1
|
Mitta P, DiFatta J, Mahler C, Huang J, Oser R, Gunn AJ, Wilson H, Raja J. Management options for pediatric venous thromboembolic disease: Beyond anticoagulation with endovascular therapies. Thromb Res 2024; 239:109027. [PMID: 38735165 DOI: 10.1016/j.thromres.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 05/14/2024]
Abstract
Venous thromboembolism (VTE) in pediatric patients is an uncommon but serious diagnosis that has an array of therapeutic options and challenges. An assessment of the existing literature on management of pediatric patients with VTE was conducted. The interventions reviewed include anticoagulation, thrombolysis, thrombectomy, inferior vena cava (IVC) filters, and venous stenting. For each intervention, a discussion of mechanism of action, indications, contraindications, and potential complications was performed. While anticoagulants are considered the first-line pediatric VTE treatment, many drugs remain investigational in this patient population and treatment recommendations are extrapolated from adult practice. Thrombolysis may be indicated in cases of acute thrombosis requiring more rapid clot resolution but presents a greater bleeding risk than anticoagulation. Similarly, thrombectomy also provides rapid clot resolution and offers a larger therapeutic window and usage in more mature thrombi than thrombolysis. In select patient groups, IVC filters may be indicated in the prevention of PE but present with inherent thrombogenicity and risk of migration. The data regarding pediatric VTE treatment options, monitoring, and long term outcomes is limited compared to the adult population. The relatively few clinical trials including pediatric patients have a relatively small sample size and are heterogenous with regards to predisposing factors that further exacerbate generalizability. Additional research is needed to help construct and evaluate a robust treatment algorithm for pediatric patients with VTE.
Collapse
Affiliation(s)
- Priyanka Mitta
- University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | - Jake DiFatta
- University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | - Chase Mahler
- University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | - Junjian Huang
- University of Alabama at Birmingham, Division of Vascular and Interventional Radiology/Department of Radiology, Birmingham, AL, USA
| | - Rachel Oser
- University of Alabama at Birmingham, Division of Vascular and Interventional Radiology/Department of Radiology, Birmingham, AL, USA
| | - Andrew John Gunn
- University of Alabama at Birmingham, Division of Vascular and Interventional Radiology/Department of Radiology, Birmingham, AL, USA
| | - Hope Wilson
- Children's of Alabama, Division of Hematology Oncology/Department of Pediatrics, Birmingham, AL, USA
| | - Junaid Raja
- University of Alabama at Birmingham, Division of Vascular and Interventional Radiology/Department of Radiology, Birmingham, AL, USA.
| |
Collapse
|
2
|
Ma Z, Elango J, Hao J, Wu W. Purification and Characterization of a Novel Fibrinolytic Enzyme from Marine Bacterium Bacillus sp. S-3685 Isolated from the South China Sea. Mar Drugs 2024; 22:267. [PMID: 38921578 PMCID: PMC11204972 DOI: 10.3390/md22060267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/09/2024] [Accepted: 06/09/2024] [Indexed: 06/27/2024] Open
Abstract
A novel fibrinolytic enzyme, BSFE1, was isolated from the marine bacterium Bacillus sp. S-3685 (GenBank No.: KJ023685) found in the South China Sea. This enzyme, with a molecular weight of approximately 42 kDa and a specific activity of 736.4 U/mg, exhibited its highest activity at 37 °C in a phosphate buffer at pH 8.0. The fibrinolytic enzyme remained stable over a pH range of 7.5 to 10.0 and retained about 76% of its activity after being incubated at 37 °C for 2 h. The Km and Vmax values of the enzyme at 37 °C were determined to be 2.1 μM and 49.0 μmol min-1 mg-1, respectively. The fibrinolytic activity of BSFE1 was enhanced by Na+, Ba2+, K+, Co2+, Mn2+, Al3+, and Cu2+, while it was inhibited by Fe3+, Ca2+, Mg2+, Zn2+, and Fe2+. These findings indicate that the fibrinolytic enzyme isolated in this study exhibits a strong affinity for fibrin. Moreover, the enzyme we have purified demonstrates thrombolytic enzymatic activity. These characteristics make BSFE1 a promising candidate for thrombolytic therapy. In conclusion, the results obtained from this study suggest that our work holds potential in the development of agents for thrombolytic treatment.
