Anesthesia management in a child with PHACE syndrome and agenesis of bilateral internal carotid arteries

Congenital absence of the bilateral internal carotid artery: a review of the associated (ab)normalities from a newborn status to the eighth decade of life

PURPOSE

Due to the fact that the internal carotid artery (ICA) is responsible for nourishing two thirds of the brain volume, our aim was to inspect the morphofunctional consequences of the bilateral lack of this artery.

METHODS

In order to examine this condition, we referred to both the library archive of our Faculty of Medicine and electronic databases of anatomical and clinical reports that included the following keywords: "absence," "aplasia," or "agenesis" in combination with "internal carotid artery," "common carotid artery," or only "carotid artery."

RESULT

We found 60 recorded cases of the bilateral ICA absence in the subjects of newborn status to the eighth decade of life, which had been discovered in 20 countries. The following ten parameters were described: the embryological base, terminology, history, incidence, general data, differential diagnosis, collateral circulation, the associated vascular aplasia and/or other variants, pathophysiology, and the importance in praxis.

CONCLUSION

This review noted all the cases of the bilateral ICA aplasia published for the past 104 years. Although there were 11.6% of cases of the associated cerebral aneurysms and 1-4 cases of 16 other diseases, approximately one quarter of the cases was without any pathology.

Aortic arch repair in children with PHACE syndrome

BACKGROUND

PHACE syndrome is characterized by infantile hemangioma and developmental abnormalities of the brain, arteries of head and neck, and aortic arch.

METHODS

We retrospectively reviewed The PHACE Syndrome International Clinical Registry to identify children with PHACE who had operative repair of aortic arch obstruction at Children's Hospital of Wisconsin.

RESULTS

Seven patients (median 11 months, range 1 week-6 years) with PHACE required aortic arch reconstruction from 1996 to 2015. All needed complex surgical approaches (4 conduit grafts, 2 patch aortoplasties, 1 subclavian flap) to relieve the obstruction because of long-segment transverse and proximal descending aortic arch dysplasia that included multiple areas of stricture with adjacent aneurysmal dilatation. Aberrant origin of a subclavian artery was found in 6 of 7. The 3 children who had surgery after age 1 showed significant progression of the arch obstruction and/or adjacent aneurysmal segment dilatation after their initial infant evaluation. No deaths or perioperative complications occurred despite associated cerebrovascular arterial dysplasia in 5 of 7. Recurrent arch obstruction developed in 3 of 7 at an intermediate follow-up interval of 6.2 years (2 had interposition graft replacement at 8 and 11 years due to somatic growth; 1 had repeat patch aortoplasty 11 months after initial repair secondary to recurrent stenosis).

CONCLUSIONS

Extensive aortic arch reconstruction is commonly required in children with PHACE syndrome and coarctation due to the bizarre nature of the obstruction. Complete preoperative imaging is needed to fully characterize the aortic and cerebrovascular arterial anomalies. Recurrent obstruction is common given the non-native tissue techniques needed to relieve the arch anomaly.

Anesthetic Management of a Parturient with PHACE Syndrome for Cesarean Delivery

PHACE syndrome is a disorder that features posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities. PHACE syndrome includes abnormalities in several organ systems that may influence anesthetic management. We discuss the anesthetic management of a 26-year-old woman with PHACE syndrome presenting for cesarean delivery. Management included careful airway examination, slowly dosed epidural anesthesia, close hemodynamic monitoring aided by a radial arterial line, and continuous intraoperative neurologic assessment.

Anesthesia for aortic reconstruction in a child with PHACE syndrome

PHACE syndrome is a neurocutaneous syndrome characterized by the association of large cutaneous hemangiomas and the cardiac and cerebral vascular anomalies. We report a 6-year-old female with PHACE syndrome presented with left facial hemangiomas, cystic lesion in the cerebral posterior fossa, coarctation of the aorta, aplasia of the left vertebral artery and stenosis of the left internal carotid artery. Surgical repair of the aorta with left heart bypass under beating heart was scheduled. We monitored regional cerebral oxygen saturation (rSO2) with infrared spectroscopy in order to detect cerebral hypoperfusion. A decrease of rSO2 ipsilateral to the cerebrovascular anomalies occurred during anastomosis of the aorta, which was treated by reducing the flow rate of left heart bypass and by increasing the inhalational oxygen concentration. As children with PHACE syndrome are frequently accompanied with cerebrovascular anomalies and at a risk of cerebral hypoperfusion, prevention of cerebral hypoperfusion is crucially important during general anesthesia.