Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
J Vasc Surg. 2018 Oct;68(4):1062-1070. doi: 10.1016/j.jvs.2017.12.070. Epub 2018 Apr 3.
Pediatric splanchnic arterial occlusive disease is uncommon and a rare cause of clinically relevant intestinal ischemia. This study was undertaken to better define the clinical manifestations and appropriate treatment of celiac artery (CA) and superior mesenteric artery (SMA) occlusive disease in children.
Clinical courses of 30 consecutive children undergoing operations for splanchnic arterial occlusive disease at the University of Michigan from 1992 to 2017 were retrospectively analyzed.
Vascular reconstructions were performed for splanchnic arterial disease in 18 boys and 12 girls, 1.5 to 16 years of age (mean, 7.5 ± 4.1 years). Isolated splanchnic arterial disease was uncommon (2 children), being more often associated with abdominal aortic coarctations (19 children) or ostial renal artery stenoses (25 children). Primary splanchnic arterial reconstructions (30) included aortic reimplantation of SMAs (15) or celiacomesenteric arteries (2), aortoceliac and aortomesenteric bypasses (7), reimplantation of the CA as a patch over the stenotic SMA orifice (3), and patch angioplasty of the CA (2) or SMA (1). There was no perioperative mortality. Two groups (I and II) were identified for study. Group I children (14) experienced symptomatic intestinal ischemia, manifested by various combinations of chronic postprandial abdominal discomfort (14), ischemia-related intestinal bleeding (2), or failure to thrive (4). Four children in group I became symptomatic after known CA and SMA occlusive disease was left untreated at the time they underwent earlier interventions for renovascular hypertension. Seven secondary redo interventions were undertaken for recurrent symptoms in six group I children. Only one major periprocedural complication occurred: segmental colon infarction. The assisted patency rate of reconstructed arteries in group I children was 93%, and intestinal ischemic symptoms resolved in every child. Group I follow-up from the most recent splanchnic arterial reconstruction averaged 4.3 years. Group II children (16) without manifestations of intestinal ischemia underwent prophylactic splanchnic arterial reconstructions in concert with combined aortic and renal artery procedures (11), isolated abdominal aortic reconstructions (3), or renal artery reconstructions alone (2). Group II children experienced no major perioperative morbidity and remained asymptomatic postoperatively, and none required secondary splanchnic artery interventions. Group II follow-up averaged 7.4 years.
Pediatric splanchnic artery occlusive lesions are often associated with developmental aortic and renal artery occlusive disease. Carefully conducted therapeutic and prophylactic reconstructive procedures are appropriate in children having splanchnic arterial occlusive disease.
儿科内脏动脉阻塞性疾病并不常见，是导致临床相关肠道缺血的罕见原因。本研究旨在更好地定义儿童腹腔动脉（CA）和肠系膜上动脉（SMA）阻塞性疾病的临床表现和适当的治疗方法。
回顾性分析了 1992 年至 2017 年期间在密歇根大学接受内脏动脉阻塞性疾病手术的 30 例连续儿童的临床病程。
18 名男孩和 12 名女孩（年龄 1.5 至 16 岁，平均 7.5±4.1 岁）因内脏动脉疾病接受血管重建。孤立性内脏动脉疾病不常见（2 例患儿），更常与腹主动脉缩窄（19 例患儿）或肾动脉开口狭窄（25 例患儿）有关。原发性内脏动脉重建术（30 例）包括 SMA（15 例）或腹腔动脉（2 例）的 SMA 再植入术，腹腔动脉和肠系膜上动脉旁路术（7 例），CA 的主动脉补片再植入术（3 例），用于狭窄 SMA 口的补丁，以及 CA（2 例）或 SMA（1 例）的补丁血管成形术。无围手术期死亡。为研究目的确定了两组（I 组和 II 组）。I 组患儿（14 例）出现症状性肠道缺血，表现为慢性餐后腹部不适（14 例）、与缺血相关的肠道出血（2 例）或生长不良（4 例）等各种组合。I 组中有 4 名患儿在先前因肾血管性高血压而进行的治疗中，未对已知的 CA 和 SMA 阻塞性疾病进行治疗，随后出现症状。6 例 I 组患儿因复发症状而进行了 7 次二次再干预。仅发生 1 例主要围手术期并发症：节段性结肠梗死。I 组患儿重建动脉的辅助通畅率为 93%，每例患儿的肠道缺血症状均得到缓解。I 组的随访时间从最近一次内脏动脉重建开始平均为 4.3 年。没有肠道缺血表现的 II 组患儿（16 例）在联合主动脉和肾动脉手术（11 例）、孤立性腹主动脉重建（3 例）或单独肾动脉重建（2 例）时进行了预防性内脏动脉重建。II 组患儿无重大围手术期并发症，术后无症状，均无需进行二次内脏动脉干预。II 组的随访时间平均为 7.4 年。
儿科内脏动脉阻塞性病变常与发育性主动脉和肾动脉阻塞性疾病有关。在患有内脏动脉阻塞性疾病的儿童中，仔细进行治疗和预防性重建手术是恰当的。
