Routine postprocedure ultrasound increases rate of detection of femoral arterial thrombosis in infants after cardiac catheterization

Progressive Protocols for Pediatric Acute Lower Extremity Ischemia Post-Catheterization Pediatric ALI Protocol Post-Catheterization

OBJECTIVES

Pediatric Acute Lower extremity Ischemia post-catheterization (PALIC) represents a significant clinical challenge. Effective management protocols that minimize aggressive interventions and complications are essential for improving patient outcomes. This investigation assesses the effectiveness of the FAST protocol (Fasudil infusion combined with Anticoagulation based on oxygen Saturation monitoring backup with Thrombolytic) series in treating pediatric acute lower extremity ischemia after catheterization (PALIC), with a particular emphasis on minimizing aggressive interventions and complications.

METHODS

A retrospective study of 1,380 pediatric catheterization cases from January 2009 to December 2022, was conducted. The research encompassed three stages: before FAST implementation (Stage 1), during initial FAST adoption (Stage 2), and subsequent FAST+ upgrade (Stage 3).

RESULTS

Acute lower extremity ischemia (ALI) was observed in 7.1% (98/1380) of pediatric cases post-catheterization. The PALIC detection rates in Stages 2 and 3 were 4.2% and 12.1%, respectively, showing a statistically significant reduction in aggressive interventions from 100% to 0% and complications from 100% to 1.2% in later stages (p<0.05).

CONCLUSIONS

The safety and effectiveness of both the FAST and FAST+ protocols in managing PALIC have been demonstrated. The enhanced FAST+ protocol notably improves early detection, thereby augmenting the effectiveness of treatment.

Risk factors and frequency of acute and permanent femoral arterial occlusion in neonates with CHD who undergo ultrasound-guided femoral arterial access

OBJECTIVE

We investigated frequency and risk factors of acute loss of the arterial pulse and permanent femoral arterial occlusion in neonates with CHD who underwent ultrasound-guided femoral arterial access.

METHODS

We divided the patients into groups according to the presence of acute loss of the arterial pulse and permanent femoral arterial occlusion. We obtained data related to patient characteristics and access variables of ultrasound-guided femoral arterial access from our database of cardiac catheterisation between August, 2017 and May, 2021. We used an echocardiography-S6, 12-MHz linear probe, 21-gauge needle, 0.018"guidewire, and a 4F sheath for arterial access.

RESULTS

Ultrasound-guided femoral arterial access was obtained in 323 (98.8%) of the 327 neonates. We identified acute loss of the arterial pulse in 130 (40.2%) patients and permanent femoral arterial occlusion in 19 (5.9%) patients. Median weight was 3.05 (Interquartile range (IQR): 2.80-3.40) kg, first attempt success rate was 88.2%, and median access time was 46 sec (IQR: 23-94). Logistic regression analysis identified coarctation of the aorta (odds ratio: 2.46; 95% CI: 1.30-4.66; p = 0.006) as independent risk factor for acute loss of the arterial pulse, but did not identify any independent risk factors for permanent femoral arterial occlusion.

CONCLUSIONS

This study showed coarctation of the aorta as an independent risk factor for acute loss of the arterial pulse, but did not identify any independent factors for permanent femoral arterial occlusion in neonates with CHD. Although most cases of acute loss of the arterial pulse resolve in the early period, the frequency of permanent femoral arterial occlusion remains high despite effective treatment.

Retrospective Study of the Application Value Analysis of Ultrasound-Guided Technology in Peripheral Deep Venous Catheterization of Neonates

Objective

To investigate the application value analysis of ultrasound-guided technology in peripheral deep venous catheterization of neonates.

Method

A total of 94 neonates who underwent peripheral deep venous catheterization treatment from March 2020 to August 2021 in our hospital were selected and divided into the study group and the control group according to the simple randomized method, and each group had 47 cases. The control group was performed peripheral deep venous catheterization through X-ray examination, while the study group was performed peripheral deep venous catheterization through ultrasound-guided technology. The catheter placement, catheter retention time and adjustment times, the incidence of complications (limb swelling, pain, fluid leakage, and phlebitis), and the intervention satisfaction of family members were counted.

