Femoral arterial thrombosis after cardiac catheterization in infancy: impact of Doppler ultrasound for diagnosis

Practice patterns in the management of pediatric iliofemoral arterial thrombosis

BACKGROUND

Acute arterial thrombosis can be life- and limb-threatening. Most pediatric patients with iliofemoral arterial thrombosis are treated successfully with medical therapy; however, expert consensus is limited, and many recommendations are based on the extrapolation of adult data. We aim to understand treatment patterns and long-term outcomes after pediatric acute iliofemoral arterial thrombosis, from which management recommendations can be informed.

METHODS

A single-institution retrospective study of pediatric patients diagnosed with iliofemoral arterial thrombosis from 2009 to 2018 was performed. Multiple parameters of management and follow-up were evaluated. Children anticoagulated for ≤28 days versus >28 days were compared. Data analysis used Fisher exact and Mann-Whitney U tests.

RESULTS

Two hundred thirty-six children were included. Median age at diagnosis was 65 days (interquartile range 17-163), with 207 diagnosed as infants, 15 diagnosed between 1 to 2 years, and 14 diagnosed between 2 to 16 years. The median treatment duration was 28 days (interquartile range 13-42); patients treated for >28 days had a longer time for thrombus resolution, and more follow-up ultrasounds were performed. Limb length discrepancy did not differ between the groups (1.0% vs 6.3%, P = .06), and no patients were documented to have developed peripheral arterial disease over a median 6.5-year follow-up. Multiple treatment strategies were employed, the most common being heparin bridged to enoxaparin (25.0%) and enoxaparin monotherapy (21.6%). Eight patients (3.4%) underwent surgical intervention.

CONCLUSION

Pediatric iliofemoral arterial thrombosis is primarily a disease of infants treated adequately with heparin or enoxaparin, infrequently requires surgical intervention, and is rarely associated with long-term complications. When guided by thrombus resolution on ultrasound, a four-week or shorter course of anticoagulation does not increase the need for surgical intervention or long-term complications.

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.

Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations

Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.

Duplex ultrasound and clinical outcomes of medical management of pediatric lower extremity arterial thrombosis

OBJECTIVES

Natural history and duplex ultrasound (DU) findings of pediatric lower extremity arterial thrombosis (PLEAT) are not well-defined. We describe acute and short-term DU findings of PLEAT to aid duplex interpretation and patient management.

METHODS

From August 2018 to April 2021 children with suspected PLEAT were identified prospectively. All had DU studies and were divided into group 1 (with DU-confirmed PLEAT) and group 2 (without DU-confirmed PLEAT). Patient demographics and DU findings were compared. Those with PLEAT and follow-up DU studies were also evaluated for recanalization and post recanalization DU findings.

RESULTS

We included 76 children (102 limbs) who had suspected PLEAT; 32 in group 1 and 44 group in 2. Fifty-seven percent had congenital heart disease, 26% a history prematurity (87%, 34% group 1; 11%, 14% group 2), with 14% of group 1 premature at PLEAT diagnosis and 68% aged less than 3 years-29 (94%) in group 1 and 23 (52%) in group 2. None had an arterial procedure to restore flow. Limb salvage was 100% with five group 1 mortalities unrelated to PLEAT. In group 1, 12 PLEATs were associated with an arterial line and 15 with cardiac catheterization. Occluded arteries included 7 external iliac, 20 common femoral, and 5 superficial femoral arteries (SFA). Peak systolic velocities (PSVs) distal to occluded segments in group 1 were lower than corresponding group 2 PSVs. SFA 18 ± 21 cm/s vs 84 ± 39 cm/s; popliteal artery (PA) 24 ± 18 cm/s vs 78 ± 38 cm/s; posterior tibial artery (PTA) 10 ± 8 cm/s versus 49 ± 27 cm/s (all P < .001). Twenty-one patients in group 1 had follow-up studies. Twelve (57%) were recanalized: 4 (19%) in less than 1 week and 10 (48%) by 6 months. Eighty-one percent of PLEATs were treated with anticoagulation (AC) and 57% recanalized. Fifty-nine percent of patients on AC recanalized, and 60% not on AC recanalized. Age, primary diagnosis, instrumentation type, and AC were not associated with failure to recanalize. After recanalization, PSVs in the CFA were not different than PSVs found in group 2 in the CFA (109 ± 50 cm/s vs 107 ± 57 cm/s; P = .88), but remained decreased in the SFA, PA, and PTA (SFA 68 ± 32 cm/s vs 83 ± 38 cm/s [P = .04]; PA 33 ± 13 cm/s vs 78 ± 37 [P = .0004]; and PTA 21 ± 8 cm/s vs 43 ± 20 cm/s [P = .0008]).

