Pediatr Surg Int (2007) 23:1–10
DOI 10.1007/s00383-006-1778-5
REVIEW ARTICLE
A review of vascular surgery in the pediatric population
Shawn D. St. Peter Æ Daniel J. Ostlie
Accepted: 13 August 2006 / Published online: 27 September 2006
Ó Springer-Verlag 2006
Introduction
As one of the most common systems requiring opera-
tive intervention in the adult population, techniques in
vascular surgery are well established. The predominant
indication for these operations is atherosclerosis, the
rate-limiting process of human longevity, which pro-
gresses throughout our life span at an individual-
dependant rate. Children are at the beginning of their
life course and are therefore not significantly affected
by atherosclerosis, which renders the necessity for
vascular surgery a rare event in this population. Since
children presenting with vascular disease will often be
in the care of pediatric surgeons, it is valuable for
pediatric surgeons to be equipped with knowledge of
the reported experience with these uncommon cir-
cumstances. We have reviewed the literature to date
with the intent of bringing forth a concise summary of
the application of vascular surgical techniques to the
pediatric population.
Vascular trauma
Central vascular injury
The central vascular system is an uncommon location
of injury, associated with high mortality [1–3]. More
contemporary experience reported in a recent series
documented over two-thirds of patients surviving after
S. D. St.Peter
D. J. Ostlie (&)

Department of Pediatric Surgery, Children’s Mercy
Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
e-mail: dostlie@cmh.edu
central vascular trauma [4]. However, this series likely
reports a survival rate that is higher than what can be
expected for all patients suffering central vascular in-
jury due to the fact that it reviewed only those patients
that arrived to the emergency room alive. Survival to
the ER alive is affected by the policies and efficiency of
the local emergency response systems. Exclusion of the
patients that died prior to arrival at the emergency
room invariably will lead to a reduced reported mor-
tality [2]. In addition, a large percentage of penetrating
traumas made up the study population, which is typi-
cally associated with less systemic injury. It is likely
that survival of central vascular injuries is much lower
than reported, which is supported in studies that report
lower survival for children when compared to adults
with central vessel injuries [1, 5–7]. It has been sug-
gested that outcome may be affected by treatment of
pediatric trauma patients at trauma centers of adult
hospitals, and children should therefore be transported
to tertiary pediatric centers after stablization [4].
Due to the small numbers in the series reported, it is
difficult to arrive at reasonable conclusions. Regarding
survival, a consistent finding, both by published series
and the National Pediatric Trauma registry, is the
importance of hemodynamic stability on presentation
[4]. Patients with central vascular injuries presenting
with hypotension (systolic blood pressure < 90 mmHg)
have worse chances of survival than those patients
presenting with systolic blood pressure > 90 mm Hg [4,
8]. Statistical comparison of survivors and non-survi-
vors after truncal vascular injury reveal significant
differences in blood pressure and estimated blood loss
on presentation [8].
Regarding surgical management of central vascular
injuries, vascular occlusion with rapid repair (‘‘clamp
123
2 Pediatr Surg Int (2007) 23:1–10
and sew technique’’) has resulted in improved out-
comes. This technique is particularly applicable to
injuries away from the aortic arch. Aortic arch injuries
rarely survive till operative repair, but hypothermic
circulatory arrest has been described to repair arch
transection in a child [9]. The remaining vascular tree is
adequately managed with adequate proximal and distal
control transiently occluding flow to allow for repair.
After control, the preferred method of repair has been
primary closure of the defect or segmental resection,
with the use of autologous graft or synthetic material
when extensive injury makes the former options
infeasible [1, 2, 4].