Collapse
Affiliation(s)
- Zibin Ma
- School of Agriculture and Bioengineering, Taizhou Vocational College of Science & Technology, Taizhou 318020, China;
| | - Jeevithan Elango
- Department of Marine Biopharmacology, College of Food Science and Technology, Shanghai Ocean University, Shanghai 201306, China;
- Center of Molecular Medicine and Diagnostics (COMManD), Department of Biochemistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600 077, India
- Department of Biomaterials Engineering, Faculty of Health Sciences, UCAM Universidad Católica San Antonio de Murcia, Guadalupe, 30107 Murcia, Spain
| | - Jianhua Hao
- Key Laboratory of Sustainable Development of Polar Fishery, Ministry of Agriculture and Rural Affairs, Yellow Sea Fisheries Research Institute, Chinese Academy of Fishery Sciences, Qingdao 266071, China
| | - Wenhui Wu
- Department of Marine Biopharmacology, College of Food Science and Technology, Shanghai Ocean University, Shanghai 201306, China;
| |
Collapse
|
3
|
Successful Use of Thrombolysis in an Extremely Low Birth Weight, Premature Infant With Aortic Thrombosis. J Pediatr Hematol Oncol 2022; 44:e888-e891. [PMID: 35398856 DOI: 10.1097/mph.0000000000002455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe neonatal aortic thrombosis is rare but can lead to significant morbidity or death if inadequately treated. Thrombolytic therapy is indicated for thrombi which are life-threatening, organ-threatening, or limb-threatening, but dosing consensus has not been established. OBSERVATION We report a case of a 700 g preterm neonate with spontaneous intestinal perforation who developed an occlusive aortic thrombus with signs of limb ischemia. He was treated successfully with tissue plasminogen activator without hemorrhagic complications. He was started at a dose of 0.06 mg/kg/h and received a maximum dose of 0.3 mg/kg/h. Long-term follow-up at 3 years and 3 months showed no negative sequelae. CONCLUSION Alteplase may be considered in premature, extremely low-birth weight infants with careful assessment of risk and benefits, along with frequent surveillance and supportive care.
Collapse
|
4
|
Bønløkke ST, Serifi MA, Mikkelsen TS, Hvas A. Catheter‐directed thrombolysis for massive deep vein thrombosis in an adolescent with severe antithrombin deficiency. Clin Case Rep 2022; 10:e05681. [PMID: 35498359 PMCID: PMC9040422 DOI: 10.1002/ccr3.5681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 03/11/2022] [Accepted: 03/22/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Søren Thorgaard Bønløkke
- Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | | | - Torben Stamm Mikkelsen
- Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Pediatrics Aarhus University Hospital Aarhus Denmark
| | - Anne‐Mette Hvas
- Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| |
Collapse
|
5
|
Ross C, Kumar R, Pelland-Marcotte MC, Mehta S, Kleinman ME, Thiagarajan RR, Ghbeis MB, VanderPluym CJ, Friedman KG, Porras D, Fynn-Thompson F, Goldhaber SZ, Brandão LR. Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest 2022; 161:791-802. [PMID: 34587483 PMCID: PMC8941619 DOI: 10.1016/j.chest.2021.09.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022] Open
Abstract
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
Collapse
Affiliation(s)
- Catherine Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Riten Kumar
- Harvard Medical School, Boston, MA,Department of Pediatrics, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | | | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA,College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Muhammad B. Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Christina J. VanderPluym
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Samuel Z. Goldhaber
- Harvard Medical School, Boston, MA,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Leonardo R. Brandão
- Department of Paediatrics, Haematology/Oncology Division, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
6
|
