patients. Normal limb length growth according to the contralateral site, and therefore bypass growth, could be documented in 14/15 patients. Children are surgically challenging. In our study, surgery by a specialized vascular surgery team using GSV grafts led to adequate limb length and bypass growth, and we observed no functional restrictions.

Microsurgical vascular bypass in the setting of pediatric limb length discrepancy

Management of pediatric iatrogenic arterial occlusions can be challenging clinically, leading to chronic complications such as claudication and limb length discrepancy. We report the case of a 6-month-old female patient who had experienced iatrogenic right external iliac and common femoral arterial occlusion. At the age of 8 years, she had developed claudication and a limb length discrepancy of 3.2 cm. She underwent common iliac artery to superficial femoral artery and profunda artery bypass via a branched autologous reverse great saphenous vein using microsurgical techniques for the distal anastomoses. In the present report, we have focused on the musculoskeletal improvements, benefits of microsurgery in pediatric vessels, and maximization of epiphyseal perfusion.

Microsurgical Salvage of Acute Lower Limb Ischemia after Iatrogenic Femoral Injury during Orthopedic Surgery in a Pediatric Patient

Acute lower limb ischemia (ALLI) in the pediatric population is rare but may lead to limb loss and life-long complications. We report the technique and outcomes of microsurgical salvage of ALLI in a preterm newborn after open reduction of congenital hip dysplasia. A 2-month-old girl was born premature at week 36 with congenital bilateral hip dysplasia. The initial management attempted was conservative and entailed placement of bilateral Von Rosen splints. The treatment was successful on the left side, but the patient had recurrent unstable hip dislocation on the right side. Subsequently, 2 attempts at close reduction under general anesthesia were done and both were unsuccessful in maintaining the right hip in the acetabulum. Therefore, an open reduction of the right hip was planned through a medial/obturator approach. During the surgical procedure, the neurovascular femoral bundle (including the superficial femoral artery [SFA], femoral vein [FV], and femoral nerve) was accidently transected with subsequent development of ALLI. Therefore, the FV was harvested distally to the injury site and a 4-cm long healthy segment was obtained. It was reversed, flushed with heparin, spatulated at both extremities, and interposed to the SFA in end-to-end fashion using two 9/0 polypropylene interrupted sutures under microscope. Reperfusion of the limb was noted immediately after releasing the vascular clamps. The final ischemia time at completion of the surgical procedure was 6 hr. Thereby, prophylactic 4-compartment fasciotomies were performed in the right leg. The patient tolerated the procedure well and the postoperative clinical course was free from adverse events. Duplex ultrasound examination at 6 weeks after the intervention confirmed sustained clinical success and showed no signs of venous thromboembolism. At the same time, X-ray examination of the right hip confirmed adequate and stable reduction of the joint in the acetabulum. ALLI due to accidental arterial injury during orthopedic surgical procedures for congenital defects in newborns is a rare but potentially devastating complication. Microsurgical salvage is a safe, feasible, and effective option to restore limb flow. Multidisciplinary expertise and meticulous technique are mandatory in order to achieve satisfactory and durable outcomes.

Dual-layer everted saphenous vein patch for pediatric femoral artery repair following ECMO decannulation

Decannulation from pediatric veno-arterial extracorporeal membrane oxygenation (VA-ECMO) involves the removal of large arterial perfusion cannulas from relatively small lower extremity arteries. While these challenging repairs are frequently performed by general pediatric surgeons, there is little standardization with regard to vascular techniques within the pediatric surgery training paradigm, resulting in variability in the repair of these arteriotomies and potential future consequences for lower extremity perfusion and growth. Herein we present a technique for repair of large common femoral arteriotomies following removal of ECMO perfusion cannulas utilizing a dual-layer patch of ipsilateral saphenous vein harvested via the arterial cutdown incision. This vein segment is everted to maximize endothelial surface area of the patch and dual layered to provide additional support against aneurysmal degeneration. The described technique is an effective repair of arteriotomy following VA-ECMO decannulation, which minimizes vascular complications and is an accessible technique to those without advanced vascular surgical training. LEVEL OF EVIDENCE: Level IV; operative technique description with small case series.

