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Contemporary Pediatric Vascular Surgical Experience For An Academic Program Affiliated With A Quaternary Children’s Hospital System
Angelle A. Hogan, MD1, Maunil Bhatt, MD
1, Sira Duson, MD MBA
1, Daniel TS Lee
1, Benjamin A. Dixson, MD
1, Michael D. Neel, MD
2, Regan F. Williams, MD
3, Erica L. Mitchell, MD EdM
1.
1The University of Tennessee Health Science Center, Memphis, TN, USA,
2St. Jude’s Children’s Research Hospital, Memphis, TN, USA,
3Methodist Le Bonheur Children’s Hospital, Memphis, TN, USA.
OBJECTIVES: Pediatric vascular disease is uncommon and results from a wide spectrum of pathology. Vascular surgical treatment is challenged by patient comorbidities, small size, future growth considerations, and availability of suitable conduits and/or endovascular options. Herein we describe our clinical experience and evolving treatment trends for vascular surgical conditions encountered within our academic system.
METHODS: Retrospective review of a prospectively collected database of all pediatric patients seen by our vascular surgeons over a 44-month period. Demographics, vascular conditions [
congenital/genetic (cardiac/non-cardiac),
acquired (dialysis access, oncologic, arterial/venous compressive syndromes), and
traumatic (penetrating, blunt, iatrogenic)], treatment strategies (surgical/non-surgical), and patient outcomes were evaluated.
RESULTS: 179 pediatric patients were surgically evaluated over 44 months. Age at initial encounter includes: birth - 3-months (8; 4.5%); >3-24-months (10; 5.6%); >2-6 years-old (13; 7.3%), >6-12 years-old (30; 16.8%), and >12-18 years-old (118, 65.8%). 67% (120) were male. For all patients seen, 14.5% (26) had
congenital/genetic conditions with >50% (14) cardiac in origin, 6.7% (12) had
acquired conditions, and 72.6% (130) had
traumatic vascular injuries. For injuries, 59.3% (77) were penetrating, 21.5% (28) blunt, and 19.2% (25) iatrogenic (13 catheter-related, 9 ECMO-related, 3 surgical). Catheter-related limb ischemia (CRLI) was evident in 87.5% consulted upon children < 3-months, majority (88.8%) of ECMO-related limb ischemia (ERLI) events occurred in children >8 years-old. Overall, 64.8% (116) patients (ages 3-months-18-years-old) required surgical intervention(s): 79 (68.1%) open, 28 (24.1%) endovascular, and 9 (7.8%) hybrid repair. Reconstructions included 53 (45.7%) arterial bypasses (29 lower/14 upper extremity, 1 carotid, 3 subclavian, 1 visceral, 5 iliac), 8 (6.9%) patch angioplasty (1 carotid, 1 aorta, 1 vena cava, 1 iliac [3-year old], 2 femoral, 2 brachial), and 2 primary-repairs (1 subclavian [ 3-month old], 1 femoral). Native conduit was used for all open. Six (3.4%) patients underwent aortic stenting. Anticoagulation was the mainstay of treatment for CRLI in all children < 2-years-old, while operative intervention was necessary for all ERLI.
CONCLUSIONS: There is a wide range of pediatric vascular conditions whose management is multifaceted. While non-operative management remains mainstay treatment for CRLI in < 2-years-olds, surgical intervention plays a critical role, across ages, in the management of ERLI & non-iatrogenic vascular trauma. Vascular surgeons supporting quaternary pediatric services need to be facile in the management of life and/or limb threatening vascular conditions.
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