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J Vasc Surg Cases Innov Tech
J Vasc Surg Cases Innov Tech
Journal of Vascular Surgery Cases, Innovations and Techniques
2468-4287
Elsevier

S2468-4287(24)00155-2
10.1016/j.jvscit.2024.101571
101571
Innovative technique
Iliac transposition technique for reconstruction of aortic bifurcation in pediatric blunt abdominal aortic injury
Hanif Hamza MD a
Clark Ross MD, MBA, RPVI b
Chavez LeAnn MD, MBA, FACS, RPVI b
Miskimins Richard MD, FACS c
Rana Muhammad Ali MD, FACS, FSVS mrana@salud.unm.edu
b∗
a Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
b Division of Vascular Surgery, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
c Division of Trauma and Acute Care Surgery, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
∗ Correspondence: Muhammad Ali Rana, MD, FACS, FSVS, Chief, Division of Vascular Surgery, Interim Chief, Division of Cardiothoracic Surgery, Director of Endovascular Surgery, Associate Professor, University of New Mexico, 1 University of New Mexico, MSC 10 5610, Albuquerque, NM 87109 mrana@salud.unm.edu
11 7 2024
12 2024
11 7 2024
10 6 10157120 5 2024
2 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Blunt abdominal aortic injuries, especially in pediatric patients, represents a rare and critical challenge. We report a unique case of a 10-year-old boy who presented after a high-speed motor vehicle collision resulting in injury to the aortic bifurcation, alongside other intra-abdominal trauma. A novel surgical approach for aortoiliac reconstruction in a contaminated field was used. This technique consisted of the mobilization of the distal aorta and common iliac arteries, ligation of right internal iliac artery, and creation of aortoiliac and common to internal iliac artery anastomoses. This method demonstrates a potentially lifesaving technique in select patients.

Keywords

Blunt abdominal aortic injury
Aortic bifurcation injury
Vascular repair
Pediatric trauma
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pmcBlunt abdominal aortic injuries are extremely rare but potentially lethal.1 Their incidence is even lower in pediatric population, with only a few reported cases in the literature.1,2 These high-mechanism injuries are often associated with other intra-abdominal trauma, including hollow viscus perforation, solid organ injuries, and spine fractures.3 In this case, we describe a novel approach to aortoiliac reconstruction in a contaminated field in a pediatric patient. The patient's legal guardians provided written consent to share the clinical information and related imaging studies.

Case report

A 10-year-old boy, previously in good health, presented to the emergency department after a high-speed motor vehicle collision in which he was a restrained passenger. Upon arrival, his heart rate was noted to be of 125 beats per min, with a blood pressure of 115/75 mm Hg. Examination revealed significant abdominal bruising, indicative of a seatbelt sign. Bilateral dorsalis pedis and posterior tibial pulses were palpable. Initial resuscitation was followed by a computed tomography scan, which identified a traumatic injury to the abdominal aorta at the bifurcation (Fig 1, A). This injury included a small pseudoaneurysm at the aortic bifurcation with traumatic flaps extending into both common iliac arteries (CIAs) (Fig 1, B). Concurrent findings included multiple mesenteric contusions with free fluid suggestive of hollow viscus injury, and compression fractures of the T2 to T7 vertebrae.Fig 1 (A and B) Preoperative computed tomography arteriogram demonstrating blunt abdominal aortic injury with traumatic flaps extending into bilateral common iliac arteries (CIAs) in axial and coronal planes, respectively.

The vascular surgery team was consulted for management of the aortic injury. Owing to absence of extravasation and the minimal appearance of injury on initial imaging, a conservative approach was taken. The initial emergent laparotomy revealed a nonexpanding zone 3 retroperitoneal hematoma, a substantial Morel-Lavallee lesion, avulsion of the rectus muscles from bilateral anterior superior iliac spines, full-thickness perforation of the terminal ileum and cecum with feculent spillage, and a bucket handle injury to the distal sigmoid colon. These injuries necessitated damage control sigmoidectomy, right hemicolectomy, pelvic packing, and temporary abdominal closure. The retroperitoneal hematoma was not explored.