Glonnegger H, Zieger B, Grohmann J, Freund G, Zeller T, Uhl M, Stiller B. Successful Secondary Endovascular Intervention in Pediatric Patients with Venous Thromboembolic Events. Hamostaseologie 2022; 43:102-109. [PMID: 35026859 DOI: 10.1055/a-1701-2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND In the past, pediatric patients with venous thromboembolic events (VTE) were treated with low-molecular-weight heparin (LMWH) which was successful in around 70% of the cases. However, anticoagulation alone might not restore patency in all patients, and advanced therapeutic options to prevent postthrombotic syndrome are needed. During recent years, endovascular interventions have become a treatment option for pediatric patients with persistent thrombotic occlusion, not only in life- or limb-threatening VTE. METHODS We evaluated 12 consecutive patients (11-17 years) with newly diagnosed VTE being treated at our department during the last 4 years (2017-2020). In case follow-up examination showed persistent venoocclusion under anticoagulation, patients received secondary interventional therapy like recanalization, percutaneous transluminal angioplasty with or without catheter-directed thrombolysis, and stenting. Patients with no clinical signs of venoocclusion or regredient thrombosis in imaging examination received anticoagulation alone. RESULTS Six of 12 (50%) patients underwent catheter intervention. Median time from diagnosis to intervention was 4 months (0-12 months). Reintervention was necessary in one (8%) case and complete recanalization failed in one (8%) case. There were no major bleeding events or other major postinterventional complications, no acute or late local recurrence, and all patients reported clinical improvement after the procedure. CONCLUSION If endovascular intervention is used in teenage patients with persistent symptomatic VTE, reduction of postthrombotic symptoms is possible, even if intervention is performed secondary to failure of anticoagulation. Multidisciplinary treatment decisions can be based on the clinical course and follow-up imaging.
Collapse
Affiliation(s)
- Hannah Glonnegger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, Germany
| | - Jochen Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Congenital Heart Disease/Pediatric Cardiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Gabriele Freund
- Department of Angiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Zeller
- Department of Angiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Markus Uhl
- Division of Pediatric Radiology, Department of Radiology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
7
|
Cohen CT, Sartain SE, Sangi-Haghpeykar H, Kukreja KU, Desai SB. Clinical characteristics and outcomes of combined thrombolysis and anticoagulation for pediatric and young adult lower extremity and inferior vena cava thrombosis. Pediatr Hematol Oncol 2021; 38:528-542. [PMID: 33646916 DOI: 10.1080/08880018.2021.1889729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Effective treatment for acute, extensive, symptomatic lower extremity (LE) thrombosis involves thrombolysis in addition to anticoagulation. There is limited available data on the outcomes and safety of thrombolysis to help guide its use in pediatrics and young adults. A retrospective study of children and young adults (<21 years of age) that received catheter directed thrombolysis (CDT) for LE and inferior vena cava (IVC) thrombosis was performed over a 5-year span at a pediatric tertiary care center. A total of 29 patients were identified for inclusion in the study, 76% (n = 22) received overnight CDT while 24% (n = 7) received tissue plasminogen activator as a bolus dose during a single interventional procedure. The median age of the cohort was 15.8 years (range 0-19.1). All patients were treated with a course of therapeutic anticoagulation. The thromboses represented were extensive, with 93% (n = 27) being occlusive and affecting multiple venous segments. Thrombus resolution occurred in 35% (n = 10) of patients. Rivaroxaban use (p < 0.01) during the course of anticoagulation and estrogen-containing hormonal therapy (p = 0.01) use prior to diagnosis were associated with thrombus resolution, while Hispanic ethnicity (p = 0.06) had a trend toward thrombus persistence. There were one major and 3 minor bleeding events that occurred as complications of thrombolysis and no treatment related deaths. This study provides baseline information that can be used to help guide clinicians treating similar patients and suggests the need to develop an improved, uniform treatment approach for superior resolution rates.
