Endovascular Treatment of Arterial Occlusive Disease in a Pediatric Patient

Purpose: Lower extremity arterial occlusive disease is rare in the pediatric population. This is the case of a 9-year-old woman with acute left lower extremity ischemia who underwent successful endovascular revascularization using a standard endovascular treatment algorithm.

Materials and Methods: A 9-year-old woman presented with acute onset left foot pain and numbness. Here only medical history was remote use of lower extremity braces for genu valgum at age 2 years. Examination shows absent left popliteal/pedal pulses with preserved motor function, consistent with class IIa acute limb ischemia. Computed tomography angiography demonstrated thrombus in the proximal popliteal artery. Heparin infusion was initiated with plans for urgent operative intervention.

Results: Lower extremity angiogram demonstrated a focal subtotal occlusion of the P1 popliteal artery with well-developed geniculate collaterals and three-vessel run-off. Percutaneous mechanical thrombectomy with a Penumbra Indigo CAT6 catheter was first attempted, but significant resistance was encountered. Intravascular ultrasound showed a stenotic lesion, indicating an acute-on-chronic process. Therefore, we decided to remove the underlying stenosis with directional atherectomy. After placing a distal embolic filter, multiple passes with a HawkOne M catheter were successful in removing the lesion, leaving minimal residual stenosis. The excised tissue had the appearance of intimal hyperplasia and was sent to pathology for analysis. Because of the patient’s young age, small vessel size, and high risk for restenosis, drug-coated balloon angioplasty with IN.PACT Admiral 4 ´ 80 mm was performed. Completion angiogram showed less than 10% residual stenosis, no dissection, and no distal embolization. Postoperatively, the patient had resolution of symptoms with palpable left DP/PT pulses. She was maintained on daily aspirin and anticoagulation for 3 months.

Conclusions: Although the patient presented with acute symptoms, intraoperative findings pointed toward a chronic process. The etiology of the lesion is suspected to be intimal hyperplasia secondary to repetitive microtrauma from a tightly placed leg brace as a 2-year-old child. Endovascular treatment was successful using a similar algorithm to approach atherosclerotic stenosis in adults. To our knowledge, this is the first reported use of directional atherectomy and antirestenotic therapy in the pediatric population. Surgical revascularization remains an option in the future.