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GENERAL CONSIDERATIONS
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Vascular pathologies in the pediatric population, specifically in children less than 5 years old, are rare but remain a challenge for vascular surgeons who are commonly consulted after failed conservative measures. The management of arterial disease in the pediatric population is unfortunately poorly outlined in the literature, consisting mostly of small series and case reports. Furthermore, surgical strategies need to contemplate patient size, conduit availability, and future patient growth. While the etiologies of vascular diseases in this population are wide-ranging, we will focus, in this chapter, on the most likely encountered ones in an academic medical center.
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ACUTE EXTREMITY ARTERIAL OCCLUSIONS
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Etiology and Risk Factors
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Acute arterial occlusions in the pediatric population are rare and commonly require immediate attention to avoid catastrophic consequences (Table 56-1). A retrospective analysis of the KID database involving more than 4 million inpatients aged from less than 12 months to 20 years of age revealed that the most common causes of extremity arterial thrombosis in the neonate and infant populations were arterial cannulations and cardiac catheterizations while in children older than 5 years, noniatrogenic traumatic injuries were responsible for the vast majority of acute extremity ischemic events. Similar findings have been described by Kayssi et al. in a retrospective analysis at The Hospital for Sick Children in Toronto. Other less common contributing factors to acute arterial occlusions include primary hypercoagulability, prothrombin gene mutation, and congenital popliteal entrapment.1,2
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The exact mechanism leading to arterial thrombosis following access for diagnostic, intervention, or monitoring remains ill-defined. Two commonly accepted theories are (1) femoral arterial spasm leading to thrombosis, and (2) intimal damage and associated platelet aggregation.3,4 Interestingly, Alexander et al. reported that besides the patient’s age, a femoral artery diameter of less than 3 mm was an independent predictor of postcatheterization loss of distal pulse. Also, a ratio between the outer sheath diameter and the cannulated artery less than 0.5 has been described as a predictor of femoral artery vasospasm.5,6
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Noniatrogenic arterial occlusions, which are more commonly seen in children older than 2 years, are often the result of mechanical compression, intimal flap with localized dissection, or penetrating trauma with transection. The most commonly affected vessels are the brachial artery, femoral ...