Current Opinions in Open and Endovascular Treatment of Major Arterial Injuries in Pediatric Patient

Abstract

Pediatric major arterial vascular injuries may belong to the same principal categories as adults, but have been poorly documented, with an estimated overall incidence of <2% of all vascular traumas. Open surgery has been the mainstay of treatment, but no clear guidelines have been developed to recommend the best practice patterns in terms of strategy or repair as well as postoperative pharmacological regimen. Herein, we report three cases and a narrative review of the available literature regarding the main aspects when dealing with pediatric arterial injuries based on the predominant series available from the most recent published literature.

Keywords: lower extremity vascular injury; pediatric arterial injury; pediatric vascular trauma; upper extremity arterial injury.

Figure 1

Patient #1: diagnostic angiography performed at non-academic non-teaching hospital after humer fracture fixation ((A), white arrow) showing the discontinuity ((A), dashed line; (B), white square) of the distal segment of the left brachial artery ((A,B), asterisk).

Figure 2

Patient #1: preoperative clinical evaluation of the antecubital expanding hematoma ((A), white arrow). Surgical exploration (B) revealed an extensive fresh hematoma (asterisk) determined by the transection of the distal brachial artery ((C), white arrows) which was clamped with endoluminal Fogarty catheter ((D), asterisk). Complete reconstruction with an autologous basilic vein ((E), white arrow).

Figure 3

Patient #3: preoperative computed tomography-angiography showing the disruption of the intimal contour ((A), white arrow) with a large intimal flap ((B), white arrow).

Figure 4

Patient #3: intraoperative angiography showing the aortic lesion ((A), white dashed square). The covered stent ((B₁), white arrows) successfully sealed the aortic lesion as confirmed by the disappearance of the most distal lumbar arteries ((B), white asterisks). At the first confirmatory angiogram (B₂) the covered stent (white dots) was correctly positioned in the infrarenal aorta (angled line). Completion angiogram (B₃) unexpectedly documented the cranial displacement of the covered stent (white dots) that now was in the suprarenal aorta (angled line) at the level of the superior mesenteric artery.

Figure 5

Patient #3: intraoperative findings. Surgical exposure of the infrarenal aorta (A) at the level of the inferior mesenteric artery (white asterisks). After longitudinal aortotomy (B) an ovale, postero-lateral lesion was confirmed (white arrow). The covered stent was explanted (C,C₁) and the lesion repaired with a paricardial patch angioplasty (D) with posterior reinforcement (E) by means of a Teflon strip felt with a good final result (F).