CONCLUSIONS

PLEAT occurs in young children, results in low distal PSVs, and often does not recanalize, but does not lead to short-term limb loss or mortality or necessarily require AC for recanalization. Normalization of CFA PSVs indicates recanalization while PSVs in segments distal to the CFA do not seem to return to normal.

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.

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.

Variations in arterial pedal circulation in idiopathic congenital talipes equinovarus: a systematic review

Variations in pedal circulation in congenital talipes equinovarus (CTEV) are well documented. There is a reported risk of vascular injury to the posterior tibial artery (PTA) during operative procedures for CTEV, potentially leading to necrosis and amputation. The aim of this systematic review was to identify the most common anomalies in arterial pedal circulation in CTEV and to determine the relevance of these to clinical practice. The systematic review was registered on PROSPERO and was carried out according to Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines by two independent reviewers. Studies that examined pedal circulation in idiopathic CTEV were included. Articles that studied nonidiopathic CTEV and those not published in English were excluded. Data extracted included patient demographics, imaging modalities, and findings. A total of 14 articles satisfied the inclusion criteria, including 192 patients (279 clubfeet), aged 0-13.5 years, at various stages in their treatment. Imaging modalities included arteriography (n = 5), duplex ultrasound (n = 5), magnetic resonance angiography (n = 2), and direct visualization intraoperatively (n = 2). The dorsalis pedis was most frequently reported as absent (21.5%), and the anterior tibial artery (ATA) was most frequently reported as hypoplastic (18.3%). Where reported (n = 36 feet), 61% of patients were noted to have a dominant supply from the PTA. The most common variation in pedal circulation in CTEV is diminished supply from ATA and dorsalis pedis, although there are documented anomalies in all of the vessels supplying the foot. We therefore recommend routine Doppler ultrasound imaging prior to operative intervention in CTEV.

Surgically placed radiopaque markers: Proof-of-concept of a novel technique to facilitate percutaneous interventions in neonates and infants

OBJECTIVES

Aim of this study was to evaluate feasibility and benefit of self-designed, radiopaque markers as a novel technique in neonates and infants with shunt- or duct-dependent lesions.

BACKGROUND

Surgically placed radiopaque markers have the potential to facilitate postoperative percutaneous interventions.

METHODS

All consecutive children with surgically placed radiopaque markers involving systemic-to-pulmonary artery connections or arterial ducts in the context of hybrid palliation and subsequent cardiac catheterization between January 2013 and March 2019 were included in this analysis. Our primary endpoint was our concept's feasibility, which we defined as a combination of surgical feasibility and the percutaneous intervention's success. Secondary endpoint was the rate of complications resulting from the surgical procedure or during catheterization.

RESULTS

Radiopaque markers that reveal the proximal entry of a surgical shunt or the arterial duct proved to be a feasible and beneficial approach in 25 postoperative catheterizations. The markers' high accuracy enabled easy probing and proper stent positioning in 13 neonates with a median age and weight of 121 days (range 9-356) and 4.7 kg (1.6-9.4) at the intervention. No procedural complications or unanticipated events associated with the radiopaque marker occurred. The markers were never lost, never migrated, and caused no local obstructive lesion. Surgical removal was straightforward in all patients.

CONCLUSIONS

Radiopaque markers are a promising and refined technique to substantially facilitate target vessel access and enabling the accurate positioning of stents during postoperative percutaneous procedures.