Collapse
Affiliation(s)
- Clay T Cohen
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah E Sartain
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Kamlesh U Kukreja
- Department of Radiology, Section of Interventional Radiology, Texas, Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sudhen B Desai
- Department of Radiology, Section of Interventional Radiology, Texas, Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
8
|
Tissue Plasminogen Activator Use in Pediatric Patients: A Single Center Experience. J Pediatr Hematol Oncol 2021; 43:e648-e651. [PMID: 33480646 DOI: 10.1097/mph.0000000000002031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 11/02/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Thrombosis is rare in children and antithrombolytic treatment is controversial. Most commonly used thrombolytic agent is tissue plasminogen activator (t-PA) in pediatrics. In this study, we report our experience in the use of thrombolytic treatment. METHODS Eighteen patients who had received systemic t-PA between January 2006 and December 2013 were recorded. The response to t-PA was evaluated as complete, partial, and no. The bleeding complication during t-PA administration was graded as minor or major. RESULTS There were 18 patients (2 mo to 12 y) who received systemic t-PA. Three patients had venous, 14 patients had arterial, and 1 patient had intracardiac thrombosis. Thrombosis was related to cardiac catheterization (61.1%), central venous catheterization (16.7%), cardiac surgery (11.1%), and arrhythmia (5.5%). In 1 patient thrombosis occurred spontaneously (5.5%). Eighteen patients received 25 courses of systemic t-PA (0.15 to 0.3 mg/kg/h). A total of 55.6% of cases had complete, 27.8% had partial, and 16.6% showed no resolution. CONCLUSION t-PA infusion at doses of median 0.2 mg/kg/h (0.15 to 0.3) seems effective and safe. There is still no consensus on indications and dosing of antithrombolytic treatment in children but in selected patients it decreases long-term complications due to thrombosis.
Collapse
|
9
|
Catheter-directed Thrombolysis for Neonatal IVC and Bilateral Renal Vein Thrombosis: A Case Report. J Pediatr Hematol Oncol 2021; 43:e554-e557. [PMID: 32569035 DOI: 10.1097/mph.0000000000001867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/23/2020] [Indexed: 11/26/2022]
Abstract
Renal vein thrombosis is the most common non-catheter-associated venous thromboembolism event in neonates, accounting for up to 20% of cases. Although mortality rates are lower than a variety of other forms of pediatric thrombosis, renal vein thrombi are associated with significant short-term and long-term sequelae. This report presents the case of a full-term neonate presenting with bilateral renal vein thrombosis with inferior vena cava involvement treated with catheter-directed thrombolysis. This case report intends to highlight the value of a multidisciplinary approach to pediatric venous thromboembolism and to outline relevant procedural details and current laboratory and imaging monitoring of catheter-directed thrombolysis.
Collapse
|
10
|
Villeda GV, Spencer R, Crystal MA, Dayton JD, Krishnan U. Pulmonary artery thromboembolism in a critically ill neonate successfully treated using thrombolytic therapy. Ann Pediatr Cardiol 2021; 14:215-219. [PMID: 34103864 PMCID: PMC8174645 DOI: 10.4103/apc.apc_156_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/03/2020] [Accepted: 11/27/2020] [Indexed: 11/25/2022] Open
Abstract
Pulmonary artery thromboembolism is a common and treatable cause of adult pulmonary hypertension. Although rare in children, if undiagnosed, it can result in significant morbidity and mortality. We report a case of a cyanotic neonate found to have bilateral pulmonary arterial thrombi who successfully underwent thrombolysis using tissue plasminogen activator with prompt resolution of right ventricular hypertension.
