Operative Treatment of Pediatric Splanchnic Arterial Occlusive Disease



Operative Treatment of Pediatric Splanchnic Arterial Occlusive Disease



Jonathan L. Eliason and James C. Stanley



Clinical Presentation


Splanchnic arterial occlusive disease in children is a very uncommon pathologic entity and a rare cause of intestinal ischemic symptoms. This disease is usually recognized as an incidental finding during studies of hypertensive children having abdominal aortic coarctations or renal artery disease. In two earlier publications from our institution, splanchnic artery occlusive lesions were encountered in 22% of patients with abdominal aortic coarctations and in 18% of patients with renal artery stenotic disease.


An occasional child has symptomatic intestinal ischemia manifest by postprandial abdominal pain and a failure to gain or maintain weight. The diagnosis in patients with suspected intestinal angina is most often confirmed by arteriographic imaging (Figures 1 and 2). The stenotic narrowings in these children invariably affect the ostia of the celiac and superior mesenteric arteries.


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FIGURE 1 Arteriographic evidence of splanchnic arterial occlusive disease in an adolescent. A, Lateral aortogram with severe celiac and superior mesenteric artery narrowings. B, Anteroposterior aortogram in a young child, exhibiting a large central mesocolic artery collateral originating from the inferior mesenteric artery passing superiorly to the circulatory beds of occluded celiac and superior mesenteric arteries. (From Upchurch GR Jr, Henke PK, Eagleton MJ, et al: Pediatric splanchnic arterial occlusive disease: Clinical relevance and operative treatment, J Vasc Surg 35:860–867, 2002.)

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FIGURE 2 Lateral aortogram documenting developmental ostial stenoses of the celiac and superior mesenteric arteries in a child with a midabdominal coarctation.


Etiology of Splanchnic Arterial Occlusive Lesions


The cause of the vast majority of pediatric splanchnic arterial narrowings appears related to certain poorly understood embryonic events that may be genetically predetermined, such as with neurofibromatosis-1. Other stenoses might result from a viral insult to the evolving vasculature, such as accompany gestational rubella infections. Alterations in the transition of fetal mesenchymal cells to vascular smooth muscle and a hindrance in its later growth are the basis for most developmental splanchnic arterial narrowings. A less common cause of pediatric arterial narrowings is an inflammatory aortoarteritis such as Takayasu’s syndrome. Aortoarteritis is seen most often in children from Asia and South America.


The events contributing to this disease occur around the 25th day of fetal development, when fusion of the two dorsal aortas into a single aortic channel occurs. At this same time, disappearance of multiple metanephric vessels results in single renal arteries in most fetuses, and reorganization of the ventral segmental vessels associated with the vitelline arteries result in formation of the celiac and superior mesenteric arteries. It is likely that a single contributing pathological process causes most of the stenoses affecting these arteries, given the high likelihood of concomitant narrowings affecting the aorta and renal arteries in addition to the splanchnic artery stenoses.



Operative Therapy


The operative treatment of pediatric splanchnic arterial occlusive disease has been infrequently addressed in the literature. Clearly, a mandate to reconstruct these vessels applies only to symptomatic cases. Nevertheless, a relative indication to reconstruct the celiac and superior mesenteric arteries exists when the proximity of the origins of these vessels to an aortic or renal artery reconstruction could place these arteries at risk for occlusion. When isolated vascular reconstructions are distant from those vessels, such as with thoracoabdominal bypass, a concomitant splanchnic revascularization in an asymptomatic child is not justified.


The operative approach that we prefer is through a transverse supraumbilical abdominal incision with a left-sided medial visceral rotation and retroperitoneal exposure of the aorta from its diaphragmatic hiatus to its bifurcation. This incision is favored when performing a patch aortoplasty and splanchnic or renal reconstruction limited to the abdomen (Figure 3). A thoracoabdominal incision may be preferred in patients requiring an aortoaortic bypass originating from the supraceliac aorta (Figure 4). Care must be taken on retracting the left colon during these procedures, so as not to compromise blood flow through existing mesocolic collaterals originating from the inferior mesenteric artery. These collaterals provide critical blood flow to foregut and midgut structures. The specific type of splanchnic arterial reconstruction is dictated by the anatomic character of the disease affecting these vessels and the need for concomitant reconstructions of the aorta and renal arteries.


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FIGURE 3 Complex splanchnic artery, aortic, and renal artery reconstruction. 1, Celiac artery stenosis; 2, superior mesenteric artery stenosis; 3, interrenal midabdominal aortic coarctation; 4 and 5, right and left renal artery stenoses; 6, celiac artery implanted onto stenotic superior mesenteric artery origin; 7, widely patent superior mesenteric artery; 8, patch angioplasty; 9 and 10, bilateral implantation of renal arteries onto aorta. (From Upchurch GR Jr, Henke PK, Eagleton MJ, et al: Pediatric splanchnic arterial occlusive disease: Clinical relevance and operative treatment, J Vasc Surg 35:860–867, 2002.)

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Aug 25, 2016 | Posted by in CARDIOLOGY | Comments Off on Operative Treatment of Pediatric Splanchnic Arterial Occlusive Disease

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