Emerging predictors of femoral artery occlusion after pediatric cardiac catheterization

The Objective was to review the prevalence of femoral artery occlusion (FAO) after cardiac catheterization in children up to 12 years old from two centers in China and identify its related risk factors. After collecting clinical data from patients who had undergone pediatric cardiac catheterization, univariate and multivariate analysis were used to evaluate the correlations between FAO and clinical factors, including sex, age, height, weight, sheath size, operation time, therapeutic strategy, sheath/age, sheath/height and sheath/weight. The ROC curve was also used to assess the influence of risk factors to predict FAO. FAO occurred in 19 (0.9%) out of 2,084 children following cardiac catheterization. Patients with younger age, lower height, longer operation time, electrophysiological (EP) diagnosis or/and therapy for arrhythmias, higher Sheath/Age, higher Sheath/Height and higher Sheath/Weight ratios had higher risk for FAO compared to their respective control groups (p < 0.05). In the multivariate analysis, sheath/age and operation time were independent risk factors for FAO. Patients with operation time > 77.5 min or sheath/age > 0.5334 had a significantly higher risk for FAO. Operation time and sheath/age were confirmed as significant and independent risk factors associated with FAO. Operation time > 77.5 min and sheath/age > 0.5334 could effectively predict high risk of FAO after pediatric cardiac catheterization.

Natural history of acute pediatric iliofemoral artery thrombosis treated with anticoagulation

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.

Extremity Arterial Thromboses in Hospitalized Children: A National Database Analysis of Prevalence and Therapeutic Interventions

OBJECTIVES

The purpose of this study was to evaluate the prevalence, demographics, predisposing conditions, therapeutic interventions, and outcomes of extremity arterial thrombosis in hospitalized children.

DESIGN

Retrospective cohort study.

PATIENTS

National discharge database analysis.

MEASUREMENTS AND MAIN RESULTS

Cases of extremity arterial thrombosis in children and neonates were extracted from the Kids' Inpatient Database 2012. These were analyzed and compared with other discharges for prevalence, demographics, treatments, outcomes, and further analyzed by age group and select predisposing conditions. A total of 961 children with extremity arterial thrombosis (prevalence of 2.35/10,000 discharges) were included in our analysis. The median age of extremity arterial thrombosis patients was significantly lower when compared with other pediatric discharges (1 yr [interquartile range, 0-15 yr) vs 3 yr [interquartile range, 0-16 yr]; p < 0.0001). The proportion of females with extremity arterial thrombosis was lower (41.4% vs 53.3%; odds ratio, 0.62; 95% CI, 0.55-0.70) with no racial/ethnic variation in the prevalence of extremity arterial thrombosis. An upper extremity was involved in 18.1% and a lower extremity in 83.3%. Arterial cannulation and cardiac catheterization were much more common in the younger age groups. External trauma was documented in 13.2% of all patients with extremity arterial thrombosis and was more frequent in older age groups. A systemic thrombolytic medication was administered to 5.7% of the patients, thromboembolectomy was performed in 11.8% of the cases, and 3.1% of the patients required amputation. There was a significant variation in the use of thrombolysis, thrombectomy/embolectomy, or requirement for amputation limb based on age groups and underlying predisposing condition.

CONCLUSIONS

The study describes the national prevalence of extremity arterial thrombosis in hospitalized children. The management strategies of extremity arterial thrombosis vary with age and underlying predisposing factors.

Acute Limb Ischemia in Pediatric Population Secondary to Peripheral Vascular Cannulation

Introduction:

In this article, we discuss published literature on the management of pediatric patients with acute limb ischemia and also present our center’s experience.

Results:

Literature review suggests that in the absence of imminent risk of limb loss, noninterventional management with anticoagulants and systemic thrombolysis is preferable and associated with better clinical outcomes than surgery such as reduced per operative morbidity and mortality. In selected more severe cases, surgery may be required. We propose an algorithm for improved clinical outcomes based on the published literature and the American College of Chest Physicians’ recommendations for antithrombotic management in the pediatric population.

