12 year old healthy male who sustained a shotgun wound to the left groin three years ago. His femoral vessels and nerve were transected and his femur was shattered. His arteries and veins were repaired with ringed PTFE, he underwent a four compartment fasciotomy and had his femur fracture surgically repaired. Despite a long recovery, his leg was salvaged. HISTORY:3 years later in follow-up he is ambulatory but was noted to have occluded his prosthetic arterial and venous reconstructions and he has shorter and smaller left leg. He has also developed scoliosis from the limb length discrepancy.
PLAN:CTA was obtained which showed occluded femoral grafts, patent distal left external iliac artery with flow reconstitution in the mid superficial femoral artery (SFA). His bilateral internal iliac arteries were too short to serve as a bypass conduit and his greater saphenous vein (GSV) was too small. Contralateral femoral vein was chosen and he underwent distal external iliac artery to SFA bypass. He did well post-operatively and is maintained on rivaroxaban 2.5 mg BID and aspirin 81 mg daily.
DISCUSSION:Indications for re-vascularization in chronic limb threatening ischemia in pediatrics also include limb length discrepancy. The choice of conduit is challenging in pediatrics as children and adolescents are growing and ideally their conduit will grow with them. In this case, prosthetic saved our patientís leg and allowed him to develop collateral arterial pathways to maintain perfusion to his foot. The GSV that is preferred in adults is often not of adequate caliber in children. Pediatric patients are known to intensely vasospasm their arteries when the arteries are manipulated. Vasodilators and heparin are critical to the success of revascularization efforts. Finally, when sewing the anastomosis, thought must be given to the growth of the patients. It is important to use interrupted suture lines when completing an anastomosis to allow for future growth of the anastomosis as the child grows in size.