Advertisement

Natural history of acute pediatric iliofemoral artery thrombosis treated with anticoagulation

Published:April 07, 2020DOI:https://doi.org/10.1016/j.jvs.2020.02.042

      Abstract

      Objective

      Acute iliofemoral artery thrombosis (IFAT) can occur in critically ill neonates and infants who require indwelling arterial cannulas for monitoring or as a consequence of cardiac catheterization. Guidelines suggest treatment with anticoagulation, but evidence supporting the optimal duration of therapy and the role of surveillance ultrasound is limited. The objectives of this study were to characterize the kinetics of thrombus resolution and to define an appropriate duration of anticoagulation and interval for surveillance ultrasound.

      Methods

      This was a single-center retrospective cohort study of pediatric patients with acute IFAT from 2011 to 2019. Medical records and vascular laboratory studies were reviewed. Patients with one or more surveillance ultrasound examinations were included. Thrombus resolution was defined as multiphasic flow throughout the index limb without evidence of echogenic intraluminal material by ultrasound. Time to resolution of thrombus was assessed using Kaplan-Meier analysis.

      Results

      Fifty-four limbs in 50 patients were identified with acute IFAT. The median age was 9.9 weeks (interquartile range, 3.1-21.7 weeks), with a median weight of 4.2 kg (interquartile range, 3.3-5.5 kg). The majority of limbs (65%) with acute IFAT presented with a diminished pedal Doppler signal, commonly after cardiac catheterization (55%). Forty-eight (89%) limbs had complete arterial occlusion on index ultrasound, and flow could not be detected below the ankle in 48%. The median number of ultrasound examinations per limb was three (range, two to seven), and 61% of limbs had a surveillance ultrasound within 7 days of diagnosis. At 14 and 30 days, 33% and 64% of patients, respectively, treated with anticoagulation had an estimated complete resolution of thrombus. Nine (17%) patients did not receive anticoagulation, and only two of these patients experienced IFAT resolution. At the time of diagnosis, one patient underwent open thrombectomy because of a contraindication to anticoagulation, and one patient was treated with thrombolysis. There were no instances of tissue loss or amputation

      Conclusions

      Management of IFAT with anticoagulation resulted in successful short-term outcomes. Based on the observed rate of resolution, management should start with anticoagulation, followed by surveillance ultrasound at 2-week intervals. With treatment by anticoagulation, resolution can be expected to occur in one-third of patients every 2 weeks.

