AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

Vascular reconstruction in pediatric patients requires an approach substantially different from that used in the adult population. Many factors must be considered when one treats a pediatric patient. Such factors include the small caliber of their vessels, the possibly of spasm, the risk of infection, the propensity for children to rapidly form collateral circulation, the inevitability of growth, and the strong tendency for restenosis and growth arrest to occur.

Alexis Carrel is credited as the pioneer of vascular surgery and the use of cardiovascular tissue allografts and is recognized for his work on vascular anastomoses. Initial results with his techniques were disappointing because of the high rate of degeneration and vascular failure due to poor preservation methods, immunologic rejection, and inflammatory reactions that produced fibrosis, calcification, and aneurysms. However, major advances have been accomplished since the when he first described his work.

One of the risks of tissue transplantation is the potential for disease transmission from the donor to the recipient. Viral, bacterial, and fungal infections have been transmitted by means of tissue allografts. Tissue donors should to be tested for transmittable infectious diseases. Synthetic materials are also prone to a high rate of failure in small- to medium-sized vessels because of thrombosis and stenosis at the site of anastomosis. In addition, these grafts are associated with an increased rate of infection that leads to repeat operation. Experimental studies have demonstrated that vascular allografts are more resistant to infection than synthetic grafts.

Use of autologous grafts has provided the best results for vascular reconstruction. The internal and external saphenous veins or the basilic and cephalic veins have been used with success, as have the neck, radial, and pelvic arteries. The present authors have successfully used the contralateral internal iliac vein graft to replace a segment of external iliac artery that was resected during a pelvic tumor extraction. Also, the ipsilateral major saphenous vein can be divided distally and flipped over to be anastomosed to the external iliac vein while leaving its normal drainage to the femoral vein intact.

Research is being conducted by using the umbilical artery and by using venous homografts for small-diameter vascular reconstruction in the newborn. In addition, minimally invasive harvesting techniques have recently been described. When the host veins are not useful or available for reconstruction, a synthetic or allogenic conduit is used.

Expanded polytetrafluoroethylene (e-PTFE) is the most commonly used synthetic conduit because of its mechanical properties. It withstands pulsatile arterial pressures given it good suture-retention strength, and its compliance is close to that of native artery. The material has increased porosity on the abluminal surface that allows for tissue ingrowth, and it has low porosity on the luminal surface to prevent graft leakage. In animals, the patency rate was 75%, even in grafts smaller than 4.5 mm (Pascual, 2005). Furthermore, e-PTFE induces a neovascularization response involving transmural capillary ingrowth, and it has good resistance to infection.

The ideal vascular graft is yet to be developed, and all materials have advantages and disadvantages. Desired characteristics of a vascular bypass grafts are mechanical stability, biocompatibility, nonthrombogenicity, infection resistance, availability, and cost-effectiveness. In children, prolonged life expectancy must also be considered during fabrication of the ideal graft. Synthetic conduits are prone to infection, and, in the particular case of pediatric patients, grafts <6 mm in diameter have a high thrombosis rate with a poor long-term patency rate of 40-50% at 5 years. Porcine small-intestinal submucosa has been used to construct vascular conduits. It is an acellular collagen matrix that is remodeled into host artery, and it resists infection.

Bovine pericardium was recently used to fabricate conduits for vascular reconstruction. It has a uniform thickness, it is easy to handle and suture, it has a low thrombogenicity, and grows adequately without causing unwarranted dilation.

Sophisticated visualization systems and miniaturized multiarticulated instruments for robotic manipulation in small spaces have proved their usefulness by enabling procedures that were technically too demanding to perform in the past. These systems permit 3-dimensional visualization, allow for precise dissection, and are safe and effective. However, some authors still believe that these systems and instruments are too expensive and cumbersome. Additional research is needed in this field.

The vast majority of the data regarding vascular surgery in pediatric patients come from experience with and research in right ventricular outflow obstruction, midaortic syndrome, renal-artery occlusive disease and hypertension, iatrogenic vascular trauma, and access for hemodialysis. This article addresses the options and rationale behind choosing vascular conduits in the pediatric population, as related to the most common circumstances requiring intervention. This article is limited to a discussion of conduits used for reconstructing the renal artery and aorta and for achieving dialysis access and trauma in pediatric patients.