Pediatric Replantation and Revascularization

Replantation and revascularization in the pediatric extremity has unique challenges that provide a fertile field of research and clinical experience. Children regenerate peripheral nerves rapidly, resulting in good sensory and motor function. They adapt well to functional deficits and mismatch errors of reinnervation. The technical aspects of microsurgical care in children can be challenging because the structures are small. Additional technical challenges include preservation of growth centers, prevention of vasospasm, protection of the reconstruction, and psychosocial care. Despite these challenges, children show excellent functional outcomes with minimal complications.

Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center

BACKGROUND

Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity.

METHODS

Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas.

RESULTS

There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency.

CONCLUSIONS

Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.

Long-term outcomes after pediatric peripheral revascularization secondary to trauma at an urban level I center

OBJECTIVE

The purpose of this investigation was to determine our limb-related contemporary pediatric revascularization perioperative and follow-up outcomes after major blunt and penetrating trauma.

METHODS

A retrospective review was performed of a prospectively maintained pediatric trauma database spanning January 2010 to December 2017 to capture all level I trauma activations that resulted in a peripheral arterial revascularization procedure. All preoperative, intraoperative, and postoperative continuous variables are reported as a mean ± standard deviation; categorical variables are reported as a percentage of the population of interest.

RESULTS

During the study period, 1399 level I trauma activations occurred at a large-volume, urban children's hospital. The vascular surgery service was consulted in 2.6% (n = 36) of these cases for suspected vascular injury based on imaging or physical examination. Our study population included only patients who received an arterial revascularization, which was performed in 23 of the 36 consultations (1.6% of total traumas; median age, 11 years). These injuries were localized to the upper extremity in 60.9% (n = 14), lower extremity in 30.4% (n = 7), and neck in 8.7% (n = 2). The mean Injury Severity Score in the revascularized cohort was 14.0 (±7.6). Bone fractures were associated with 39.1% of the vascular injuries (90% of blunt injuries). Restoration of in-line flow was achieved by an endovascular solution in one patient and open surgery in the remainder, consisting of arterial bypass in 59.1% and direct repair in 40.9%. Within 30 days of the operation, we observed no deaths, no infections of the arterial reconstruction, and no major amputations. One patient required perioperative reintervention by the vascular team secondary to the development of a superficial seroma without evidence of graft involvement. Mean follow-up in our cohort was 43.3 (±35.4) months. During this phase, no additional deaths, amputations, chronic wounds, or limb length discrepancies were observed. All vascular repairs were patent, and all but one patient reported normal function of the affected limb at the latest clinic visit.

CONCLUSIONS

Traumatic peripheral vascular injury is rare in the pediatric population but is often observed secondary to a penetrating force or after long bone fracture. However, contemporary perioperative and long-term outcomes after surgical revascularization are excellent as demonstrated in this institutional case series.

Continued Ultrasound Surveillance Required after Hand Ischemia Associated with Trauma in Children

BACKGROUND

Hand ischemia following trauma in children is rare, and the natural history after upper extremity arterial bypass in children is unknown. We hypothesize children with brachial artery repair are at long-term risk of developing aneurysmal degeneration or thrombosis, thus necessitating annual duplex ultrasonography and physical examination.

METHODS

A retrospective review of children who had brachial artery repair (bypass or vein patch) for hand ischemia secondary to trauma at a level I trauma pediatric hospital was performed. Telephone interviews were conducted to assess the presence of arm/hand symptoms (pain, weakness, fatigue, sensory function, limb length discrepancy).

RESULTS

Between 2003 and 2016, 16 children (12 males), mean age 8 years (3-13 years) underwent brachial artery repair (12 bypass with vein, 4 vein patch). Mechanism of injury included 11 supracondylar fractures and 5 lacerations. All patients were seen at 2 weeks with a duplex ultrasound. Thirteen patients were lost to follow-up. The 3 patients with follow-up had patent bypasses, but one patient 6 years out from the repair had aneurysmal degeneration of the vein graft. Seven patients were never seen again. Phone interviews were conducted for the remaining 6 patients and 2 complained of arm fatigue and intermittent hand pain. Only one patient reported that the pediatrician checked pulses in the affected extremity.

