Pediatric Aortic Surgery
Lauren Story, MD, Mohammed Moursi, MD
UAMS, Little Rock, AR
Demographics: Case #1 - 9 y/o (35 kg), Case #2 - 2 y/o (14 kg) age appropriate male, 9 y/o (23 kg).History: #1 - involved in head on collision and presented with a seat belt sign, hemodynamically stable and GCS 15. No femoral/pedal pulses and abdominal exam positive for peritonitis. CT showed free fluid, bilateral common iliac filling defects and a Chance fracture. #2- presented with a pulsatile abdominal mass. CTA showed an AAA measuring 5.5 cm with normal caliber vessels proximally and distally. #3 - back seat passenger involved in head on collision that presented in shock not moving the lower extremities. Exam revealed a seat-belt sign, no femoral/pedal pulses and no rectal tone. CT scan showed a small bowel injury, spinal fractures and no enhancement of the abdominal aorta distal to the IMA.
Plan: #1- In the OR, a small bowel injury was repaired. Bilateral iliac arteries were occluded. Repair consisted of deep femoral vein harvest, with reconstruction in an end-to-end fashion. Pedal pulses palpable at conclusion of the case. ABI's one-year post op were 1.0 bilaterally. Pt is involved in all age appropriate activities. #2 - Original operative plan was to re-implant the iliac arteries into the aorta but the tissue would not hold the sutures. Two 4mm PTFE grafts were syndactylized on one end to create a bifurcated graft from infrarenal aorta to bilateral common iliac arteries. Patient was discharged on day 5 with palpable pulses. Duplex at 3 months showed no abnormalities. #3- The small bowel injuries were resected. There was a severe intimal defect in the distal aorta, resulting in distal aortic occlusion, extending into the bilateral common iliac arteries. Right common femoral vein was harvested and found to have a large side branch. The bifurcated vein graft was used as the conduit to reconstruct the aortic bifurcation, in an end-to-end fashion. Patient left the OR with palpable pulses. He was discharged home after 6 weeks in the hospital, with palpable pulses. Unfortunately, he had lower extremity paralysis due to a spinal cord injury.
Discussion: Pediatric aortic surgery is uncommon but can be accomplished with good results using deep femoral vein or synthetic material. All three children will require further operations to compensate for growth
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