HEMODIALYSIS ACCESS IN THE PEDIATRIC PATIENT

Section 3 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

Every year, 3-5 per 1 million children develop chronic renal failure. Approximately 70% require temporary hemodialysis, and 23% require long-term hemodialysis. Dialysis is intended to be temporary, with the ultimate goal being renal transplantation. However, this approach is not always rapidly feasible. Hence, many of the techniques developed for hemodialysis in adult patients have been adapted to pediatric patients. Because of the small diameters and low flow rates in the arteries of children, success in maintaining long-term access for hemodialysis can be challenging.

Indwelling central venous dialysis catheters have been used extensively, but problems such as kinking, infection, thrombosis, and vascular stenosis, have plagued their use in children as in adults. Children also encounter the same issues adults do when arteriovenous access is being considered. Concerns that the surgeon must consider are the location, protection, maintenance, vascular immaturity, vascular size, and patient factors (eg, the potential inability of children to protect or care for their access sites).

Creation of an arteriovenous fistula is the method of choice in children weighing more than 30 kg, but a vein of adequate caliber (1.5 mm) must be found. Fistulae are usually placed in radiocephalic or brachiocephalic positions. Use of the interrupted suture method and loupe magnification during construction has been suggested.

In 1980, Applebaum et al reported satisfactory use of e-PTFE bridge fistulae in children. Such e-PTFE grafts have been used in children weighing as little as 3.8 kg with long-term patency rates of 88% (though patency was not defined). In 1994, Lumsden et al demonstrated a mean patency of 11 months with e-PTFE bridge grafts, but grafts placed in children weighing less than 30 kg demonstrated poor function. In addition, they found patency decreased for femoral e-PTFE grafts compared with upper-extremity grafts. This result was attributed to rapidly developing outflow stenosis, thrombosis, and graft infection.

Dialysis access in children remains a persistent problem. Each conduit has limitations, which are usually related to durability. Consider fistulae as the primary choices when feasible. If not, placing e-PTFE bridge grafts in the upper extremity is an alternative. Polytetrafluoroethylene (PTFE) grafts placed in the groin may also be considered. However, because of consistently poor patency rates, early use of PTFE grafts is discouraged. When traditional methods are exhausted, nonconventional conduits (eg, free saphenous vein grafts interposed into the arterial circulation, femoral-to-popliteal subcutaneous arterial-to-arterial grafts) have been used.

AORTIC OCCLUSIVE DISEASE AND RENOVASCULAR HYPERTENSION

Section 4 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

Fibromuscular dysplasia (FMD) and middle aortic syndrome (MAS, coarctation) are the 2 most common causes of surgically remediable hypertension in young patients, and a considerable amount of research has focused on surgical intervention in this group. Takayasu or temporal arteritis, neurofibromatosis, retroperitoneal fibrosis, mucopolysaccharidosis, and the Williams syndrome are other etiologic factors. Developmental anomaly in the fusion and maturation of the paired embryonic dorsal aortas are mentioned as congenital causes for MAS. Patients with aortic obstruction, as observed with coarctation or MAS, typically present with severe hypertension, weak or absent femoral pulses, and an abdominal bruit. MAS results from diffuse narrowing of the distal thoracic and abdominal aorta and commonly involves the visceral and renal arteries.

Surgical treatment of patients with MAS requires an individualized approach. The proper procedure and conduit must be selected with future growth and durability in mind. The timing and sequence for reconstruction of the aorta and the renal and visceral arteries must be carefully considered in each patient. The timing of surgery ultimately depends on the severity of the hypertension and on the patient's age. If possible, postponing surgery until the patient has completed growth is best. As an alternative, when a patient has severe hypertension and the potential to develop end-organ damage, surgical intervention should not be delayed.