Injuries of the vena cava
Injuries of the vena cava in children are difficult to
diagnose, and extremely arduous to manage. Survival
rate in children after such injuries has been shown to
be worse than adults [3]. A series focusing on blunt
vascular trauma found injury to the inferior vena cava,
hepatic vein and portal vein to be over-represented
relative to equivalent adult injuries, leading to the
speculation that the more compliant chest wall of
children forces large movement of the liver with trac-
tion and avulsion of fixed perihepatic venous structures
[3]. Juxtahepatic caval injuries near the ostia of the
major hepatic veins are particularly difficult to manage
and one should expect very low survival [11]. Veno-
venous bypass without heparinization has been re-
ported to allow for repair of a complex retrohepatic
caval injury [12]. In the event of irreversible coagul-
opathy and uncontrollable hemorrhage after injury to
the infrahepatic vena cava, caval ligation been re-
ported with success in a young child [13]. In this case,
not only did the patient survive without sequellae of
venous congestion, but renal function was also pre-
served despite renal vein ligation. Complete caval
ligation in a controlled setting (complete excision of
the vena cava beneath the hepatic veins to the level of
the iliac bifurcations bilaterally including the left renal
vein and left kidney for Wilm’s tumor with caval
thrombus) has been performed with no edema at 3-
year follow-up [14].
Vascular injuries of the neck
Vascular damage to the neck is almost invariably the
result of penetrating trauma. The management of such
lesions differs little from similar lesions in adults, which
has produced favorable survival rates in the series re-
ported [4, 15–17]. As the debate between selective
management and mandatory exploration for zone II
123
injuries in adults continues, less data exist on children
to fuel an even-handed discussion. The largest reported
series of zone II injuries in children clearly demon-
strates the efficacy of observation if clinical signs on
presentation do not indicate vascular, esophageal or
airway injury [15]. In this series, only 15% of gunshot
wounds, and 18% of stab/glass wounds required sur-
gery. As opposed to the adult literature where non-
operative management includes complete work-up, in
children, observation includes only clinical studies as
indicated. In children, angiography is more hazardous,
endoscopy requires anesthesia, and undetected esoph-
ageal injuries appear to be more indolent [15, 18].
Concurrently, authors of smaller series have also ar-
rived at the conclusion that conservative management
of penetrating neck wounds is preferred in children [16,
17].
Peripheral vascular injury
In the pediatric population, peripheral arterial injury is
associated with a greater degree of vasospasm and
retraction than the older cohort, which can complicate
diagnosis [19–22]. The duration of this arterial re-
sponse to injury can persist into the operating room
where some authors have noted anastomotic tension
inappropriate for the amount of vessel excised leading
to the use of a vein segment [22]. Local infusion of
papaverine can aid in attenuation of this phenomenon
[22].
Penetrating trauma
Penetrating vascular injury, secondary to firearms,
provides considerable experience in peripheral vascu-
lar injury to pediatric surgeons in the United States,
and the incidence of these non-lethal gunshot wounds
in children is on the rise [23, 24]. Surgical consider-
ations are less oriented around the youth among the
patients as the pediatric cohort suffering gunshot
wounds is predominantly of teenagers, which approxi-
mates the adult experience [24–28]. However, the se-
vere mechanism of injury holds considerations. Rate of
gunshot wound fractures approach 50% in most re-
ported series [24–28]. Gunshot wound fractures impose
potential damage to the epiphyseal plate, providing a
mechanism for limb disparity independent of the vas-
cular injury. One series documented the presence of
physeal injury from high-velocity bullet wounds not
directly involving the bone or epiphyseal plate [28].
Although physeal injury is uncommon, when it does
occur the development of subsequent growth disparity
in the affected limb is nearly universal [25]. Infection
Pediatr Surg Int (2007) 23:1–10
risk after gunshot wound injury is debated. Empiric use
of antibiotics after surgery for penetrating vascular
trauma has been advocated by several authors [25, 29].
However, the only comparative trial on the subject, a
prospective, randomized trial in adult gunshot frac-
tures found no difference in infection rate with the use
of empiric antibiotics [30].
In the domestic setting, multiple series have noted
the frequency of peripheral vascular injury from acci-
dents involving broken glass, leading some to the
conclusion that plate glass should be limited in chil-
dren’s recreation areas [31, 32]. Vascular injuries in
children resulting from blunt trauma most often occur
via the sharp edge of fractured bone [22].
After any small vessel anastamosis, the post-opera-
tive management is a careful consideration. Simple
volume expansion when tolerated to avoid concomi-
tant vasospasm in response to hypovolemia is prudent.