Results

The success rate of one-time catheterization in the study group was higher than that in the control group, the operation time was shorter than that in the control group, and the amount of bleeding was less than that in the control group. The indwelling time of catheter in the study group was longer than that in the control group, and the number of adjustments was less than that in the control group. The incidence of complications in the study group was lower than that in the control group. The intervention satisfaction of family members in the study group was higher than that in the control group.

Conclusion

Peripheral deep venous catheterization in neonates through ultrasound-guided technology can reduce operation time and blood loss and ensure the success rate of one-time catheterization, resulting in a long indwelling time of catheter, low number of adjustments, and low incidence of complications, which has safety and high intervention satisfaction of family members.

Infrared thermography as an adjunctive tool for detection of femoral arterial thrombosis after cardiac catheterization: A prospective, pilot study

OBJECTIVES

To assess the utility of infrared thermography (IRT), to map skin temperature, in the detection of femoral arterial (FA) thrombosis after cardiac catheterization.

BACKGROUND

Ultrasound is a validated method for thrombus detection but is generally reserved as a confirmatory test for clinical suspicion due to various constraints.

METHODS

Prospective study of infants and children undergoing cardiac catheterization via FA access, comparing IRT and pulse examination. The thermograms, displayed in a color map with each pixel representing a temperature, were examined by qualitative assessment of symmetry in thermal patterns and quantitative image analysis with abnormal thermographic asymmetry defined as a difference of >10% between limbs.

RESULTS

In the 20 children enrolled, excellent agreement was found between the two methods with a Kappa value of 0.89. The median thermographic asymmetry in the nine children with pulse loss was 36 (13-76)%. Using receiver operating characteristic analysis, the asymmetrical pattern of ≥18% between limbs predicted the need for anticoagulation with a sensitivity of 100% and specificity of 89%. The area under the curve was 0.97 (95% confidence interval: 0.95-1). Children with absent pulse requiring anticoagulation showed a slower recovery in thermal asymmetry compared to those with a reduced pulse. By qualitative IRT assessment, all children with absent pulse requiring anticoagulation were correctly identified by 10 independent assessors.

CONCLUSIONS

This pilot study showed that IRT is feasible and reliable as an adjunctive tool for thrombus detection postcatheterization and treatment monitoring. Specific advantages of IRT include portability, affordability, and contactless image acquisition.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Patient Characteristics and Treatment Outcomes of Symptomatic Catheter-Related Arterial Thrombosis in Infants: A Retrospective Cohort Study

OBJECTIVE

To describe the clinical characteristics, outcomes, and adverse events of treatment for symptomatic infant catheter-related arterial thrombosis.

STUDY DESIGN

Single-center retrospective medical record review of 99 infants (age <365 days) with catheter-related arterial thrombosis, either following indwelling arterial catheter placement or cardiac catheterization, who were treated with anticoagulation over an 8-year span at a pediatric tertiary care center. Outcomes measured include thrombosis progression, bleeding events, and thrombus resolution following the treatment period.

RESULTS

Thromboses were secondary to indwelling arterial catheter placement in 51 (51.5%) and cardiac catheterization in 48 (48.5%). The median age at diagnosis of catheter-related arterial thrombosis was 52 days. All patients received therapeutic anticoagulation with either unfractionated heparin or low molecular weight heparin for a maximum of 28 days. Progression of catheter-related arterial thrombosis occurred in 8 (8.1%) patients. One (1%) major and 3 (3%) minor bleeding events occurred within the cohort. Complete thrombus resolution was observed in 60 (60.6%), partial resolution in 33 (33.3%), and no resolution in 6 (6.1%) following the treatment period. Factors associated with complete thrombus resolution included time from intervention to catheter-related arterial thrombosis diagnosis (median of 1 day vs 5 days in those who experienced thrombus resolution vs those who did not, P = .035), and iliac and/or femoral artery involvement (P = .015).

