Percutaneous hydrodynamic thrombectomy for femoral arterial thrombosis after arterial catheterization

Post-catheterisation arterial thrombosis in children--pathophysiology, prevention, and treatment

Lower limb ischaemia is the most frequent complication of cardiac catheterisation in children. It is often overlooked, but it can cause significant disability and may limit arterial access sites to repeat diagnostic or interventional catheterisations. A narrative review of the literature on arterial access site thrombosis in children was carried out with a special focus on current evidence that supports preventive and treatment strategies. Anticoagulation, thrombolysis, and thrombectomy have been used successfully to treat arterial access site thrombosis. However, it is not completely established which is the role of each treatment modality and what is the most appropriate timing to deliver it. Therefore, diagnostic and therapeutic strategies have to be prospectively investigated, particularly for clarifying the role of new pharmacologic interventions and of percutaneous and surgical thrombectomy in the current era.

Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children.

METHODS

The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

RESULTS

We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C).

CONCLUSIONS

The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.

Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

This chapter about antithrombotic therapy in neonates and children is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see Guyatt et al in this supplement, pages 123S-131S). In this chapter, many recommendations are based on extrapolation of adult data, and the reader is referred to the appropriate chapters relating to guidelines for adult populations. Within this chapter, the majority of recommendations are separate for neonates and children, reflecting the significant differences in epidemiology of thrombosis and safety and efficacy of therapy in these two populations. Among the key recommendations in this chapter are the following: In children with first episode of venous thromboembolism (VTE), we recommend anticoagulant therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1B]. Dosing of IV UFH should prolong the activated partial thromboplastin time (aPTT) to a range that corresponds to an anti-factor Xa assay (anti-FXa) level of 0.35 to 0.7 U/mL, whereas LMWH should achieve an anti-FXa level of 0.5 to 1.0 U/mL 4 h after an injection for twice-daily dosing. In neonates with first VTE, we suggest either anticoagulation or supportive care with radiologic monitoring and subsequent anticoagulation if extension of the thrombosis occurs during supportive care (Grade 2C). We recommend against the use of routine systemic thromboprophylaxis for children with central venous lines (Grade 1B). For children with cerebral sinovenous thrombosis (CSVT) without significant intracranial hemorrhage (ICH), we recommend anticoagulation initially with UFH, or LMWH and subsequently with LMWH or vitamin K antagonists (VKAs) for a minimum of 3 months (Grade 1B). For children with non-sickle-cell disease-related acute arterial ischemic stroke (AIS), we recommend UFH or LMWH or aspirin (1 to 5 mg/kg/d) as initial therapy until dissection and embolic causes have been excluded (Grade 1B). For neonates with a first AIS, in the absence of a documented ongoing cardioembolic source, we recommend against anticoagulation or aspirin therapy (Grade 1B).

Iliofemoral Deep Vein Thrombosis in Childhood; Developing a Management Protocol

OBJECTIVE

To develop an evidence-based protocol for the management of iliofemoral deep vein thrombosis (IDVT) in childhood.

METHODS

A search of the literature was undertaken. All publications pertaining to IDVT in childhood were analysed and then categorised according to their level of evidence. Recommendations were then made on the basis of this.

RESULTS

The commonest presenting symptoms were pain and swelling in the affected limb (evidence level II). Predisposing risk factors of special significance in children included the recent use of a venous access device, malignancy, prothrombotic disorders, infection, surgery and congenital venous anomalies (evidence level II). The most frequently described imaging modalities were B-mode ultrasonography, duplex, venography, and helical CT (evidence level III). The mainstay of treatment was anticoagulation with LMWH alone or followed by warfarin (evidence level I). Early clot removal through catheter-directed thrombolysis or surgical thrombectomy has been shown to be beneficial (evidence level II/III). There is little evidence for the benefit of early mobilisation and compression therapy in childhood.

CONCLUSION

Level I evidence relating to IDVT in childhood is sparse. The possibility of IDVT should be considered when examining a child with a swollen and painful limb. Imaging should be with duplex ultrasound, followed by spiral CT to include assessment of the IVC. A thrombophilia screen should be taken prior to anticoagulation with LMWH (and warfarin). Thrombolysis should be considered in cases of extensive IDVT.

Percutaneous hydrodynamic thrombectomy for congenital deep vein thrombosis in a neonate

A 1-day-old boy with a complete occlusive inferior vena cava and bilateral renal vein thrombus removed successfully using a hydrodynamic thrombectomy catheter is reported. Although blood flow to the inferior vena cava and bilateral renal veins was restored with no distal embolism or vascular injury, he died of bleeding complications due to fibrinolytic therapy after hydrodynamic thrombectomy. To the best of our knowledge, this is the first report of hydrodynamic thrombectomy of a neonate.

Percutaneous treatment of pediatric thrombosis

While rare, thrombosis in the pediatric population can result serious sequelae including death. The best treatment options have not yet been firmly established for this age group. During childhood, there are age-related changes in components of the coagulation system that can affect treatment choices. This review article gives an overview of pediatric coagulation and describes the current state of percutaneous treatment options including local thrombolysis and thrombectomy.