Low-dose heparin, subcutaneous heparin, and low-
molecular weight heparin, all of which have been
shown to be safe and effective peri-operatively with
major operations as a means of preventing deep venous
thrombosis in adults should be considered as an ad-
junct to the post-operative management. We feel this is
particularly true when caval or large vein injuries are
repaired wherein there is a high risk of thrombosis.
However, these measures have yet to be carefully
studied to define their relative efficacy in these settings.
Concomitant nerve injury
In peripheral vascular trauma, nerve damage is a
dominant variable impacting long-term functional
outcome, and the extent of nerve injury corresponds
with return of function, with nerve transection pre-
senting the poorest outcome [22, 33]. However, neu-
rologic deficit at presentation has not been found to
correlate well with anatomic nerve injury at operation
[32]. Authors have therefore disagreed on the necessity
of routine nerve exploration in the face of preoperative
neurologic deficit [25, 34, 35]. An argument has been
forwarded that early exploration identifies those with
nerve transection allowing for delayed repair that may
potentiate the opportunity for functional recovery [25].
However, adequate long-term data are not available to
validate a standard recommendation.
It is generally felt that arterial reconstruction en-
hances nerve regeneration. However, in the forearm,
ligation of arterial injuries has been performed without
effect on nerve regeneration when a patent second
artery exists [36]. Even in this scenario, operative re-
pair may still be of benefit to reduce hypothermic
discomfort of the fingers [36].
3
Role of angiography
Most authors advocate angiography to facilitate man-
agement of suspected peripheral arterial injury, partic-
ularly for patients with penetrating trauma and no clear
injury requiring immediate operation [19, 29, 37–40]. As
most of these series contain older patients nearing their
final vascular size, it is reasonable in this population to
have a low-threshold for utilizing angiography when
there is no evidence for ongoing ischemic injury. How-
ever, arterial catheterization in smaller children poses a
higher risk of iatrogenic vascular injury [20]. Age has
been shown to significantly correlate with development
of thrombosis following percutaneous catheterization in
infants and children [41]. In addition, small children
present delays in performing these tests due to inability
to cooperate and increased technical demand, which
must be balanced against the care of all active issues. In
a study from the Gaza Strip, a series of 15 children with
bullet-induced peripheral vascular injury were reported,
where 100% limb-salvage was accomplished with no
angiography, heparin, intensive care unit, or synthetic
grafts [42]. On the basis of this data, it is likely that we
have the capacity to be more conservative with angi-
ography or systemic heparinization without significant
detriment to the outcome of vascular repair.
Iatrogenic injury
Despite increased awareness and technical advance-
ments [43], iatrogenic vascular injury after percutane-
ous vascular puncture remains a significant dilemma in
pediatric healthcare [44, 45]. Therefore, pediatric sur-
geons should be equipped with knowledgeable solu-
tions of anticipated complications.
The femoral artery is the most common vessel of
entrance for intravascular techniques [45]. Undesirable
consequences of femoral puncture include hemor-
rhage, acute thrombosis, dissection, chronic occlusion,
arteriovenous fistula and pseudoaneurysm [45, 46].
Procedures performed for intervention have been
found to have a higher incidence of complication than
diagnostic procedures [45]. Risk of complications also
correlates with younger age, number of catheteriza-
tions, and size of catheter [41, 45, 47, 48]. Specifically,
age less than 3 years, greater than three catheteriza-
tions, and catheter size of at least 6F have been found
to increase the rate of complications [45]. Originally,
degree of vasospasm was shown to correlate with ad-
verse outcomes [41], but catheter size relative to vessel
size was subsequently found to be the determining
variable for vasospasm [48].
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4 Pediatr Surg Int (2007) 23:1–10
Acute occlusion
Considerable disagreement exists regarding manage-
ment of acute loss of femoral pulse after catheterization.
