Arterial vascular injuries of the upper arm in children: saphenous vein graft or endovascular treatment? To the Editor, We read with great interest the article recently published in your journal by Chang et al [1]. The authors present the second published case of a pediatric peripheral vascular injury treated by endovascular stenting. As proposed by Angiletta et al [2], the endovascular approach is a minimally invasive procedure that is quick and easy to perform in emergency situations. However, subsequent body growth could represent the Achilles' heel of similar techniques in the pediatric age group [2]. Chang et al report the case of a 14-year-old adolescent boy, hemodynamically stable, with a stab wound of the axillary artery diagnosed by computed tomography (CT) angiography. It was successfully treated by inserting an endovascular stent. The authors stressed the importance of the CT angiogram and the stenting procedure, especially in stable patients with a minor trauma, and evoked a widespread diffusion of this adult-like approach. In our Division of Pediatric Surgery, we recently treated a similar case, in which we decided to repair the vascular injury with an autogenous reversed saphenous vein graft. Herein, we briefly present this case, discussing it in light of Dr Chang's suggestions. A 14-year-old adolescent boy arrived in the emergency department with a wound of the medial surface of the left upper arm. He accidentally fell from a bicycle. His medical history was unremarkable. He felt coldness in the left hand, without other symptoms. The physical examination showed a reduction of all distal pulses of the hand. An initial Doppler ultrasonography (US) did not demonstrate altera- tions of the flow from the axillary artery to the radial artery. However, after 2 hours, the patient's course worsened, with complete absence of the radial pulse noted. A second Doppler US showed the distal absence of arterial flow, with a hematoma at the wound level. Suspecting a humeral artery injury, the patient was taken to the operating room. Under general anesthesia, surgical exploration identified a humeral artery laceration. We decided to remove the injured segment of the artery and replaced it with a reversed segment of saphenous vein (Fig. 1). The Doppler US showed satisfactory flow up to the radial artery. He was given prophylactic broad-spectrum antibiotics, and sodium enox- aparin 4000 IU/d was started. The patient was discharged on the fifth postoperative day with enoxaparin for 1 month; and then, acetylsalicylic acid 100 mg/d was prescribed. The 1- month follow-up showed a warm hand with only mild edema. After 6 months, the arterial flow appeared normal on Doppler US. As expressed in the literature, there are some peculiarities when comparing children and adults: the different vessel size, the increased arterial spasm, and the presence of a growing body [3]. In contrast to the practice proposed by Chang et al, we preferred not to use the CT angiogram. In fact, in the presence of an open wound, clinical examination and use of a Doppler US permitted a clear diagnosis, avoiding unnecessary radiation and contrast injection. The Doppler US was also the imaging method of choice for follow-up. Regarding endovascular stenting, in our case, it appeared at least inappropriate for a humeral artery injury. However, it could be effective in proximal arterial lesions, as suggested by the authors, to avoid a thoracotomy or other invasive procedures. Furthermore, the presence of a vascular surgeon, especially in a district hospital setting, may be quite useful because of the limited experience some pediatric surgeons may have in similar rare cases [4]. In major hospitals with a pediatric trauma center, the use of endovascular stenting could become an interesting approach in highly selected cases. Aurelio Mazzei Antonella Centonze Giuseppe Stranieri Division of Pediatric Surgery “Pugliese-Ciaccio” Hospital Catanzaro, Italy Girolamo Placida Division of Vascular Surgery “Pugliese-Ciaccio” Hospital Catanzaro, Italy Andrea Siani Emanuele Baldassarre Division of Urology “Umberto Parini” Hospital 11100 Aosta, Italy E-mail address: emanuele.baldassarre@alice.it doi:10.1016/j.jpedsurg.2009.12.031 Fig. 1 The reversed saphenous vein graft in place. 850 Correspondence