Microvascular reconstruction of major arteries in neonates and small children

doi:10.1016/0022-3468(91)90689-Q

Journal of Pediatric Surgery

Volume 26, Issue 9, September 1991, Pages 1136-1140

https://doi.org/10.1016/0022-3468(91)90689-Q Get rights and content

Abstract

Arterial injuries in neonates and children under 2 years of age, although relatively uncommon, should be treated by prompt exploration and reconstruction using microvascular techniques. In the past, a reluctant attitude has prevailed in cases involving neonates or infants because of small vessel caliber and the problem of spasm. We reviewed our experience with 9 nonreplantation, arterial reconstructions in children under 2 years of age. The most frequent age at reconstruction was 1.0 month and extended from the immediate newborn period to 24 months of age. All patients were at risk for tissue necrosis. Eight children sustained iatrogenic injuries related either to invasive catheter manipulation (n = 6) or operative transection (n = 2). The ninth patient required reconstruction of the subclavian artery sacrificed during excision of a malignant tumor. There were 5 femoral, 1 subclavian, 1 brachial, 1 posterior tibial, and 1 radial artery repairs. Direct arterial repair was accomplished in one patient with a brachial artery thrombus and another with a transected superficial femoral artery. Reversed saphenous vein grafts were used in the remaining patients. Iatrogenic dissection of the ipsilateral iliac artery necessitated use of a femofemoral bypass graft to achieve adequate inflow in one newborn. There were no operative deaths, no reexplorations, and normal perfusion was restored to all involved extremities. We conclude that microvascular technique allows early, successful arterial reconstruction and limb salvage in neonates and small children.

References (21)

IJ Shaker et al.
Special problems of vascular injuries in children
J Trauma
(1976)
WM Whitehouse et al.
Pediatric vascular trauma: Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment
Arch Surg
(1976)
DP Meagher et al.
Vascular trauma in infants and children
J Trauma
(1979)
C Smith et al.
Pediatric vascular injuries
Surgery
(1981)
JD Richardson et al.
Arterial injuries in children
Arch Surg
(1981)
MO Perry
Iatrogenic injuries of arteries in infants
Surg Gynecol Obstet
(1983)
DP Flanigan et al.
Experience with iatrogenic pediatric vascular injuries
Ann Surg
(1983)
JA O'Neill et al.
Management of major thromboembolic complications of umbilical artery catheters
J Pediatr Surg
(1981)
J Upton et al.
Testicular autotransplantation in children
Am J Surg
(1983)
KL Mutimer et al.
Microsurgical reattachment of totally amputated ears
Plast Reconstruct Surg
(1987)

There are more references available in the full text version of this article.

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Microvascular surgery in the congenital cardiac patient: A case series exploring feasibility and practical applications
2017, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
This has caused us to question whether the use of vasopressors is contraindicated or even a major factor affecting patency. Microvascular surgery for extremity ischemia in the pediatric population has been described in detail in multiple reports but not in the congenital heart disease population.1,2,15–25 In our institution, initial treatment includes prompt removal of the catheter, followed by systemic heparin therapy.
Pediatric congenital heart disease patients are at risk for vascular injuries during surgical procedures or when the arterial system is accessed for monitoring or diagnostic studies. Our treatment of emergent situations in this patient population using microvascular techniques shows the feasibility of such techniques.
A retrospective chart review of patients aged 0–18 years with congenital heart disease identified six patients who underwent microvascular surgery by the senior surgeon from June 2007 to May 2015. We studied this series, highlighting technical aspects of surgery and perioperative care to determine their effect on outcome.
Six patients with congenital cardiac defects requiring cardiothoracic surgery were studied, body weight ranging from 3.2 to 19.1 kg at the time of surgery. Five suffered iatrogenic arterial injury to the heart or vessels used for access or diagnostic studies, including coronary artery laceration, brachial artery thrombosis, and external iliac artery avulsion. Interventions included direct end-to-end repair and vein grafting. Vessel diameter averaged 1 mm. Patients received vasopressors intraoperatively and were on vasopressors and antihypertensives postoperatively. One patient died because of disseminated intravascular coagulation on postoperative day 17, but bypass graft was patent prior to death. The rest survived with clinical evidence of patency of the repaired vessel for a long-term.
Microsurgical intervention may be life-saving as a revascularization procedure to the heart by direct coronary repair or bypass grafting. Iatrogenic injuries to the limb may cause critical ischemia; limbs can be salvaged by microsurgical repair. Despite technical and physiological challenges, microsurgery is feasible and sometimes crucial in this patient population.
Brachial artery repair using the basilic vein as a reliable conduit in a 3-year-old child
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Citation Excerpt :
Furthermore, revascularization through similar means was successfully established 7 patients less than two years old. However, Le Quaglia et al. presented 1 of the 6 patients under two years of age with reversed saphenous vein grafts had the revascularized limb about 1 cm shorter than the other limb at the 6-year follow-up [24]. Further follow-up assessment on the success of autogenous grafts less than three years of age needs to be completed.
A supracondylar fracture of the humerus is the most common upper extremity fracture in children with concurrent neurovascular complications. However, bypass grafting in the management of a pediatric open elbow dislocation with an arterial injury has rarely been reported in the literature. Hence, an adequate conduit for a vessel graft interposition remains questionable when a primary anastomosis is limited in an arterial reconstruction. The purpose of this study is to present a brachial artery reconstruction in a 3-year-old patient with an open supracondylar fracture of the humerus. In the clinical and surgical examination of the patient, an open wound in the left antecubital fossa presented with accompanying brachial artery injury. To repair the artery, a reverse end-to-end anastomosis was conducted using basilic vein graft from the ipsilateral arm under general anesthesia. The patient had palpable radial pulses in the postoperative clinical examination and was discharged without complications. The great saphenous vein (GSV) has proven to be the most common and the best conduit for arterial reconstruction of the upper extremity in the adult patients. However, the GSV graft is known to have the propensity for becoming aneurysmal in pediatric patients. Some studies have demonstrated the basilic vein as a suitable conduit in pediatric patients, in that it has durable patency, fewer branches, size compatibility for anastomosis, and proximity to the brachial artery. Our case confirms the safety of using this autogenous vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. The management of pediatric elbow fractures accompanying vascular injuries can be technically demanding due to relatively small, delicate structures and concurrent neurovascular network. Nonetheless, a vascular injury should be treated with high level of suspicion and immediate intervention to avoid any limb ischemia or loss. In situations where the brachial artery is compromised and needs repair with a bypass, the basilic vein should be considered as a conduit for its greater accessibility and long-term patency.
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^☆: Presented at the 42nd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Boston, Massachusetts, October 6–7, 1990.

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Microvascular reconstruction of major arteries in neonates and small children☆

Abstract

Special problems of vascular injuries in children

J Trauma

Pediatric vascular trauma: Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment

Arch Surg

Vascular trauma in infants and children

J Trauma

Pediatric vascular injuries

Surgery

Arterial injuries in children

Arch Surg

Iatrogenic injuries of arteries in infants

Surg Gynecol Obstet

Experience with iatrogenic pediatric vascular injuries

Ann Surg

Management of major thromboembolic complications of umbilical artery catheters

J Pediatr Surg

Testicular autotransplantation in children

Am J Surg

Microsurgical reattachment of totally amputated ears

Plast Reconstruct Surg