Regardless of the patient's age, surgical relief of the aortic constriction can be accomplished with patch angioplasty, bypass, or both. Patch aortoplasty with polyethylene terephthalate (Dacron) is recommended for young patients who are still growing. This allows for thoracoabdominal bypass at an older age when growth is completed. Polyethylene terephthalate (Dacron) patches or tubular conduits are associated with the most success and are frequently used. Aortic cryopreserved homografts have also been used, usually with success, but further experience is needed to establish their true usefulness and durability.

Contrary to the growing amount of literature supporting early 1-stage operations with arterial autografts, Panayiotopoulos et al (1996) suggested that children with MAS who are younger than 6 years should be treated medically with every effort to avoid surgical intervention. If surgery must be performed, they suggest splenorenal or hepatorenal bypass if the celiac axis is normal. Otherwise, they advocate thoracoabdominal-to-infrarenal aortic bypass with reconstruction of the renal artery, renal autotransplantation, or both. Panayiotopoulos et al make these recommendations with the accepted understanding that further surgery may be necessary as the patient outgrows the graft.

Renal-artery occlusive disease is another curable cause of pediatric hypertension and is recognized with increased frequency. Renovascular problems account for as many as 20% of cases of severe hypertension observed in tertiary centers. Renal revascularization is the preferred method for managing this disease. Debate continues regarding the appropriate time to intervene because one must weigh the potential for growth and a second operation versus the progression of the disease to the point of permanent end-organ damage. When children and young adults with renal occlusive disease are treated, therapeutic options include medical care, balloon-dilation angioplasty, and surgical reconstruction or bypass.

Percutaneous transluminal renal angioplasty (PTRA) has been described. It is technically feasible and usually provides worthwhile clinical improvement, but experience in the pediatric population is still limited. Several options are available for aortorenal arterial bypass. Suggested bypass conduits include an autogenous hypogastric artery, saphenous vein, or a prosthetic graft. Patch angioplasty, splenorenal bypass, and renal autotransplantation have also been suggested.

In brief, prosthetic grafts are associated with poor long-term outcomes for reconstruction of the renal artery. Prosthetic conduits tend to potentiate the intimal proliferative response, which leads to restenosis. In addition, prosthetic bypasses do not grow with the child and can lead to recurrence of hypertension later in life. Prosthetic bypass conduits also pose a lifelong risk of infection. As such, prosthetic conduits are not recommended for reconstruction of the renal artery in young patients.

By far the most experience with surgical management of pediatric renovascular hypertension comes from the University of Michigan. In 1995, Stanley et al published their experience with 57 pediatric patients aged 10 months to 18 years. They strongly disagreed with balloon dilation to manage renovascular occlusive disease with or without MAS, and they favored a 1-stage surgical approach.

Stanley et al evaluated several conduits for the aortorenal reconstructive procedures. Use of saphenous vein grafts and hypogastric artery autografts result in the most success. However, Stanley et al noted significant dilatation of vein grafts in the pediatric population, particularly those receiving aortorenal bypass grafts. They reported a 20% incidence of aneurysm formation when the vein was used for renal-artery bypass or as replacement grafts in children. Hypogastric arterial conduits are relatively resistant to dilation and have demonstrated far improved durability. For ostial lesions, Stanley et al favor direct reimplantation of the renal artery into the aorta or a branch artery.

In accordance with Stanley et al, Messina et al (1986) reported that arterial autografts are preferred in young patients who are still growing and who have small vessels. They advocated prosthetic grafts in patients who have reached maturity.

In 1978, Novick et al found that splenorenal bypasses had poor durability, that they frequently became kinked, and they tended to become thrombotic. In addition, disease could progress in the celiac artery, leading to compromised flow that may require further intervention. In situ aortic or iliac-inflow renal autotransplantation are other options to manage renovascular hypertension. In situ aortic reimplantation is useful in patients with short orificial stenoses. Autotransplantation into the iliac fossa may be useful after complex ex vivo reconstruction of renal-branch lesions. Renal autotransplantation is also recommended in patients with MAS who are too small for definitive surgery but whose renal function is in serious jeopardy.

Over the years, surgery for pediatric renovascular hypertension has changed as experience revealed shortcomings with saphenous vein grafts, splenorenal bypass, and prosthetic conduits in young patients. The hypogastric artery has the greatest durability and has become the preferred conduit in pediatric renal artery bypass. Renal autotransplant has also been successful in selected patients. Regardless of the conduit, comprehensive patient follow-up is essential.