CONCLUSIONS

Eighty percentage of children had no further follow-up after the postoperative visit. Asymptomatic aneurysmal degeneration of the vein graft was noted 6 years following repair in one patient, and 2 patients had unevaluated hand complaints. These patients are at risk for late complications and are unlikely to return for routine follow-up. The importance of graft surveillance must be more clearly emphasized at time of initial surgery.

Arterial reconstructions for chronic lower extremity ischemia in preadolescent and adolescent children

OBJECTIVE

Chronic lower extremity ischemia in pediatric patients is uncommon. The intent of this study was to better define the arterial reconstructive options and their long-term durability in preadolescent and adolescent children having clinically relevant arterial occlusions affecting the lower extremity.

METHODS

The medical records of 33 consecutive pediatric patients who underwent lower extremity revascularization for chronic ischemia at the University of Michigan from 1974 to 2016 were reviewed. Patients were categorized by age, clinical manifestation, surgical intervention undertaken, and outcomes.

RESULTS

Operative treatments involved 26 preadolescent children (mean age, 6.1 years; range, 3-9 years) and 7 adolescent children (mean age, 13.9 years; range, 10-17 years). Occlusions were due to earlier injury related to catheter (14), cannula (2), or both catheter and cannula (14); penetrating trauma (2); and vasculitis (1). Preoperative manifestations included symptomatic extremity ischemia (25), growth retardation manifested by documented limb length discrepancies (21), and scoliosis (5). Primary arterial reconstructions were delayed after the precipitating vascular event an average of 5.3 and 11.2 years in the preadolescent and adolescent children, respectively. Primary procedures involved revascularizations of 36 extremities (in preadolescents and adolescents) including autologous vein (26/5), polyethylene terephthalate (Dacron; 1/0), and expanded polytetrafluoroethylene (0/3) bypasses and vein patch angioplasty (0/1). Vein grafts traversing the abdominal cavity (15) were wrapped with a synthetic mesh. Excluding one early graft occlusion, there were no major early postoperative complications after the primary procedures. Secondary operations followed 31% of the primary operations, being performed an average of 8.8 and 6.7 years later (in 8 preadolescent and 3 adolescent children, respectively) for late graft occlusions (6), graft stenoses (3), aneurysmal vein grafts (2), and anastomotic pseudoaneurysm (1). The unassisted primary graft patency rate was 69%, and the assisted secondary graft patency rate was 94%. Symptomatic ischemia resolved in all but two children. Mean postoperative ankle-brachial indices improved to 1.08 from 0.76 preoperatively. Among children having postoperative documentation of limb lengths, the limb length discrepancies became less (11), were unchanged (1), or progressed (3). Follow-up averaged 8.0 years. There was no operative mortality in this experience.

CONCLUSIONS

Primary lower extremity arterial reconstructions in children with chronic lower extremity ischemia can be successfully undertaken with excellent results. Nevertheless, the potential for late primary graft failures, evident in nearly a third of this experience, mandates careful long-term follow-up and may necessitate secondary interventions to maintain satisfactory outcomes.

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.

Natural History of Iatrogenic Pediatric Femoral Artery Injury

BACKGROUND

Iatrogenic femoral artery trauma complicates the course of critically ill neonates and children. Complications from persistent arterial occlusion may include claudication and limb length discrepancies. Data supporting risk factors for such and need for revascularization are lacking.

METHODS

Review of a prospectively maintained database at a tertiary institution of iatrogenic pediatric femoral artery injuries incurred between 2013 and 2014 was performed. Additional injuries were identified by review of pediatric arterial duplex performed between 2008 and 2013. Demographics, risk factors, and outcomes were queried. Data analysis utilized Fischer's exact t-test and logistic regression.