Conclusion:

Literature review suggests an inverse relationship between age and surgical success, particularly in preschool pediatric population. Conservative management as a preliminary strategy seems most beneficial. It is hoped that the proposed intercalated algorithm of medical and surgical management of these patients can further improve clinical outcomes.

Incidence and predictors of cardiac catheterisation-related arterial thrombosis in children

OBJECTIVE

Arterial thrombosis is one of the most reported complications of cardiac catheterisation (CC) in children. The aim of the study was to evaluate the incidence and predictors of arterial thrombosis in children with cardiac diseases (CDs).

METHODS

During 12 consecutive months, all children aged 0-19 years undergoing CC of the femoral arteries were included in this observational study. After CC, clinical evaluation of impaired limb perfusion was performed according to local guidelines. Doppler ultrasonography was performed when decreased limb perfusion was suspected.

RESULTS

123 children (30% aged <12 months, 70% aged >12 months) underwent CC. Arterial thrombosis occurred in 14 of the 123 children (11.4%). Twelve cases (12/14=86%) of arterial thrombosis occurred in infants aged <12 months and 2 (2/14=14%) in older children. Overall younger age (p<0.01, OR (95% CI) 0.49 (0.28 to 0.86)) and low body weight (p<0.004, OR (95% CI) 0.78 (0.65 to 0.92)) were significantly associated with an increased risk of arterial thrombosis. Cyanotic CD (p=0.07, OR (95% CI) 2.87 (0.90 to 9.15)) showed a trend towards increased thrombotic risk.

CONCLUSIONS

Arterial thrombosis is a common complication of CC in infants. Diagnosis of CC-related arterial thrombosis remains a challenge. Well-defined clinical monitoring protocols may be valuable methods for timely detection and treatment of arterial thrombosis.

Transient flow response after femoral artery catheterization for diagnostic neuroangiography in infants and children: Doppler US assessment of the ipsilateral femoral artery

BACKGROUND

Hemodynamic changes in the distal arteries during transfemoral catheterization in children have not been documented.

OBJECTIVE

To evaluate arterial flow changes of the lower extremities ipsilateral to the puncture site using Doppler US during transfemoral cerebral angiography in children.

MATERIALS AND METHODS

Twenty-seven children who underwent transfemoral cerebral angiography at our institution between April 2013 and August 2013 compose our study population. Doppler US was performed to evaluate diameters and peak systolic velocities of the common femoral artery and superficial femoral artery before and after femoral sheath insertion. Children were classified into three groups based on the spectral waveform changes of the superficial femoral artery after femoral sheath insertion. Thereafter, one-way ANOVA followed by the Bonferroni post-hoc comparisons test were performed to compare values among the groups.

RESULTS

Mean common femoral artery and superficial femoral artery baseline diameters were 4.10 mm and 3.32 mm, and mean baseline peak systolic velocities were 218.26 and 166.51 cm/s, respectively. Fourteen of 27 children showed persistent triphasic flow in the superficial femoral artery (group 1); 7 children showed altered flow of biphasic (n = 3) or monophasic (n = 4) waveforms (group 2); and 6 children showed pulsus tardus et parvus pattern (group 3) after femoral sheath insertion. Mean baseline diameter of the common femoral artery and mean subtracted value between common femoral artery and femoral sheath size were significantly smaller in group 3 than the other groups. Size discrepancy between common femoral artery and femoral sheath was <1 mm in all cases of group 3. Superficial femoral artery diameter and peak systolic velocity significantly decreased after femoral sheath insertion in group 3 compared to groups 1 and 2. A significant skin temperature drop after sheath insertion in the ipsilateral lower extremity was noted in group 3 (-1.83°C), compared to groups 1 and 2 (+0.42 and -0.86°C, respectively).

CONCLUSION

Changes in the spectral waveforms of superficial femoral arteries frequently occur in children during transfemoral cerebral angiography (13/27, 48%). Significant arterial flow disturbance was noted on Doppler US in children with a common femoral artery <1 mm larger than the femoral sheath diameter.