CONCLUSIONS

Our treatment approach to infant catheter-related arterial thrombosis is safe and effective. Limitations of the study are its retrospective nature with a limited number of patients from a single institution. Additional prospective studies are needed to determine the optimal treatment approach to catheter-related arterial thrombosis in infants.

Femoral Artery Thrombosis After Pediatric Cardiac Catheterization

Femoral artery thrombosis (FAT) is an adverse event post-catheterization. We decided to study the incidence and risk factors of FAT before and after initiation of a pulse loss monitoring program. All cardiac catheterization cases performed using femoral arterial vascular access were retrospectively reviewed. The study period was divided into two eras: before (era 1), and after the initiation of the protocol (era 2). The primary outcome was FAT requiring therapy. Univariable and multivariable logistic regression models were used to identify factors associated with FAT. Receiver operating characteristic curve were generated to predict FAT. Our cohort consisted of 2,388 cases including 467 (19.6%) infants weighing < 10 kg. The overall incidence of FAT was 1.7% (n = 41). The incidence of FAT was 3.5 times higher in era 2 (p < 0.001). Multivariable model showed that era, weight, sheath exchange, and coarctation intervention were significantly associated with FAT. Infants younger than 7.7 months and less than 6.7 kg were found to be at highest risk for FAT. Our study shows that the incidence of FAT may be underestimated without a monitoring program. Small infants and coarctation interventions requiring larger sheaths or sheath exchanges are at highest risk for FAT.

Thrombosis in infants in the neonatal intensive care unit: Analysis of a large national database

BACKGROUND

Thrombosis in the neonatal population is rare, but increasing. Its incidence and management are not well understood.

OBJECTIVES

To investigate the incidence, associated factors, and management of thrombosis in the neonatal intensive care unit (NICU) population.

PATIENTS/METHODS

We performed a retrospective cohort study of infants admitted to a Pediatrix Medical Group-affiliated NICU from 1997 through 2015. We determined the prevalence of venous and arterial thrombosis, and assessed demographic characteristics and known risk factors. Categorical variables were compared with the Pearson χ2 test and continuous variables with Wilcoxon rank-sum tests. Stepwise logistic regression was used to identify associated factors. The primary outcome was incidence of thrombosis. Secondary analyses investigated correlations between clinical and demographic characteristics and thrombosis.

RESULTS

Among 1 158 755 infants, we identified 2367 (0.20%) diagnosed with thrombosis. In a multivariable regression analysis, prematurity, male sex, congenital heart disease, sepsis, ventilator support, vasopressor receipt, central venous catheter, invasive procedures, and receipt of erythropoietin were associated with increased risk of thrombosis, while Black race and Hispanic ethnicity were associated with reduced risk. The majority of infants diagnosed with thrombosis (73%) received no anticoagulation, but anticoagulant use in infants with thrombosis was higher than those without (27% versus 0.2%, P < .001). Thrombosis in infants was associated with higher mortality (11% versus 2%, P < .001) and longer hospital stays (57 days, [interquartile range (IQR) 28--100] versus 10 days, [IQR 6--22], P < .001).

CONCLUSIONS

In the largest national study to date, we found that thrombosis in NICU patients is associated with prematurity, low birth weight, sepsis, and invasive procedures.

Congenital right internal mammary artery to portal vein arteriovenous malformation

Neonatal cases of systemic artery to portal venous system arteriovenous malformations (AVMs) can present unique challenges in terms of diagnosis, management, and treatment. Prompt identification of these AVMs is necessary for minimizing long-term sequelae and optimizing prognosis. Our report describes the diagnosis and successful endovascular coil embolization of a congenital right internal mammary artery (IMA) to portal vein AVM in a young infant initially presenting during routine fetal screening with an incidentally discovered congenital thoracic vascular abnormality.

Transradial approach for pediatric interventions: A review and analysis of the literature

BACKGROUND

Transradial access for interventions has been well studied in the adult population, but there is a paucity of literature of its use in the pediatric population.

METHODS

We conducted a systematic literature review and gathered and synthesized all of the available data into a cohesive resource for review and analysis of the topic.