RESULTS

Seventy-six patients were identified of which 68 presented with acute limb ischemia (ALI) and 8 with chronic iliofemoral arterial occlusion resulting in claudication (n = 6) or limb length discrepancy (n = 2). Mean weight at injury was 6.3 kg; mean age at injury was 49 weeks (50% aged <3 months). Mean follow-up was 14 months (out to 11 years). Six patients required surgery for ALI, and 6 required delayed operation for limb length discrepancy (n = 4) or for persistent external iliac artery (EIA) occlusion. Mean age at delayed revascularization was 6 years (range: 2-13 years). Vasopressor use, mechanism/location of injury, and concomitant venous thrombosis were not significantly correlated with need for operation; trends suggested that cardiac catheterization and EIA thrombosis may correlate with chronic disease. Increased age at injury was associated with need for operation.

CONCLUSIONS

Although a majority of children with ALI may be successfully treated medically, 9% will require operation for ALI and 16% ultimately required revascularization during follow-up. Persistent iliofemoral arterial thrombosis is a likely risk factor for limb length discrepancy with growth; identifying risk factors for this and improved methods for surveillance requires ongoing investigation.

Outcomes of arterial vascular extremity trauma in pediatric patients

BACKGROUND

Vascular trauma in children, although rare, carries significant risk for repair. Here we report outcomes from a single trauma center for children with extremity vascular trauma, proximal to the digits.

METHODS

Retrospective chart review of patients less than age 18years with an acute, non-iatrogenic traumatic arterial vascular injury of the upper and/or lower extremity between January 2008 and December 2013. Abstracted patient demographics, injury characteristics, surgical management, and disposition were summarized and compared with nonparametric methods.

RESULTS

23 children comprised the study cohort: median age of 8years (IQR: 4.6-12), 61% (n=14) males, 100% survival. Penetrating injuries were the predominate mechanism (n=17, 74%). The median time to presentation was 154min (IQR: 65-330). Acute operations for revascularization included a primary repair (n=15, 65%) or reversed vein graft (n=7, 30%). Fasciotomies were done for 3 (13%) patients. Three amputations were done for failed revascularization. Upper extremity vascular injury (n=15, 65%) was more common. The rate of associated extremity fracture was similar between upper (21%) and lower (33%) extremities (p=0.643). Eight (35%) patients required additional surgery most commonly for debridement, washouts and dressing changes. Three patients' hospital stays were complicated by infection. Impaired function was the most common short- and long-term complication (60%, 75%).

CONCLUSION

Pediatric vascular injuries are commonly associated with penetrating injuries and male gender and occurred more frequently in the upper extremities. Overall patency rates after repair were 87%. Fasciotomies were done in 13% of patients, and the overall surgical amputation rate was 13%. There was no mortality in this cohort; however, multiple operations are commonly required, including the return to OR for washouts, debridements and dressing changes. The most common short- and long-term complication was impaired function. Overall good results are achievable in pediatric vascular trauma treated with revascularization.

Innovative Use of Interventional Hardware in Surgical Embolectomy in Small Infants

Surgical embolectomy for thrombosis and ischemia following femoral arterial cannulation in small infants is rare. The nonavailability of embolectomy balloons in small sizes and the small size of the native vessels pose a challenge in repair. We describe the use of a coronary angioplasty balloon for the purpose of embolectomy in a 2.5-kg infant with femoral arterial occlusion and limb ischemia.

Post-catheterisation arterial thrombosis in children--pathophysiology, prevention, and treatment

Lower limb ischaemia is the most frequent complication of cardiac catheterisation in children. It is often overlooked, but it can cause significant disability and may limit arterial access sites to repeat diagnostic or interventional catheterisations. A narrative review of the literature on arterial access site thrombosis in children was carried out with a special focus on current evidence that supports preventive and treatment strategies. Anticoagulation, thrombolysis, and thrombectomy have been used successfully to treat arterial access site thrombosis. However, it is not completely established which is the role of each treatment modality and what is the most appropriate timing to deliver it. Therefore, diagnostic and therapeutic strategies have to be prospectively investigated, particularly for clarifying the role of new pharmacologic interventions and of percutaneous and surgical thrombectomy in the current era.