Collapse
Affiliation(s)
| | - Robert Spencer
- Division of Pediatric Cardiology, Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, USA
| | - Matthew A Crystal
- Division of Pediatric Cardiology, Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, USA
| | - Jeffrey D Dayton
- Division of Pediatric Cardiology, Weill Cornell Medicine, New York, NY, USA
| | - Usha Krishnan
- Division of Pediatric Cardiology, Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, USA
| |
Collapse
|
11
|
Woods GM, Kim DW, Paden ML, Viamonte HK. Thrombolysis in Children: A Case Report and Review of the Literature. Front Pediatr 2021; 9:814033. [PMID: 35141182 PMCID: PMC8818955 DOI: 10.3389/fped.2021.814033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/23/2021] [Indexed: 12/24/2022] Open
Abstract
Thromboembolism (TE), including venous thromboembolism (VTE), arterial TE, arterial ischemic stroke (AIS), and myocardial infarction (MI), is considered a relatively rare complication in the pediatric population. Yet, the incidence is rising, especially in hospitalized children. The vast majority of pediatric TE occurs in the setting of at least one identifiable risk factor. Most recently, acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have demonstrated an increased risk for TE development. The mainstay for the management pediatric TE has been anticoagulation. Thrombolytic therapy is employed more frequently in adult patients with ample data supporting its use. The data for thrombolysis in pediatric patients is more limited, but the utilization of this therapy is becoming more commonplace in tertiary care pediatric hospitals. Understanding the data on thrombolysis use in pediatric TE and the involved risks is critical before initiating one of these therapies. In this paper, we present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to MIS-C requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children.
Collapse
Affiliation(s)
- Gary M Woods
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Dennis W Kim
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Heather K Viamonte
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| |
Collapse
|
12
|
Grizante-Lopes P, Garanito MP, Celeste DM, Krebs VLJ, Carneiro JDA. Thrombolytic therapy in preterm infants: Fifteen-year experience. Pediatr Blood Cancer 2020; 67:e28544. [PMID: 32710708 DOI: 10.1002/pbc.28544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To report a single-center experience with thrombolytic therapy using recombinant tissue plasminogen activator (rt-PA) in preterm neonates with severe thrombotic events, in terms of thrombus resolution and bleeding complications. STUDY DESIGN This retrospective study included 21 preterm neonates with severe venous thrombotic events admitted to the neonatal intensive care unit, identified in our pharmacy database from January 2001 to December 2016, and treated with rt-PA until complete or partial clot lysis, no-response or bleeding complications. Our primary outcome was thrombus resolution. RESULTS Twenty-one preterm neonates were treated with rt-PA for an average of 2.9 cycles. Seventeen patients (80.9%) had superior vena cava thrombosis and superior vena cava syndrome. All patients had a central venous catheter, parenteral nutrition, mechanical ventilation, and sepsis. Fifteen patients (71.4%) were extremely preterm, 11 (52.4%) were extremely low birth weight, and seven (33.3%) were very low birth weight. The patency rate was 85.7%, complete lysis occurred in 11 (52.4%) patients, and partial lysis in seven (33.3%). Minor bleeding occurred in five (23.8%) patients, three patients (14.2%) had clinically relevant nonmajor bleeding events, and major bleeding occurred in six (28%) patients. CONCLUSION In this study, the rate of thrombus resolution in preterm neonates treated with rt-PA were similar to the percentages reported in children and adolescents, with a high rate of bleeding. Therefore, rt-PA thrombolytic therapy should only be considered as a treatment option for severe life-threatening thrombosis in premature neonates for whom the benefits of the thrombolytic treatment outweigh the risks of bleeding.