Many authors recommend early operative intervention
after development of signs of acute ischemia or absence
of femoral pulse [1, 22, 49–51]. However, others feel that
non-operative management should be considered [43,
52, 53]. A non-operative approach is supported by the
hypothesis that severe vasospasm may account for the
acute lack of pulse, which can abate spontaneously. A
period of observation can therefore be conducted,
ranging from 3 to 48 h, during when; heparin therapy
can be initiated [43, 49, 52, 53]. Supporting an early
surgical intervention, exploration for absent femoral
pulse after 3 h of observation discovered thrombosis in
every case [52]. In spite of the high rate of thrombosis
after only a few hours of no detectable pulse, those
recommending an extended period observation do so on
the basis of poor early operative results, and the
opportunity for later intervention [53]. In small chil-
dren, an early operation may be technically onerous,
and limbs can remain viable despite an absent pulse via
collateral flow, which allows for future vascular recon-
struction if symptoms become evident [53, 54].
At operation, standard balloon thrombectomy is
sufficient, although particular attention should be given
to identifying and repairing the segment of intimal
injury precipitating thrombosis. Patch angioplasty or
resection with primary anastomosis has been recom-
mended by some authors given the presence of an
intimal flap or an injury involving over 30% of vessel
diameter [54]. Operative results of emergent thromb-
ectomy depend on age. Outcomes after emergent
thrombectomy have been worse for patients younger
than 2 years of age when compared to older patients
[45, 52, 55, 56]. Post-operatively, observation for
compartment syndrome is important. However, the
lack of comparative data in the literature make us
recommend the following standard adult criteria for
peripheral compartment syndrome by measuring
compartment pressures and following peripheral exam
whenever possible. After fasciotomy, progressive
wound approximation ‘‘shoelace closure’’ has been
found to decrease the need for grafting [57].
Persistence of a detectable femoral pulse despite
cannulation injury can occur with injuries distal to the
bifurcation of the common femoral artery. The clinical
course of these injuries has historically been uneventful
without treatment [58]. Subsequent limb length dis-
crepancy in over 10% of these cases has, however, led
to the recommendation that injury distal to the bifur-
cation be managed with anticoagulation [59].
123
Thrombolytics
Thrombolytics for acute thrombosis is an exciting
alternative to an operation, particularly in infants
where the operative outcomes are poor due to the
small vessels with fragile endothelium. The use of
thrombolytics has been reported to dissolve infected
mural thrombi in infants and children [60–64]. In
these studies, the thrombolytic agents of choice are
urokinase or tissue plasminogen activator (tPA),
although neither has been shown to be superior.
Systemic fibrinolysis is an obviously dangerous prop-
osition in premature neonates due to the risk of
cerebral haemorrhage. Low dose treatment has been
proposed with directed infusion of the thrombolytic
agent at the site of thrombus when possible. This
strategy has been shown to be safe and effective for
treating newborn and preterm infants. Recommended
doses are 1,000–3,000 U/kg/h for urokinase or 0.01–
0.05 mg/kg/h for tPA. Systemic proteolysis resulting in
severe clotting dysfunction will not be induced by this
low dose, although fibrinogen levels should measured
and kept above 100 mg/dl during low dose treatment
where lower levels of fibrinogen will indicate the
presence of an unwanted systemic fibrinolysis. The
data for mural thrombi is useful to understand that
systemic fibrinolysis can be considered part of the
armamentarium, but more specifically to peripheral
thrombus; the issue is less clear. A series of 17 pa-
tients treated with higher dose fibrinolysis (0.5 mg/kg/
h of tPA) for peripheral arterial thrombi after cardiac
catheterization, a response in 16 patients with mild
bleeding complications in nine patients [65]. In a
larger series of 65 patients treated the same, 65% had
complete response, 20% partial, and no effect in 15%
[66]. There were major complications in 40% and
minor complications in 30% with two patients suf-
fering severe hemorrhage and another two with
cerebral hemorrhage. These authors appropriately
conclude that the safety profile of this management is
uncertain. However, this series did show little asso-
ciation in success with length of therapy implying that
perhaps the safety profile could be improved if a
decision was made in the first hour of treatment
whether a response is developing and terminating
infusion when there is none although this remains to
be studied. Further as interventional cardiac tech-
niques have advanced, catheter directed thrombolysis
is now possible in the small infants. This is an exciting
alternative to systemic therapy with excellent results
in adults, although in our limited experience, we have
had little success thus far and await more experience
of our own and that of others.
