Microvascular surgery in the congenital cardiac patient: A case series exploring feasibility and practical applications

Abstract

Background: Pediatric congenital heart disease patients are at risk for vascular injuries during surgical procedures or when the arterial system is accessed for monitoring or diagnostic studies. Our treatment of emergent situations in this patient population using microvascular techniques shows the feasibility of such techniques.

Methods: A retrospective chart review of patients aged 0-18 years with congenital heart disease identified six patients who underwent microvascular surgery by the senior surgeon from June 2007 to May 2015. We studied this series, highlighting technical aspects of surgery and perioperative care to determine their effect on outcome.

Results: Six patients with congenital cardiac defects requiring cardiothoracic surgery were studied, body weight ranging from 3.2 to 19.1 kg at the time of surgery. Five suffered iatrogenic arterial injury to the heart or vessels used for access or diagnostic studies, including coronary artery laceration, brachial artery thrombosis, and external iliac artery avulsion. Interventions included direct end-to-end repair and vein grafting. Vessel diameter averaged 1 mm. Patients received vasopressors intraoperatively and were on vasopressors and antihypertensives postoperatively. One patient died because of disseminated intravascular coagulation on postoperative day 17, but bypass graft was patent prior to death. The rest survived with clinical evidence of patency of the repaired vessel for a long-term.

Conclusions: Microsurgical intervention may be life-saving as a revascularization procedure to the heart by direct coronary repair or bypass grafting. Iatrogenic injuries to the limb may cause critical ischemia; limbs can be salvaged by microsurgical repair. Despite technical and physiological challenges, microsurgery is feasible and sometimes crucial in this patient population.

Keywords: Congenital cardiac defects; Iatrogenic injury in infants; Microsurgery in neonates; Safety issues in surgery for neonates.