RECURRENCE OF AORTIC NARROWING

Section 5 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

Various approaches have been suggested for recurrent aortic narrowing after a proximal aortic coarctation or interrupted aortic arch is repaired. Options include percutaneous balloon dilatation with or without stents, resection of the narrowed segment with direct reanastomosis, patch aortoplasty with polyethylene terephthalate (Dacron), tube grafts as interposition grafts, or extra-anatomic grafts from the ascending aorta to the descending aorta.

Kanter et al (2000) studied extra-anatomic bypass in depth. They stressed that surgery is not the first option and that bypass should not be a first choice. They examined 19 pediatric patients aged 2 months to 18 years. Fifteen had coarctation with hypoplastic arch, 3 had an interrupted arch, and 1 had diffuse aortic hypoplasia. Kanter et al preferred resection of the affected area with primary anastomosis or patch aortoplasty. However, they advocated extra-anatomic bypass in selected patients. Patients who are unlikely to have success with traditional techniques, patients who have underdeveloped collateral vessels, and patients who need concomitant cardiac repair may require bypass. The preferred technique for extra-anatomic bypass involves sternolaparotomy and an extra-anatomic bypass from the ascending to the descending aorta by using a polyethylene terephthalate (Dacron) conduit.

Other extra-anatomic bypass procedures performed by using a multitude of incisions and repeated left thoracotomy have been described with success. In some children, regardless of the incision, extra-anatomical bypass grafting (by using polyethylene terephthalate [Dacron]) to manage recurrent aortic obstruction is a feasible option for complex aortic reconstruction.

Aortic aneurysmal disease is exceedingly rare in the pediatric population. Thoracic and thoracoabdominal aneurysms have been encountered and treated with some success. In 1996, Hashimoto et al successfully reconstructed a thoracoabdominal aneurysm with a surplus polyethylene terephthalate (Dacron) graft. Surplus grafts are designed to eventually straighten with the growth of the child. In 1998, Clark et al repaired an abdominal aortic aneurysm (AAA) and an injury to the left common femoral artery in an 11-year-old child with aneurysmorrhaphy and reversed saphenous-vein interposition. During 25-year follow-up, normal caliber was demonstrated in the distal aorta and only slight dilatation was observed in the left femoral vein graft.

VASCULAR TRAUMA IN THE INFANT AND CHILD

Section 6 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

Vascular injuries in infants and children are rare and usually iatrogenic. They often require an approach substantially different from that used to manage similar injuries in older children and adults. Many injuries, particularly injuries in infants, must be approached with the understanding that surgical intervention may not be fully successful because of the technical difficulties related to small vessels and to vascular spasm. Also, peripheral vascular injuries that may result in limb loss in adults rarely do so in infants or children. Children have a particular propensity to rapidly develop collateral vessels, which often allows for limb preservation without surgical intervention. However, the development of an adequate collateral circulation for limb preservation is not necessarily sufficient to ensure normal patterns of limb growth. This quandary has created controversy surrounding the indications for surgical intervention.

In 1983, Flanigan et al reviewed iatrogenic pediatric vascular injuries and reported a 23% incidence of leg length discrepancies after nonoperative treatment compared with a 9% incidence when the injuries were treated aggressively. On the contrary, Klein et al (1982) supported nonoperative management for iatrogenic vascular injuries in small children, noting poor surgical results. They advocated close observation with a possible delay in surgical reconstruction until later in life. In 1981, Smith and Green asserted that good surgical outcomes occurred least often in children younger than 2 years.

The timing of operation has also been a topic for debate. Whitehouse et al (1976) evaluated 4 children who underwent late operations and reported no improvement in leg-length discrepancy. Klein et al (1982) reported 3 late operations with equalization of leg lengths after surgery. In 2001, Cardneau et al presented a series of 14 children with saphenous-vein bypasses who underwent lower-extremity revascularization at a mean of 5.7 years after the initial ischemic insult. Five children had limb-length discrepancy, which markedly improved after late revascularization. Although the timing of surgery remains controversial, most agree that surgical reconstruction is indicated in all but the youngest patients.

