Catheter-Directed Thrombolysis of Acute Deep Vein Thrombosis in the Lower Extremity of a Child with Interrupted Inferior Vena Cava

Lower extremity endovenous reconstruction for symptomatic occlusive disease in pediatric patients: techniques, clinical outcomes, and long-term stent patencies

BACKGROUND

Endovascular stent reconstruction is the standard of care for chronic venous occlusive disease in adults, but it has not been reported in pediatric patients.

OBJECTIVE

This study reports the technical success, complications, clinical outcomes, and stent patency of iliocaval stent reconstruction for chronic iliocaval thrombosis in pediatric patients.

MATERIALS AND METHODS

Fourteen patients, 13 (93%) male with a mean age of 16.4 years (range: 8-20 years), underwent iliocaval stent reconstruction for chronic iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.5 (range: 0-4), including 7 (50%) patients with inferior vena cava atresia. At initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology classification (CEAP) score was C3 in 2 (14%) patients, C4 in 11 (79%) patients, and C6 in 1 (7.1%) patient. Time course of presenting symptoms included chronic (>4 weeks) (n=7; 50%) and acute worsening of chronic symptoms (2-4 weeks) (n=7; 50%). Aspects of recanalization and reconstruction, stenting technical success, complications, clinical outcomes and stent patency were recorded. Clinical success was defined as a 1-point decrease in the CEAP. Primary, primary-assisted, and secondary patency were defined by Cardiovascular and Interventional Radiological Society of Europe guidelines.

RESULTS

Most procedures employed three access sites (range: 2-4). Intravascular ultrasound was employed in 11 (79%) procedures. Blunt and sharp recanalization techniques were used in 12 (86%) and 2 (14%) patients, respectively. Stenting technical success was 100%. Two (14%) minor adverse events occurred and mean post-procedure hospitalization was 2.8 days (range: 1-8 days). Clinical success rates at 2 weeks, 6 months and 12 months were 85%, 82%, and 83%, respectively. At a mean final clinical follow-up of 88 months (range: 16-231 months), clinical success was 93%. Estimated 6- and 12-month primary stent patencies were 86% and 64%, respectively. Six- and 12-month primary-assisted and secondary stent patency rates were both 100%.

CONCLUSION

Iliocaval stent reconstruction is an effective treatment for symptomatic chronic iliocaval thrombosis in pediatric patients with high rates of technical success, 6- and 12-month clinical success, and 6- and 12-month primary-assisted and secondary patency rates.

Pharmacomechanical thrombectomy and catheter-directed thrombolysis of acute lower extremity deep venous thrombosis in a 9-year-old boy with inferior vena cava atresia

Lower extremity deep venous thrombosis (DVT) is uncommon in the pediatric population, but it can be associated with severe symptoms and potential long-term morbidity secondary to post-thrombotic syndrome. Inferior vena cava (IVC) atresia can predispose a patient to the development of extremity DVT. There is no clear consensus on optimal management of extensive extremity DVT in pediatric patients, especially in patients with IVC anomalies. We report a case of iliofemoral DVT in a 9-year-old boy with IVC atresia and presumed protein S deficiency that was treated successfully using pharmacomechanical thrombectomy and catheter-directed thrombolysis. He was maintained on long-term anticoagulation and remained symptom free at 6 months' follow-up.

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.

Successful Treatment of Phlegmasia Cerulea Dolens with Combination Surgical and Catheter-Assisted Thrombectomy

Phlegmasia cerulea dolens is a rare condition caused by complete venous occlusion that leads to impaired arterial flow. Prompt diagnosis and treatment initiation are paramount in preventing progression to gangrene, the need for amputation, and possibly the death of the patient. Thrombolysis or surgical thrombectomy, for advanced disease and cases in which anticoagulation is contraindicated, represent the current standard treatment. Here we report the case of a 47-year-old male who sustained severe trauma during a car accident. After having a prophylactic retrievable inferior vena cava filter placed, he developed caval thrombosis with progression to phlegmasia cerulea dolens. He was successfully treated with a combination of surgical thrombectomy of the lower extremity veins and catheter-assisted thrombectomy of the iliac veins and inferior vena cava, in the setting in which an initial attempt at balloon thrombectomy of the iliac veins and inferior vena cava failed. He was discharged from the hospital in stable condition and on follow-up visits had full resolution of symptoms. Ultrasound evaluation showed no residual venous clot. The presented case illustrates how the use of catheter-assisted thrombectomy alleviated the need for a laparotomy and direct caval evacuation of the thrombus and provided a timely and effective treatment of phlegmasia cerulea dolens with impending gangrene.

Sacral preservation in cauda equina syndrome from inferior vena cava thrombosis

Acute cauda equina syndrome can occur due to a variety of causes. Inferior vena cava (IVC) thrombosis has been reported as the causal source of this phenomenon twice in the relevant literature, both cases of which presented in a form complete with a component of bowel and/or bladder dysfunction. The authors report an atypical case of cauda equina syndrome in a patient in a hypercoagulable state with an extensive IVC thrombosis, resulting in acute paraparesis in the absence of incontinence or perineal anesthesia. An increasing number of prophylactic and/or therapeutic IVC filters placed in the perioperative period should engender an increased clinical suspicion for IVC thrombosis in patients presenting with acute paraparesis.

Manual Aspiration Thrombectomy with Stent Placement: Rapid and Effective Treatment for Phlegmasia Cerulea Dolens with Impending Venous Gangrene

Phlegmasia cerulea dolens is an uncommon but potentially life-threatening complication of acute deep vein thrombosis. It is an emergency and delay in treatment may cause death or loss of the patient's limb. Surgical thrombectomy is the recommended treatment in venous gangrene. Catheter-directed intrathrombus thrombolysis has been reported as successful, but it may require a lengthy infusion. Manual aspiration thrombectomy may clear the entire thrombus with no need for thrombolytic administration and provide rapid and effective treatment for patients with phlegmasia cerulea dolens with impending venous gangrene.