Surgical repair of lower extremity vascular injuries in children: two cases

The use of percutaneous devices is commonplace for the treatment of many congenital heart defects. However, there are some situations where procedure-related complications are encountered and surgical help is required to ameliorate this issue. Vascular injury due to transcatheter intervention is a significant and challenging complication and occasionally requires surgical approach. In this case report, we aimed to present successful surgical management of vascular injuries associated with percutaneous interventions in children.

Trauma vascular na população pediátrica

CONTEXTO: O trauma vascular na população pediátrica apresenta-se como um desafio único, frente à sua incidência relativamente baixa, mesmo em centros médicos de referência. Devido à fragilidade dos tecidos, ao reduzido tamanho dos vasos e à sua baixa incidência, manifesta-se com taxas significativas de morbidade e mortalidade. OBJETIVO: Descrever e analisar os casos de trauma vascular em pacientes pediátricos admitidos em hospital terciário. MÉTODOS: Por meio de estudo retrospectivo, analisaram-se os casos de trauma vascular em pacientes menores de 18 anos, admitidos de janeiro de 2000 a julho de 2010, levando-se em conta dados demográficos, mecanismos de lesão, traumas associados, tratamentos empregados e complicações. RESULTADOS: Foram estudados 242 pacientes com trauma vascular, sendo 37 (15,2%) pertencentes à população pediátrica. A média de idade foi de 12,5 anos, sendo 81% dos participantes da pesquisa do sexo masculino. Entre os mecanismos de lesão, o trauma penetrante foi o mais comum (57%), seguido do contuso (38%) e do iatrogênico (5%). Das técnicas cirúrgicas empregadas, o enxerto arterial com veia autóloga foi o procedimento mais comum (13 casos). Houve um caso de amputação primária (infrapatelar) e quatro amputações no período pós-operatório precoce (três transfemorais e uma transtársica). Dos 11 pacientes admitidos com lesão de artéria poplítea, a taxa de amputação transfemoral pós-operatória foi de 27,3%. Houve apenas um óbito devido a trauma iatrogênico em lactente hemofílico. CONCLUSÕES: O trauma vascular pediátrico envolve vários desafios técnicos, como o vasoespasmo e o calibre dos vasos. As altas taxas de amputações observadas em pacientes com lesões de artéria poplítea, apesar das tentativas de revascularização, reforçam a gravidade desse tipo de trauma.

Congenital-idiopathic superficial femoral artery aneurysm in a 7-year-old child

Superficial femoral artery aneurysm in children is distinctly uncommon, and usually results from infection, vasculitis, connective tissue disorder, or trauma. We report a 7-year-old girl who had multiple fusiform aneurysms of the right superficial femoral artery, with no evidence of related disorders. The patient successfully underwent aneurysm resection and femoral artery reconstruction with autogenous saphenous vein. Histologic examination revealed intimal thickening with fibroplasia without severe inflammatory infiltrates or cystic medial necrosis, suggesting a congenital-idiopathic arterial aneurysm. Three years after the procedure, the saphenous vein graft is fully patent and the patient is in good condition.

Pseudoaneurysm of the popliteal artery complicated by peroneal mononeuropathy in a 4-year-old child: report of a case

Pseudoaneurysms of the popliteal artery (PPA) rarely occur in children. In fact, we found only 10 cases reported in the medical literature. We report the case of a 4-year-old boy who presented with a painful palpable mass in the right popliteal fossa. He also had mild, painless right foot-drop and difficulty toe-walking on the same side. The diagnosis of a PPA was based on the findings of triplex ultrasound and computed tomographic-angiography. We attributed the cause of the lesion to blunt trauma, which he had suffered 2 years earlier. Thorough preoperative evaluation excluded the possibility of a self-immune process or a bone tumor in the region. Neurological examination demonstrated a mild, isolated, peripheral mononeuropathy of the right peroneal nerve. Thus, we performed surgical repair using an autologous reversed great saphenous vein graft. The patient had an uneventful postoperative course and his peripheral neuropathy and foot-drop resolved completely within 1 month after surgery. Now, after 3 years of follow-up, the patient has a patent graft and a fully functioning limb. PPAs are rare, especially in children, and trauma is the predominating underlying cause. PPAs should be treated immediately after diagnosis because their complications are associated with high rates of functional impairment and even limb loss.

