Thrombectomy in baby -technique for CFA repair without patch

bluebabyleg

The patient is a baby who had undergone cardiac catheterization prior to repair of tetralogy of Fallot. Postoperatively he developed acute limb ischemia and was found to have an occlusion of his left common femoral artery. This was unusual, as typically, these babies tolerate catheterization and a high rate of CFA occlusion without ill effect. Usually treatment with heparin for a period of time is sufficient. In this child, there was clearly severe ischemia. What was different about this child was that his mother and her two siblings suffered from severe Raynaud’s disease, suggesting in this baby, vasospasm played a role. The foot was cold and not moving, and there were no signals from the groin down. The baby was taken to the OR for a CFA exploration and thrombectomy, as I felt the likelihood of infarction in this baby was high. The common femoral artery was exposed via an oblique incision and it was about 2mm in diameter, translucent, and very elastic. There was thrombus and I performed a longitudinal arteriotomy. There was minimal thrombus and a gossamer dissection flap. Inflow was easily established. There was no backbleeding.

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Repairing the artery was initially not straightforward. The available nearby vein was even smaller for lack of blood flow and in spasm, and primarily repairing it was not a good option. There is literature describing patch angioplasty, but I felt there had to be a faster, better solution that did not require 8x magnification. Then it struck me that the artery was so pliable that it was every easy to mobilize a length of it from under the ligament.

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My inspiration was the Heineken-Mikulicz pyloroplasty. IMG_1174.JPG

 

 

Once the laterally oriented stay sutures were in, interrupted (always) 8-0 sutures created a nice repair. IMG_1175.JPGThe blood flow was high resistance, but the outcome was immediate. The baby had had over two days of ischemia, and I did go ahead and perform fasciotomies of the leg. There was dead muscle in all the compartments, but with VAC therapy, the baby healed within a few weeks, and a year later came in walking without a limp!

postop blue baby leg

 

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