Balloon aortic valvuloplasty in a 1,600-gram infant

Early Onset of Atherosclerosis of The Carotid Bifurcation in Newborn Cadavers

INTRODUCTION

The anatomy of arterial bifurcations affects blood flow and has a significant role in the development of vascular disease. Therefore, it is important to know the structural characteristics of the Common Carotid Artery (CCA) and its branches for early onset of atherosclerosis in newborns.

AIM

The present study was conducted to evaluate the characteristics of CCA in newborn cadavers.

MATERIALS AND METHODS

Eight carotid arteries obtained from newborn cadavers were used. The outflow to inflow area ratios was calculated to evaluate vessel diameters. Additionally, scanning electron and light microscopic investigations were conducted with tissue samples. The brachial artery of each cadaver was used as controls. Correlation between area ratios and atherosclerotic endothelial damage was determined.

RESULTS

Light microscopic investigations demonstrated that control group sections showed no positivity for Oil red O staining, while carotid bifurcation regions depicted widespread occurrence of intimal lipid accumulations. Scanning electron microscopic examination of control group sections presented regular endothelial topography, while carotid bifurcation region topography exhibited numerous blood cells and separated endothelial cells. Fibrin accumulation on endothelial surface in low area ratios was another important finding in the examination of its endothelial surface degeneration. The above-mentioned morphological findings seemed to be quite parallel to outflow to inflow area ratio data favouring low area and degeneration.

CONCLUSION

The correlation between area ratios and the histological characteristic of cerebral vessels of newborn cadavers indicate that early stages of atherosclerosis began in early embryologic life.

Percutaneous Common Carotid Artery Access for Pediatric Interventional Cardiac Catheterization

Background—

Surgical cutdown for access to the common carotid artery provides a more direct route for certain pediatric cardiac interventions and avoids femoral artery injury in small infants. The safety of percutaneous carotid access (PCA) in children is unknown.

Methods and Results—

Retrospective review of PCA at Texas Children’s Hospital and Children’s Healthcare of Atlanta. From July 2006 to November 2014, 42 patients underwent 47 attempts at catheterization via PCA. Median (range) age was 20 days (0 days–2.9 years) and weight was 3.2 kg (1.1–12.2). Two patients had failed PCA with no sequelae. Of the 45 catheterizations with successful PCA and sheath placement, 44 interventions were performed, the most common being stenting or stent redilation of the ductus arteriosus, balloon aortic valvuloplasty, and stenting or angioplasty of Blalock–Taussig shunts. After sheath withdrawal, hemostasis was achieved with manual compression, with no need for surgical control of bleeding. Follow-up carotid imaging was performed in all. Acutely, 3 patients developed carotid thrombosis with resolution in 1 and mild residual narrowing in 2 after anticoagulation therapy. At follow-up, 40 of 42 patients (95%) had a normal carotid artery, with 2 instances of mild stenosis. There were no neurological sequelae attributable to PCA.

Conclusions—

PCA is safe even in small infants, and hemostasis can be achieved without surgical repair, with a carotid patency rate superior to published data after surgical cutdown. Surgical cutdown is not routinely required for pediatric cardiac catheterization via the carotid artery.

Transapical aortic balloon valvuloplasty in a 6-year-old child with unsuccessful retrograde approach

Severely stenotic aortic valves can be treated by percutaneous techniques. However, in rare conditions it could not be possible because of vascular access and valvular passage problems due to small and eccentric orifice. Hybrid approach to balloon aortic valvuloplasty may be considered an alternative to surgery. Here, we present a case of a patient with severe aortic stenosis who has had two failed attempts of percutaneous intervention.

The diameters of common carotid artery and its branches in newborns

The common carotid artery (CCA) bifurcation is of clinical importance due to its vascular access site for intravascular intervention. Additionally, it is also one of the most common sites of atherosclerotic plaque formation. There are numerous studies on the diameters of CCA, internal carotid artery (ICA), and external carotid artery (ECA) in adults, but few studies on newborns. Cadaver and angiographic studies have shown dimensional variations in the carotid arteries within/between individuals and also between different sexes. It is well known that the initial lesions of atherosclerosis begin very early in fetal life. Therefore, it is important to know the anatomical details of the CCA and its branches. In the present study, the neck regions of 20 (11 males and 9 females) fixed newborn cadavers were dissected. The CCAs were cut below the bulb of the carotid bifurcation further; ICA and ECA were cut above the bulb of the carotid bifurcation. The internal diameters of the CCA, ICA, and ECA were measured using a light microscopy. ECA/CCA, ICA/CCA, ICA/ECA ratios, and outflow to inflow area ratio were calculated. The mean outflow to inflow area ratio was 1.14+/-0.28. Our results highly correlated with the defined optimal ratio (1.15). The ECA/CCA, ICA/CCA, and ICA/ECA ratios were 0.78+/-0.12, 0.71+/-0.13, and 0.93+/-0.16, respectively. There were no statistically significant differences between male and female and also between right and left sides. These findings are of importance in understanding the anatomy of carotid artery during newborn period.

Cardiac catheterisation in infants weighing less than 2500 grams

OBJECTIVES

To investigate the indications for, and outcome of, cardiac catheterisation in infants weighing less than 2500 g at a single institution over an 8-year period.

PATIENTS AND METHODS

We assessed all infants who were less than 2500 g at the time of cardiac catheterisation at Texas Children's Hospital from January 1993 to January 2001. Comparisons of morbidity and mortality were drawn with an equivalent number of infants of similar age weighing greater than 2500 g seen over the same period of time.

RESULTS

We performed interventional procedures in 22, and diagnostic catheterisations in 12 infants weighing less than 2500 g. Interventions included pulmonary valvoplasty in six patients, balloon angioplasty of critical coarctation in one, aortic valvoplasty in two, septostomy in ten, and coil occlusion of an arteriovenous malformation, redirection of a subclavian venous line, and coil occlusion of a patent arterial duct in one patient each. The median age at catheterisation was 5 days for children less than 2500 g, and 10 days for those above 2500 g. The median weights were 2.3 kg and 3.3 kg, and the median gestational ages were 35 weeks and 38 weeks, for the two respective groups. Of those weighing less than 2500 g, two died (6%), with no deaths occurring in those weighing more than 2500 g. In 3 patients weighing less than 2500 g (9%), there was vascular compromise, one child with bilateral femoral venous obstruction requiring fasciotomy compared, to one in the group weighing greater than 2500 g (2%).

CONCLUSION

There is a significantly increased risk of mortality and vascular compromise in infants weighing less than 2500 g. Interventional catheterisation in these infants may be lifesaving, but given the aforementioned risks, diagnostic catheterisation should be deferred if possible in favor of noninvasive modalities.