Pediatr Surg Int (2007) 23:1–10
Anti-coagulation
Regardless, if thrombolysis is successful or operative
thrombectomy has been performed, it is prudent to
enroll a hematologist to assist with follow-up treat-
ment, preferentially low-molecular-weight heparin for
neonates at adjusted doses for a minimum 6 weeks in
the absence of a thrombophilic factor [63, 64]. A longer
course of 3–6 months is recommended when thromb-
ophilic factors exist like a hereditary disorder or cath-
eter still in place [63, 64]. All neonates with thrombosis
should be evaluated for a hypercoagalable disorder,
and if detected, those patients will require lifelong
therapy as directed by the hematologist.
Chronic occlusion
In the setting of chronic occlusion, it is the current
recommendation that patients be followed on a regular
basis for signs of ischemia such as claudication or limb
length discrepancy, and that operative intervention be
reserved for the presence of symptoms [44, 45]. Careful
follow-up investigation revealed some degree of
occlusion in one-third of patients who underwent
diagnostic femoral catheterization before 5 years of
age. Therefore, careful follow-up for all young children
who have undergone this procedure is necessary [44].
Regarding management of chronic occlusive lesions,
angiography is neccessary for appropriate operative
planning [45]. Operative results have been favorable in
abating symptoms of claudication [45].
Limb length disparity
Treatment of peripheral arterial lesions in growing
children is compounded in complexity by the potential
for vascular insufficiency to hinder future growth of the
injured extremity. Although this can be well tolerated
in upper extremities, the implications of lower limb
discrepancy on posture, hip stability, spine stability,
and gait pattern can make these defects devastating to
functional outcome and daily comfort. Limb length
discrepancy is relatively common when arterial inflow
is compromised. Prospective evaluation of a group of
15 children with chronic femoral occlusion docu-
mented uniform development of limb disparity [52]. A
significant inverse relationship between ankle/brachial
index and leg growth retardation has been documented
[44], and the degree of limb discrepancy directly im-
pacts functionality, with disparity of more than 2 cm,
significantly altering gait pattern [45, 75].
Diagnosis of limb disparity is straightforward and
should be routinely sought in patients with a history of
5
arterial injury. Management, however, is a more
imposing task. Operative intervention via ileofemoral
bypass has resulted in sporadic improvement [45, 53,
54]. However, in series of preadolescent children trea-
ted with direct revascularization, a reduction of limb
length discrepancy was reported in 70% [76]. Due to
small study groups, variations in the age of study pop-
ulations, and lack of uniform criteria for defining clini-
cally significant improvement of limb discrepancy, firm
management recommendations cannot be supported by
the current literature. Until more data clearly define the
role of bypass surgery, it seems fundamentally sound to
correct any lesions producing vascular insufficiency in
those with limb growth retardation, to maximize
remaining growth in the injured limb.
Abdominal aortic aneurysm
Abdominal aortic aneurysms (AAA) are found in
children with extreme rarity, the reported causes of
which include tuberus sclerosis [69, 70], Marfan’s dis-
ease [71], Kawasaki’s disease [72], granulomatous
inflammation [73], mycotic [74–76], tumor [77], trauma
[78] and congenital [79–82]. The reports of ‘‘congeni-
tal’’ aortic aneurysm without specific diagnosis can be
considered idiopathic, for which a diagnosis cannot be
made in the current state of medicine. Although the
work-up for known structural protein disorders was
negative in these cases, histologic abnormalities were
reported in the some of the aortic walls [79, 80].
In the reported cases of AAA, repair has resulted in
good outcomes with detectable pulses on post-opera-
tive exams, but long-term data is unavailable. Inter-
estingly, post repair angiogram can demonstrate graft
patency or aortic occlusion despite the presence of
bilateral femoral pulses palpable on physical exam [72,
73, 77].