Vascular reconstruction using deep vein for limb length discrepancy in a child

Iatrogenic vascular injuries can result in claudication and limb length discrepancy in growing children. Traditional reconstruction has been performed with great saphenous vein as a conduit. We report the case of a 7-year-old boy with a symptomatic limb length discrepancy and vascular reconstruction using femoropopliteal vein. The use of deep vein as an autogenous conduit may facilitate reconstruction of iliofemoral arteries in preadolescent children, providing an excellent size match and an efficacious means of restoring normal blood flow.

Peripheral vascular injuries due to firearms in children

BACKGROUND

Vascular injuries caused by firearms are rare among children. In this paper we discuss the surgical methods of treating peripheral vascular injuries due to firearms in children.

MATERIALS AND METHODS

Forty-four patients with peripheral vascular injuries due to firearms were included in this retrospective study. The patients were under the age of 14 and treated in our clinic between January 1985 and December 2004.

RESULTS

Vascular injuries due to firearms in children made up 4.9% of all cases of vascular trauma in our clinic. The male to female ratio was 38:6, and the age range was 3-14. The survival rate was 98% and the rate of limb salvage was 91%. For arterial and venous injuries, a saphenous vein interposition graft and interrupted sutures were often preferred surgically.

CONCLUSION

Peripheral vascular injuries due to firearms in children and other accompanying traumas can be easily identified and treated, and have low morbidity and mortality with an acceptable limb salvage rate if a rapid and effective approach is used.

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.

Iliac artery stenosis in a child with cutis marmorata telangiectatica congenita

Cutis marmorata telangiectatica congenita (CMTC) is a rare congenital disorder. We describe an 8-year-old boy with CMTC who presented with symptomatic claudication and diminished distal pulses. Imaging showed severe stenosis of the right common iliac artery, and the child underwent uncomplicated ilio-iliac bypass using prosthetic graft. This is the first report of a patient with CMTC and major vessel stenosis, successfully treated with a prosthetic graft bypass.

Open surgical repair of children less than 13 years old with lower extremity vascular injury

PURPOSE

We sought to review the diagnosis and treatment of children with lower extremity vascular injury.

METHODS

We performed a query of our vascular surgery database from 1996 through 2002 to determine those with lower extremity vascular injuries requiring surgery who were also less than 13 years of age. Patient demographics, presentation, cause, surgical specifics, and outcome were sought.

RESULTS

Six children (2 girls and 4 boys) with an average age of 6.8 years (range, 2-9 years) were found. The causes were 3 blunt injuries, 2 iatrogenic injuries, and 1 penetrating injury. Associated injuries were common. There were 3 femoral and 3 popliteal artery injuries. Two were pseudoaneurysms (common femoral and popliteal artery), and 4 were acute occlusions, of which 3 experienced a delay in diagnosis. There was one primary below-knee amputation. Four reverse vein bypasses were performed, and one vein patch repair of a pseudoaneurysm was performed. Generally, 7 to 9 O interrupted Prolene (Ethicon, Inc, Somerville, NJ) repairs were performed. A delay in diagnosis (2 blunt injuries) resulted in 2 major amputations and 1 insensate foot. Four reconstructions are functioning with viable limbs (follow-up, 5-49 months). An associated brain injury resulted in the only death.

CONCLUSIONS

Vascular blunt injury is especially insidious in children. However, an aggressive approach of vascular repair, even extensive bypasses with reverse vein, will allow limb salvage in the absence of a diagnostic delay.