Society For Clinical Vascular Surgery

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Endovascular Management of Lower Extremity Malperfusion in a Pediatric Patient with Acute Type B Aortic Dissection.
Hannah Carroll, BS, Thomas Kania, BS, Matthew Hanlon, MD, Kwame S. Amankwah, MD.
SUNY Upstate, Syracuse, NY, USA.

OBJECTIVES: Aortic dissection is a rare diagnosis in the pediatric population. Malperfusion of an organ or extremity is a possible complication of aortic dissection, which requires immediate intervention to avoid morbidity and mortality. There is limited data in the pediatric literature comparing open and endovascular techniques for treatment of lower extremity malperfusion. We present a case of a pediatric patient successfully treated with endovascular intervention.
METHODS: An 18-year-old male with no family history of connective tissue abnormalities presented with acute onset of sharp chest pain and left leg pain, weakness, and numbness. Examination of the lower extremity found no palpable femoral or distal pulses. The right leg had palpable pulses proximally and distally. A CT angiogram of the thoracic and abdominal aorta with lower extremity runoff revealed a Stanford Type B aortic dissection. The dissection extended from the l descending aorta to the level of the common iliac arteries bilaterally, obstructing flow in the left common iliac artery. The patient underwent emergent intervention.RESULTS: Initial attempt to access the true lumen of the left iliac from the right was unsuccessful. The false lumen was cannulated and the sheath was advanced into the proximal portion of the iliac vessel. Under fluoroscopic guidance, a Glidewire was advanced down into the blind end of the false lumen at the level of the external iliac-common femoral junction. A left femoral artery cut-down was performed and under direct visualization, the true lumen could be visualized. A sheath was placed and angiography confirmed true lumen placement. Flow to the left lower extremity was restored by stenting the left common iliac artery. There was a palpable left femoral pulse and evidence of doppler signals at the dorsalis pedis and posterior tibial arteries. A four-compartment fasciotomy was performed. The patient was treated post-procedure with anticoagulation and blood pressure medications. Fasciotomies were closed prior to discharge. Genetic testing revealed an ACTA-2 mutation. Three-month follow-up demonstrated normal perfusion and leg function.
CONCULSIONS: Given the rare occurrence of aortic dissection and lower extremity malperfusion in the pediatric population, there is limited evidence to suggest whether open or endovascular repair is the better management option. This case demonstrates the feasibility of endovascular intervention as a treatment modality in lieu of open repair techniques.

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