Aortoiliac reconstruction in infants and toddlers: replacement with decellularized branched pulmonary artery allograft

Open repair of a ruptured abdominal aorta with an aortoiliac vein fistula in a 7-month-old infant and review of the literature

Ruptured abdominal aortic aneurysms are extremely rare in the pediatric population. In this video case report, we describe the successful repair of a ruptured abdominal aortic aneurysm in a 7-month-old female infant.

Microsurgical and Endovascular Management of Congenital Iliac Aneurysms in the Neonatal Period: Two Cases and a Literature Review

Introduction

Congenital aneurysms of major arteries are very rare diagnoses and prognosis can be poor if treatment is not initiated rapidly. This is the presentation of two cases of infants with congenital iliac aneurysms who underwent treatment in the neonatal period. The report then proceeds with a literature review of paediatric iliac aneurysms.

Report

Case 1: A female neonate was diagnosed antenatally with right common iliac (CIA) and internal iliac (IIA) artery aneurysms. Embolisation on day of life (DOL) eight was impossible because of partial thrombosis. The infant was subsequently observed for several months and the aneurysm was injected percutaneously with thrombin on DOL 78. A small residual aneurysm was coil embolised at five months of age. Satisfactory results were observed at one year follow up. Case 2: A female neonate was diagnosed antenatally on routine third trimester ultrasound with voluminous, bilateral CIA aneurysms. The patient underwent surgery on DOL 9 for aneurysm resection and microsurgical vascular reconstruction. The intervention was successful with triphasic flow through the anastomoses on colour Doppler ultrasound at six week follow up.

Discussion

Ten cases of congenital iliac aneurysms have been reported previously, with just two diagnosed in the neonatal period and eight undergoing surgical intervention. Definitive management to avoid aneurysm rupture or thrombosis should be timed carefully, and sometimes delayed with watchful waiting, to maximise success and minimise complications. Surgery is the key treatment modality, but endovascular intervention can be considered in selected cases. Congenital iliac aneurysms should be addressed at the safest time for the patient. Following resection, primary microvascular anastomosis is the ideal reconstructive technique, but other options for neonates have been described. Endovascular treatment should be considered for anatomically amenable saccular aneurysms.

Congenital Abdominal Aortic Aneurysm in a Four Year Old Girl

Introduction

Abdominal aortic aneurysm (AAA) in neonates, infants, and children is uncommon, usually occurring as a result of infections, connective tissue disorders, vasculitis, or iatrogenic trauma. A case of idiopathic congenital AAA, an extremely rare disease of unknown origin, is described.

Report

In March 2018, a 40 mm hypoechoic mass adjacent to the left kidney was detected incidentally by abdominal ultrasound for investigation of hypercalciuria in a four year old girl. Contrast enhanced computed tomography (CT) revealed an infrarenal fusiform AAA measuring 39 mm in maximum diameter, a 15 mm left renal artery aneurysm, a 14 mm right hypogastric artery aneurysm, and a 12 mm left hypogastric artery aneurysm. Cerebral magnetic resonance imaging revealed multiple intracranial aneurysms between 8 and 15 mm in diameter. Considering the size of the AAA and risk of rupture, surgical repair was planned. In May 2018, the congenital AAA was successfully repaired with a 10 mm Dacron aorto-aortic tube graft. Increases in the size of the left renal artery aneurysm and a left middle meningeal artery aneurysm were detected 12 and 14 months post-operatively, respectively. Coil embolisations were performed. An intracranial dural arteriovenous fistula (AVF) was discovered incidentally by cerebral angiography for treatment of the left middle meningeal artery aneurysm. Transarterial embolisation for AVF was also performed. At the 21 month post-operative follow up, the patient is doing well, and the untreated aneurysms have not grown.

Conclusion

Long term outcomes after surgical repair for congenital AAA are unclear. Moreover, growth of residual aneurysms was detected post-operatively, so follow up with frequent multimodality imaging for multiple aneurysms is necessary.

Aortic bypass surgery using synthetic conduits in a child with mycotic aneurysmal disease

A six-year-old child developed multiple aortic aneurysms as a consequence of fungal infection following thoracic aortic surgery for coarctation. Several repairs of both the thoracic and abdominal aorta were carried out using synthetic material combined with long-term postoperative antifungal treatment. We describe the surgical interventions performed and follow-up. The choice of conduit continues to be the main concern; however, when other alternatives are not available, synthetic material combined with indefinite antifungal treatment can produce satisfactory medium-term results.

Diagnosis and treatment of congenital abdominal aortic aneurysm: a systematic review of reported cases

Background

Congenital abdominal aortic aneurysm (AAA) is distinctly rare in infants and children and carries a high mortality rate. Our objective was to summarize the experience of the diagnosis and treatment in patients with congenital AAA.

Methods

Reported cases of congenital AAA published prior to November 8, 2014, were identified through PubMed, EMBASE, Web of Science, and reference lists. All selected cases were evaluated for main clinical characteristics.