On the following day during reexploration, the zone 3 hematoma was decompressed while mobilizing the rectosigmoid junction, which unroofed torrential bleeding from the pelvis. This bleeding resulted from dislodgement of a thrombus at the aortic bifurcation, resulting in free rupture. After achieving vascular control, the injured area was inspected. Initially, a bovine pericardial patch repair was attempted, which led to high-grade stenosis of bilateral CIAs and the distal aorta. Owing to the extent of the sheer injury to the aortic bifurcation, the vascular surgery team was consulted. The arterial tissue, being extremely friable, was deemed unsalvageable. This necessitated resection of the aortic bifurcation, resulting in a 2-cm defect. Owing to the contaminated surgical field and no appropriate autologous conduit, alternative reconstruction strategies were considered.

The reconstruction involved mobilization of distal aorta inferiorly by ligating several lumbar branches. The right CIA, external iliac artery, and internal iliac artery (IIA) were then mobilized proximally in an attempt to reach the aorta. Owing to the tethering effect and relative immobility of the IIA in the deep pelvis, it was clamped and transected just proximal to the bifurcation into anterior and posterior divisions. The distal stump was closed using a 5-0 Prolene suture. This maneuver allowed the right CIA to reach the distal aortic end without tension. An end-to-end anastomosis between the aorta and the right CIA was created. This process was facilitated by a reverse bevel on the CIA stump. A 5-0 Prolene suture was used to create the anastomosis in a running fashion for the posterior wall and interrupted anteriorly, allowing for future growth. For additional medial reinforcement, posterior rectus sheath pledgets were used. The flow was restored into the right lower extremity, while keeping the right IIA clamped. Following this, a left CIA to right IIA end-to-end anastomosis was created using a similar technique. This allowed for patent unilateral blood flow into the pelvis through the left IIA (Fig 2). After restoring flow into bilateral lower extremities, the patient had strong pulses in the groin at the conclusion of the case.Fig 2 Intraoperative image at the conclusion of the reconstruction.

After the initial surgeries, the patient underwent multiple procedures for complex abdominal wall reconstruction, colostomy closure, and wound care. The postoperative recovery was lengthy, culminating in discharge to a rehabilitation facility. Aspirin was continued for 6 months. A follow-up computed tomography arteriogram at 6 months demonstrated excellent patency of the aortoiliac reconstruction without any evidence of distal ischemia (Fig 3, A and B).Fig 3 (A) Three-dimensional reconstruction of the computed tomography arteriogram demonstrating patency of the reconstruction of aortic bifurcation at 6 months. (B) Centerline analysis of the computed tomography arteriogram centered over the aorta, left common, and external iliac arteries at 6 months.

Discussion

Reconstruction of the aortoiliac system in pediatric patients, especially within a contaminated surgical field, presents unique challenges owing to the smaller anatomical structures, the imperative to accommodate future growth, and the increased risk of infection.1,4 The case presented here highlights the complexity of such repairs and the necessity for innovative approaches to ensure immediate and long-term success.

The majority of blunt abdominal aortic injuries are treated conservatively.3 Surgical intervention, particularly in a pediatric patient, is exceedingly rare and documented only in a few publications.5, 6, 7 These injuries, primarily resulting from high-mechanism trauma, are often associated with hollow viscus injuries that result in a contaminated surgical field. In such scenarios, the preference leans heavily toward the use of autologous tissue for reconstruction. Although infected prosthetic grafts and endografts are the most commons indication for autologous aortoiliac reconstruction, traumatic injuries also necessitate its use.8, 9, 10 Moreover, in the pediatric population, there is a need for repair that accommodates future growth, further limiting the use of synthetic grafts.1,2 In such cases, the options for reconstruction are limited. Although primary repair most preferred, it is often not feasible. Other options include autologous vein grafts and neo-aortoiliac systems; however, vessel size mismatch and procedural morbidity are serious considerations. Nonprosthetic materials such as bovine pericardial patch or cryopreserved homografts can also be used. However, long-term durability can be problematic and the availability can be a challenge.11

In this case, a moderate-sized defect was noted at the aortic bifurcation. The described technique focuses on gaining length enough to cover the defect to perform a primary anastomosis, which is highly preferred in the given scenario. By ligating the lumbar branches, at least some aortic length is gained. Mobilizing the iliac vessels can be challenging owing to the tethering of the common iliac vessels by the IIA in the deep pelvis. By dividing unilateral IIA, enough length can be achieved to perform a primary repair, while preserving pelvic perfusion through the contralateral vessel. However, despite interrupting anastomotic sutures anteriorly and preserving pelvic perfusion unilaterally, there is a theoretical risk for stenosis and pelvic claudication. In patients sustaining blunt or penetrating injuries resulting in gross contamination near a vascular injury, every effort should be made to avoid the use of nonautologous materials.

Disclosures

None.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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