Common iliac aneurysm has been reported in one
infant (secondary to familial fibromuscular dysplasia),
wherein surgical repair with synthetic graft interposed
between proximal common iliac and external iliac ar-
tery was used with success, although no long-term
follow-up was described in this case [83].
Renovascular disease
Occlusive disease of the aortorenal region results in
hypoperfusion of the kidney(s) resulting in the elabo-
ration of renin causing systemic hypertension. Up to
10% of patients seen in pediatric referral centers for
hypertension have renovascular lesions [84, 85]. Med-
123
6 Pediatr Surg Int (2007) 23:1–10
ical control of hypertension secondary to aorto-arteri-
opathy has been essentially ineffective [86, 87] and
these lesions are surgically correctable in about 75% of
young children, and about 20% of teenagers [88].
Surgical treatment
Surgical options include percutaneous transluminal
balloon angioplasty (PTBA), aortorenal bypass, renal
autotransplantation, and nephrectomy. No prospective
evaluation has been conducted to delineate the supe-
rior method.
Angioplasty
The least invasive of these interventions, PTBA, has
been most effective for isolated, non-occlusive, non-
ostial lesions, particularly those occurring secondary to
fibromuscular dysplasia or after transplant [89–91].
PTBA is only temporizing in managing the dense le-
sions associated with Takayasu’s arteritis, which tend
to recoil after treatment [87, 92, 93]. Therefore, at-
tempts to dilate these lesions with PTBA are better
served by deployment of metallic stents [92, 94]. Ste-
notic lesions of the aorta treated by PTBA result in
frequent recurrence and can lead to aneurysm forma-
tion [92, 94, 95]. Although some authors advocate a
trial of percutaneous intervention prior to surgical
revascularization [96] the rate of failure and known
complications of arterial cannulation in children have
led others to contrary conclusions [97].
Renal autotransplantation
Unilateral renal autotransplantation has been shown to
improve medical control of hypertension, albeit with-
out cure [87]. In the presence of contralateral renal
artery or suprarenal aortic stenosis, which is a signifi-
cant consideration since isolated unilateral disease is
less common than bilateral or aortic stenosis, unilateral
autotransplant predictably does not prevent contralat-
eral elaboration of the vasoconstrictive cascade [98].
Bilateral renal autotransplantation has shown efficacy
in some series with high cure rates in patients with
bilateral renovascular hypertension [88]. Therefore,
bilateral renal autotransplantation or bypass offers
superior management to unilateral treatment in the
face of aortic or bilateral disease [87].
Aortorenal bypass
Aortorenal bypass is a viable, albeit extremely tech-
nically difficult, means of surgical treatment if the le-
123
sions can be effectively circumvented via the presence
of disease-free segments in the proximal aorta and
distal renal artery [99]. In addition, the complexity of
bypass operations is compounded with considerations
of future patient growth and graft durability over the
potential course of an entire lifespan. Autologous vein,
a historical standard in adult surgery, has been found in
several series to dilate and in some cases, become an-
eurismal [96, 100, 101]. In response, autogenous arte-
rial grafts harvested from internal iliac have been
applied to aortorenal bypass with markedly lower
incidence of graft dilation [102]. Autogenous arterial
grafts have the disadvantages of potential disease
involvement, unknown future implications, and limited
length when midaortic lesions require bypass [97]. A
novel tactic to address the limiting factors of arterial
grafts without compromising strength has been the use
of saphenous vein grafts buttressed with tubular syn-
thetic mesh, which demonstrated resistance to dilation,
although extended follow-up is pending [98]. The
dilemmas associated with finding an ideal conduit for
vascular bypass in children highlight the notion that
renal autotransplantation is probably the best method
currently available to treat medically-refractory reno-
vascular hypertension, when anatomy and distribution
of disease does not limit its application.
Midaortic syndrome
Of special consideration in the spectrum of disease
culminating in the manifestations of renovascular
hypertension is midaortic syndrome, which can include
visceral vessels with consequent visceral ischemia [103–
106]. Some authors advocate preemptive aortovisceral
bypass prior to symptoms [107]. However, on the
anatomic basis of vast visceral collaterals, a conserva-
tive approach employing surgery only when symptoms
mandate, has resulted in rare progression to symp-
tomatic diseases in the long term [108]. When repair is
performed, favorable results have been obtained with
large bore synthetic grafts with redundant length,
anticipating subsequent growth [98, 106, 107, 109].