Meagher et al (1979) conducted a 20-year retrospective evaluation of vascular trauma in 53 infants and children with blunt or penetrating injuries. The most common sites of injury were the brachial and superficial femoral arteries and the inferior vena cava. The authors concluded that, when surgical management is indicated, primary anastomosis with interrupted cardiac suture should be attempted. When this is not feasible and when a graft must be used, they recommended the use of internal iliac artery in small children and saphenous vein in large children. To accommodate for growth, the vessels should be spatulated to allow for an anastomotic lumen 3 times the diameter of the vessel, and the anastomosis should be performed with interrupted suture by using the principles of meticulous microvascular arterial reconstruction. Polyethylene terephthalate (Dacron) or e-PTFE conduits should be reserved for repair of large arteries in children whose arteries are similar in size to those of adults.

In 2006, Lazarides et al reported 23 children aged 13 years or younger who had arterial extremity trauma. They concluded that school-aged children (>6 y) can safely undergo surgical repair but that neonates, infants, and preschool children are best treated nonoperatively if they have an ischemic though nonthreatened extremity. As long as a distal Doppler signal was present, limb loss was rare. Patients treated nonoperatively received systemic heparin, and the authors noted limb-length discrepancy in only 1 patient. They reported an 87% limb-salvage rate with this approach.

Aortic injury usually requires resection of the injured or pseudoaneurysmal segment and reconstruction with a synthetic e-PTFE or polyethylene terephthalate (Dacron) graft. The size of the child obviously presents a dilemma because the conduit does not grow with the child's aorta.

No single therapeutic strategy can be applied to all young patients with vascular injury. In a child of any age with a severely ischemic extremity, surgery remains the first choice. However, all persons involved must recognize that a good outcome may not be forthcoming in small patients and in patients requiring complex reconstructions unless the surgeons are experienced in using advanced microsurgical techniques.

SUMMARY

Section 7 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

Arterial reconstructions in the pediatric population pose notable challenges to cardiac and vascular surgeons. Surgeons must account for small vessels, spasm, and the potential for growth over time. Moreover, they must be familiar with microvascular techniques, which require tremendous discipline and skill.

The choice of conduit for vascular reconstruction in the pediatric patient depends on the patient's specific circumstance. No single therapeutic strategy can be applied to all children. The patient's age, developmental status, and indications for reconstruction dictate the choice of conduit. Further clarification of the choices and alternatives in young patients is still required.

Research is being performed on tissue-engineered conduits to decrease their thrombogenicity and to investigate prosthetic material lined with endothelial cells or heparin. In the future, stem cells derived from bone marrow or embryonic stem cells might be used to regenerate vascular structures, probably over a synthetic, absorbable conduit bed. The re-creation and construction of complex vascular structures by using computer-aided design may be used to fabricate custom-made tissue-engineered replacement conduits in the future.

Wide-spread acceptance of minimally invasive intraluminal bypass surgery in pediatric patients will increase as flexible, small-diameter grafts and low-profile insertion systems become available. In adults, these designs have already markedly reduced perioperative morbidity, shortened hospital stays, and hastened recovery.

In robotic surgery, future advances in reducing the size of instruments, improving image guiding systems, and incorporating tactile feedback may expand the application of this technology to treat patients with cardiovascular disease.

MULTIMEDIA

Section 8 of 9  

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

Media file 1:  Symptomatic Takayasu arteritis involving both common carotid arteries in a 7-year-old child.
	View Full Size Image
Media type:  X-RAY

Media file 2:  Magnetic resonance angiogram (MRA) in the same patient as in Image 1, 18 years later, demonstrates mild dilatation of the venous graft.
	View Full Size Image
Media type:  MRI

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Hemodialysis Access in the Pediatric Patient
• Aortic Occlusive Disease and Renovascular Hypertension
• Recurrence of Aortic Narrowing
• Vascular Trauma in the Infant and Child
• Summary
• Multimedia
• References

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Article Last Updated: Dec 12, 2006