RESULTS

Pooled analysis of the available data shows that transradial access in pediatric patients has a success rate of 91%, a vasospasm rate of 11.4%, and loss of pulse rate of 3.0% for a total complication rate of 14%. No permanent complications, or complications requiring surgery, were observed in any study. After stratifying for indication of intervention, neurological indications were associated with a lower complication rate compared to cardiac indications (0.1 vs 0.43, respectively, p = 0.004). In addition, studies published after 2013 were associated with a lower complication rate compared to those published during or before 2013 (0.11 vs 0.33, respectively, p = 0.01).

CONCLUSION

Compared to prior studies on pediatric transfemoral access, transradial access has a higher complication rate. But there may be a lower rate of complications that require surgical intervention. Further studies are needed to clarify any advantages that transradial access may have over transfemoral access for pediatric patients.

The Developing Balance of Thrombosis and Hemorrhage in Pediatric Surgery: Clinical Implications of Age-Related Changes in Hemostasis

Bleeding and thrombosis in critically ill infants and children is a vexing clinical problem. Despite the relatively low incidence of bleeding and thrombosis in the overall pediatric population relative to adults, these critically ill children face unique challenges to hemostasis due to extreme physiologic derangements, exposure of blood to foreign surfaces and membranes, and major vascular endothelial injury or disruption. Caring for pediatric patients on extracorporeal support, recovering from solid organ transplant or invasive surgery, and after major trauma is often complicated by major bleeding or clotting events. As our ability to care for the youngest and sickest of these children increases, the gaps in our understanding of the clinical implications of developmental hemostasis have become increasingly important. We review the current understanding of the development and function of the hemostatic system, including the complex and overlapping interactions of coagulation proteins, platelets, fibrinolysis, and immune mediators from the neonatal period through early childhood and to young adulthood. We then examine scenarios in which our ability to effectively measure and treat coagulation derangements in pediatric patients is limited. In these clinical situations, adult therapies are often extrapolated for use in children without taking age-related differences in pediatric hemostasis into account, leaving clinicians confused and impacting patient outcomes. We discuss the limitations of current coagulation testing in pediatric patients before turning to emerging ideas in the measurement and management of pediatric bleeding and thrombosis. Finally, we highlight opportunities for future research which take into account this developing balance of bleeding and thrombosis in our youngest patients.

Use of Near-Infrared Spectroscopy to Monitor Lower Extremity Perfusion in Pediatric Patients Undergoing Cardiac Catheterization

Acute femoral artery occlusion is common in pediatric patients following cardiac catheterization. A variety of means are utilized to assess lower extremity (LE) perfusion and arterial patency following cardiac catheterization including palpation of pulses, pulse oximetry, subjective assessment of lower extremity color and temperature, and ultrasound. We sought to evaluate the utility of Near-Infrared Spectroscopy (NIRS) to monitor LE perfusion in pediatric patients undergoing cardiac catheterization. INVOS pediatric sensors were placed on bilateral LE in all pediatric patients ≤ 40 kg undergoing cardiac catheterization. Data were recorded continuously from the start of the procedure until 4-6 h after completion of the procedure. NIRS readings were compared between the accessed versus non-accessed LE at baseline before start of case, time of vascular access, arterial sheath exchange when applicable, sheath withdrawal, and Safeguard application, deflation, and removal. 133 patients underwent 152 catheterizations with mean age 2.4 ± 2.3 years and mean weight 12.4 ± 13.2 kg. NIRS oximetry readings were significantly decreased in the LE with arterial access compared to non-accessed LE from time of sheath insertion until removal of the pressure assist device post procedure. A greater difference was noted in smaller patients. NIRS oximetry readings did not correlate with subjective assessment of lower extremity perfusion after arterial sheaths were removed. One patient had pulse loss 4 h post procedure with a decrease in oximetry readings noted at this point on review. Weight-based heparin protocol was initiated, and a gradual improvement in oximetry readings was noted over the next 5 h. Vascular ultrasound 12 h later showed no evidence of arterial thrombus. NIRS may be helpful in identifying patients who are risk for developing arterial thrombus post cardiac catheterization and for monitoring response to therapy; however, further study in these patients is warranted.