Technical considerations
Restricted luminal size is not merely an additional
technical compromise in the repair of peripheral vas-
cular injury of children, but has been shown to be a
significant variable in outcome with statistically lower
patency rates in children under 3 years of age or less
than 12.5 kg [56]. The narrow quarters for laminar flow
in pediatric patients amplify the impact endothelial
damage that activates platelets and subsequent
Pediatr Surg Int (2007) 23:1–10
thrombosis [110]. Investigations of endothelial damage
with electron microscropy have emphasized the
importance of preventing dessication, clamping with
minimal force, avoiding stretch, and delicate vessel
manipulation [110]. Small mural thrombi, which de-
velop commonly after such endothelial injuries, are
more likely to be significant thrombus or embolus in
the pediatric patients.
Vascular surgery in children is challenged not only
by small vessel size, but compensation for future
growth both in terms of both length and diameter. The
above discussion on the long-term results of aortorenal
bypass grafting illustrates the limitations of currently
available surgical techniques to provide durable grafts,
without limiting future options, and allowing for ade-
quate growth. In general, running sutures that are not
tied to each other to close the ring or interrupted
anastomosis allows growth, although no comparative
data exist. In the animal model, absorbable suture
(polyglyconate) has been shown to significantly im-
prove growth of venous anastomoses when compared
to non-absorbable suture (polypropylene) [111]. Poly-
diaxanone suture has also been described in infants
facilitating growth, which may be easier to use for
semi-continuous anastamosis because of its monofila-
ment non-braided style comparable to polypropylene
while still offering absorbability [112]. The use of U-
clips to facilitate an interrupted anastomosis to be
performed quickly has been shown to be effective in
infants [113]. These clips are an exciting advance for
difficult anastamosis, particularly when a lot of stitches
will be necessary and we have found them quite useful
in an array of situations. Utilization of surgical adhe-
sive has been attempted, however, bovine albumin
combined with glutaraldehyde to buttress arterial
anastomoses in growing animals has resulted in stric-
tures [114].
When a conduit is required, graft options in children
result in a quandary due to the necessity for longitu-
dinal and circular growth. Synthetic grafts can allow for
unlimited size options, can be sewn in with slack for
longitudinal growth. They also provide good long-term
durability, however, the patency rates are not as good
due to the lack of endothelium and the lifelong risk of
infection is a matter of consideration with these grafts.
Saphenous vein grafts provide good tissue, are usually
adequately sized for most functions, however, they will
dilate under long-term arterial pressure. As mentioned
previously, reinforcing these grafts with a tubular
synthetic mesh has been reported [98]. Arterial auto-
grafts when size matched, offer an attractive solution.
In a recent comparative study with renal bypass in
children, internal iliac autograft was reported to be the
7
preferred conduit [115]. In traumatic situations, these
considerations are less demanding given the urgency of
the situation. Saphenous vein grafts offer a decreased
risk of infection in these situations, but the graft should
be followed by Doppler at regular intervals with the
anticipation that the graft will dilate which can be
treated electively with a different option like arterial
autograft.
Summary
Whether acute or chronic, the most common indication
for vascular intervention in children is to repair lesions,
which are a consequence of trauma. Violent injury is
epidemic in the adolescent population and in the
domestic setting; injuries from glass accidents are
common in the pre-adolescent group. In the infant
and young child iatrogenic vascular trauma due to
vessel cannulation is still the predominant etiology of
vascular injury. Nerve injury is a cornerstone consid-
eration in the treatment of acute penetrating trauma,
while future limb growth is a primary concern with
chronic lesions. Vessel size, compensation for future
growth, and durability of vascular conduits pose addi-
tional complexity to surgical treatment of vascular
disease in children, and when possible, preoperative
planning that thoroughly weighs each of these vari-
ables may improve the outcome.
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