      Graphical abstract

      Keywords

      To read this article in full you will need to make a payment
      SVS Member Login
      Society Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Veldman A.
        • Nold M.F.
        • Michel-Behnke I.
        Thrombosis in the critically ill neonate: incidence, diagnosis, and management.
        Vasc Health Risk Manag. 2008; 4: 1337-1348
        • Girod D.A.
        • Hurwitz R.A.
        • Caldwell R.L.
        Heparinization for prevention of thrombosis following pediatric percutaneous arterial catheterization.
        Pediatr Cardiol. 1982; 3: 175-180
        • Knirsch W.
        • Kellenberger C.
        • Dittrich S.
        • Ewert P.
        • Lewin M.
        • Motz R.
        • et al.
        Femoral arterial thrombosis after cardiac catheterization in infancy: impact of Doppler ultrasound for diagnosis.
        Pediatr Cardiol. 2013; 34: 530-535
        • Mortensson W.
        • Hallbook T.
        • Lundstrom N.R.
        Percutaneous catheterization of the femoral vessels in children. II. Thrombotic occlusion of the catheterized artery: frequency and causes.
        Pediatr Radiol. 1975; 4: 1-9
        • Sarkar S.
        • Rosenkrantz T.S.
        Neonatal polycythemia and hyperviscosity.
        Semin Fetal Neonatal Med. 2008; 13: 248-255
        • Franken Jr., E.A.
        • Girod D.
        • Sequeira F.W.
        • Smith W.L.
        • Hurwitz R.
        • Smith J.A.
        Femoral artery spasm in children: catheter size is the principal cause.
        AJR Am J Roentgenol. 1982; 138: 295-298
        • Andraska E.A.
        • Jackson T.
        • Chen H.
        • Gallagher K.A.
        • Eliason J.L.
        • Coleman D.M.
        Natural history of iatrogenic pediatric femoral artery injury.
        Ann Vasc Surg. 2017; 42: 205-213
        • Taylor Jr., L.M.
        • Troutman R.
        • Feliciano P.
        • Menashe V.
        • Sunderland C.
        • Porter J.M.
        Late complications after femoral artery catheterization in children less than five years of age.
        J Vasc Surg. 1990; 11 (discussion: 304-6): 297-304
        • Monagle P.
        • Chan A.K.
        • Goldenberg N.A.
        • Ichord R.N.
        • Journeycake J.M.
        • Nowak-Gottl U.
        • et al.
        Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
        Chest. 2012; 141: e737S-e801S
        • Monagle P.
        • Ignjatovic V.
        • Savoia H.
        Hemostasis in neonates and children: pitfalls and dilemmas.
        Blood Rev. 2010; 24: 63-68
        • Peuster M.
        • Bertram H.
        • Fink C.
        • Paul T.
        • Hausdorf G.
        Percutaneous transluminal angioplasty for the treatment of complete arterial occlusion after retrograde cardiac catheterization in infancy.
        Am J Cardiol. 1999; 84: 1124-1126, A11
        • Sadat U.
        • Hayes P.D.
        • Varty K.
        Acute limb ischemia in pediatric population secondary to peripheral vascular cannulation: literature review and recommendations.
        Vasc Endovascular Surg. 2015; 49: 142-147
        • Friedman J.
        • Fabre J.
        • Netscher D.
        • Jaksic T.
        Treatment of acute neonatal vascular injuries—the utility of multiple interventions.
        J Pediatr Surg. 1999; 34: 940-945
        • Kim J.
        • Sun Z.
        • Benrashid E.
        • Southerland K.W.
        • Lawson J.H.
        • Fleming G.A.
        • et al.
        The impact of femoral arterial thrombosis in paediatric cardiac catheterisation: a national study.
        Cardiol Young. 2017; 27: 912-917
        • Brotschi B.
        • Hug M.I.
        • Kretschmar O.
        • Rizzi M.
        • Albisetti M.
        Incidence and predictors of cardiac catheterisation-related arterial thrombosis in children.
        Heart. 2015; 101: 948-953
        • Brotschi B.
        • Hug M.I.
        • Latal B.
        • Neuhaus D.
        • Buerki C.
        • Kroiss S.
        • et al.
        Incidence and predictors of indwelling arterial catheter-related thrombosis in children.
        J Thromb Haemost. 2011; 9: 1157-1162
        • Kayssi A.
        • Shaikh F.
        • Roche-Nagle G.
        • Brandao L.R.
        • Williams S.A.
        • Rubin B.B.
        Management of acute limb ischemia in the pediatric population.
        J Vasc Surg. 2014; 60: 106-110
        • Dumond A.A.
        • da Cruz E.
        • Almodovar M.C.
        • Friesen R.H.
        Femoral artery catheterization in neonates and infants.
        Pediatr Crit Care Med. 2012; 13: 39-41
        • Kulkarni S.
        • Naidu R.
        Vascular ultrasound imaging to study immediate postcatheterization vascular complications in children.
        Catheter Cardiovasc Interv. 2006; 68: 450-455
        • Ding L.
        • Pockett C.
        • Moore J.
        • El-Said H.
        Long sheath use in femoral artery catheterizations in infants <15 kg is associated with a higher thrombosis rate: proposed protocol for detection and management.
        Catheter Cardiovasc Interv. 2016; 88: 1108-1112
        • Lim S.
        • Javorski M.J.
        • Halandras P.M.
        • Kuo P.C.
        • Aulivola B.
        • Crisostomo P.
        Epidemiology, treatment, and outcomes of acute limb ischemia in the pediatric population.
        J Vasc Surg. 2018; 68: 182-188
        • Lazarides M.K.
        • Georgiadis G.S.
        • Papas T.T.
        • Gardikis S.
        • Maltezos C.
        Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities.
        J Vasc Surg. 2006; 43 (discussion: 76): 72-76
        • Matos J.M.
        • Fajardo A.
        • Dalsing M.C.
        • Motaganahalli R.
        • Akingba G.A.
        • Murphy M.P.
        Evidence for nonoperative management of acute limb ischemia in infants.
        J Vasc Surg. 2012; 55 (discussion: 1158-9): 1156-1159