Peripheral Vascular Bypass with Cadaveric Arterial Allograft in a Toddler with FemoralMycotic Aneurysm

Abstract

<h3>Introduction & Objective</h3> Mycotic aneurysms are exceedingly rare in the pediatric population. The optimal surgical treatment for children with this disease is unclear as aneurysm resection and vascular reconstruction are uncommonly performed in young children. We present the unique case of a21-month-old child with a complex cardiac history who presented with leg ischemia and a femoral mycotic aneurysm that was successfully repaired with an external iliac to profunda femoris artery vascular bypass with cryopreserved arterial allograft and femoral vein reconstruction. <h3>Case Report</h3> Our patient presented with leg ischemia and blood cultures positive for <i>Aspergillus</i>, with CT angiography demonstrating complete occlusion of the left common femoral artery and proximal superficial femoral artery (Figure 1Figure 1Axial computed tomography shows large left common femoral artery mycotic aneurysm with dense inflammatory reaction.Figure 1). Upon operative exploration, there was an extremely dense inflammatory response with purulent material extruding from the region and bulky reactive lymphadenopathy (Figure 2AFigure 2A-B. (A) Intraoperative photograph demonstrating large mycotic aneurysm involving the femoral artery. (B) Intraoperative photograph demonstrating the completed anastomosis between the left common iliac artery and the profunda femoris artery, along with femoral vein reconstruction.Figure 2) with extension of thrombosis from the external iliac artery immediately at the inguinal ligament to the superficial femoral artery. The 2 mm profunda arterywas the remaining outflow to the lower extremity. A 6 mm cryopreserved artery allograft (CryoArtery) was used to perform the vascular bypass between the external iliac artery and the profunda femoris artery in an end-to-side fashion. The mycotic aneurysm and underlying vesselswere dissected and resected from the external iliac artery to the proximal superficial femoral artery. As the femoral vein was densely adherent to the inflammatory mass, a segment was removed and reconstructed in a similar fashion with CryoArtery. Completed anastomosis is shown in Figure 2B. At the conclusion of the procedure, the patient had biphasic doppler signal in the dorsalis pedis artery. <h3>Conclusions</h3> Successful vascular reconstruction can be performed in a young child with an Aspergillus mycotic aneurysm using cadaveric arterial allograft. For our patient, a cryopreserved artery allograft was used as the iliofemoral bypass conduit. Although an autologous conduit would have been the preferred bypass method, it was not possible in this case owing to the patients immaturevenous system and prior surgical manipulation. Not only is restoring flow to the distal extremity of the utmost importance in young pediatric patients to avoid future limb-length discrepancies, but flow must also be maintained in the bypass conduit postoperatively without conduit occlusion. Our patient received intravenous heparin in the immediate postoperative period and was bridged to prophylactic enoxaparin for three months and aspirin indefinitely. If the use of an autologous conduit is not possible, we show here that a cadaveric arterial allograft can be a suitable and durable alternative and report the successful vascular reconstruction of a 20-month-old with an Aspergillus mycotic aneurysm using cadaveric arterial allograft and no limb-length discrepancy as of thirty-six months follow-up.