Results

Twenty-six cases of congenital AAA were identified in the English language literature. Congenital AAA occurred primarily in children under three years old, but it was also found in young adults and fetuses. With regards to the localization, the great majority of congenital AAA was infrarenal AAA. The majority of the AAA patients lacked specific symptoms, and a painless pulsatile abdominal mass was the most common clinical presentation. The diagnosis of AAA was based on ultrasound scanning in twenty-five cases, multi-slice spiral computed tomography angiography (MSCTA) in sixteen cases, and magnetic resonance angiography (MRA) in nine cases. Histopathological analyses were available in seven cases. Seven patients received conservative management. Surgical treatment was performed in seventeen cases, and open repair with an artificial graft was the main surgical intervention. The mortality associated with congenital AAA was high (30.76%). Ruptured aneurysm and renal failure were the main causes of death.

Conclusions

Good outcomes can be achieved in children with early identification of congenital AAA and individualized surgical repair with grafts.

eNOS transfection of adipose-derived stem cells yields bioactive nitric oxide production and improved results in vascular tissue engineering

This study evaluates the durability of a novel tissue engineered blood vessel (TEBV) created by seeding a natural vascular tissue scaffold (decellularized human saphenous vein allograft) with autologous adipose-derived stem cells (ASC) differentiated into endothelial-like cells. Previous work with this model revealed the graft to be thrombogenic, likely due to inadequate endothelial differentiation as evidenced by minimal production of nitric oxide (NO). To evaluate the importance of NO expression by the seeded cells, we created TEBV using autologous ASC transfected with the endothelial nitric oxide synthase (eNOS) gene to produce NO. We found that transfected ASC produced NO at levels similar to endothelial cell (EC) controls in vitro which was capable of causing vasorelaxation of aortic specimens ex vivo. TEBV (n = 5) created with NO-producing ASC and implanted as interposition grafts within the aorta of rabbits remained patent for two months and demonstrated a non-thrombogenic surface compared to unseeded controls (n = 5). Despite the xenograft nature of the scaffold, the TEBV structure remained well preserved in seeded grafts. In sum, this study demonstrates that upregulation of NO expression within adult stem cells differentiated towards an endothelial-like lineage imparts a non-thrombogenic phenotype and highlights the importance of NO production by cells to be used as endothelial cell substitutes in vascular tissue engineering applications.

An idiopathic congenital abdominal aortic aneurysm with impending rupture in a 23-month-old boy

Abdominal aortic aneurysms are distinctly uncommon in infants and children. These aneurysms, which are idiopathic in nature without any definite predisposing factors, are exceedingly rare. We present the case of a giant idiopathic congenital infrarenal abdominal aortic aneurysm with impending rupture in a 23-month-old boy, which was successfully treated with surgical repair using a cryopreserved cadaveric allograft. To the best of our knowledge, this is the oldest case and the third successful treatment of an idiopathic congenital abdominal aortic aneurysm repaired with a cryopreserved allograft in infants and children. Continued follow-up with multimodality imaging is required.

Extensive congenital abdominal aortic aneurysm and renovascular disease in the neonate

Primary congenital abdominal aortic aneurysm is an extremely rare entity, with only 15 patients reported in the literature. Options for repair are often limited secondary to branch vessel size and other anatomic limitations. We present a neonate diagnosed with an abdominal aortic aneurysm on prenatal ultrasound. A postpartum computed tomography angiogram revealed an extensive type IV thoracoabdominal aortic aneurysm extending to the aortic bifurcation and resulting in bilateral renal artery stenosis. The unique features of this patient and challenges in management are discussed.

Primary aortoenteric fistula due to a swallowed twig in a three-year-old child

Aortoenteric fistulae are infrequent causes of gastrointestinal bleeding and usually occur as a late complication of aortic aneurysm repair. Primary aortoenteric fistulae are very rare and most have an aetiological association with atherosclerotic aneurysmal disease.(1,2) We report a primary aortoenteric fistula (PAEF) occurring in a 3 year old as a result of duodenal perforation after ingestion of a twig. To our knowledge this is the first case of a primary aortoenteric fistula reported in a child. Emergency aortic surgery in children needs certain considerations which are briefly discussed.

Anatomical repair of a congenital aneurysm of the distal abdominal aorta in a newborn

Congenital (primary) neonatal abdominal aortic aneurysm (AAA) is an extremely rare truncular arterial abnormality among numerous congenital vascular malformations. Only seven cases have been reported as congenital origin in newborns. This report presents the case of a male infant in whom a 33-mm congenital AAA was diagnosed prenatally and was successfully treated 10 days after birth without exogenous graft material or aneurysmorrhaphy. Follow-up study at 39 months demonstrated excellent clinical, ultrasound scan, and computed tomography scan findings. Anatomic reconstruction with native vessels is the preferred surgical technique to ensure the child's potential for harmonious growth.