Collapse
Affiliation(s)
- Priscila Grizante-Lopes
- Division of Pediatric Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marlene Pereira Garanito
- Division of Pediatric Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Daniele Martins Celeste
- Division of Pediatric Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vera Lucia Jornada Krebs
- Division of Neonatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jorge David Aivazoglou Carneiro
- Division of Pediatric Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
13
|
Kumwenda MJ, Dougherty L, Jackson A, Hill S. Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters in haematology and oncology patients (PASSPORT 2). J Vasc Access 2020; 22:568-574. [PMID: 32867568 DOI: 10.1177/1129729820950997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Central venous catheter dysfunction may be associated with intraluminal clots, drug precipitates and lipid residues or extra luminal causes such as fibroblastic sleeve, tip malposition, pinch-off syndrome and venous thrombosis at the tip of central venous catheter. Failure to restore patency after addressing these causes, empirical treatment with thrombolytic agents should be considered. Urokinase is used widely as a thrombolytic agent but very few outcome studies have been published. METHODS A multicentre group conducted a prospective audit of management of central venous catheter dysfunction after exclusion of common causes using in centre standardised doses of urokinase from September 2017 to February 2018 in haematology and oncology units. Data of catheter blood flow were collected anonymously following administration of 5000- to 25,000-IU urokinase in dysfunctional central venous catheter. RESULTS A total of 117 patients were recruited from eight centres, 54 females and 63 males, median age was 60 (46-68). In total, 53% presented as partial withdrawal occlusion and 47% total occlusion. In partial withdrawal occlusion, patency was restored in 80% of interventions, in 82% of interventions using push lock and in 76% using dwell lock. In total occlusion, patency was restored in 88% of the interventions. The central venous catheter clearance rate was dose dependent; patency was restored in 83% of central venous catheter with 5000 IU, 89% with 10,000 IU and 92% with high dose of 25,000 IU. No adverse events were recorded. CONCLUSION In this study, treatment of dysfunctional central venous catheter using standardised urokinase doses was safe and effective in restoring patency when no other mechanical causes could account for central venous catheter dysfunction.
Collapse
Affiliation(s)
| | | | - Andrew Jackson
- Rotherham Hospital, The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Steve Hill
- The Christie NHS Foundation Trust, Manchester, UK
| |
Collapse
|
14
|
Díaz-Díaz ÁM, Ardila-Gutiérrez MA, Cáceres-Ramírez C, Zuluaga-Salazar S, Zuluaga-Amaya MF, Galvis-Méndez M. Fibrinolytic therapy in newborns with superior vena cava syndrome. Case report. CASE REPORTS 2020. [DOI: 10.15446/cr.v6n2.83526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Superior vena cava syndrome is described as the obstruction of blood flow through the superior vena cava. The literature reports that the incidence of this pathology varies from 1 case in every 650 inhabitants and 1 case in every 3 100 inhabitants. Since this condition is very rare in the pediatric population, no clear figure has been reported regarding its incidence in children. The use of a central venous catheter in newborns is a risk factor for this condition, as it may cause a thrombus due to the inflammatory reaction against the device. Therefore, it is necessary to initiate anticoagulation management and remove the catheter.Case presentation: Premature male newborn, (31.4 weeks gestation), with acute respiratory distress syndrome, early neonatal sepsis, pneumonia, necrotizing enterocolitis on 2 occasions, intestinal obstruction due to adhesions and intestinal volvulus. At 90 days of age, he presented thrombosis of the superior vena cava without involvement of the jugular and subclavian vein junction in the right atrium. Anticoagulant management was started, but given his unfavorable evolution, a multidisciplinary medical board was held to assess the risks, benefits, and treatment options in this age group. It was decided to start intracavitary tissue plasminogen activator treatment associated with mechanical thrombectomy and angioplasty of the superior vena cava. Due to the difficulty of conducting clinical trials in this population and the rates of major bleeding complications obtained with thrombolytic therapies, there is very little information available on the use of tissue plasminogen activator in newborns. For this reason, alteplase is seldom considered as the therapy of choice. However, in patients with life-threatening thrombosis, such as the present case, the results obtained in adults could be extrapolated in search of a favorable outcome.Conclusions: Fibrinolytic therapy is a way to reduce the size of the thrombus, but it dramatically increases the risk of bleeding; consequently, these patients must be strictly monitored. In pediatric populations, due to the diameter of the blood vessels, thrombectomy is difficult to perform; additionally, recurrent thrombosis and the need for transfusion of blood products are frequent.
Collapse
|
15
|
Zhang DZ, Tan TH, Wong KPL, Sundaraghavan S, Choo JTL. Reperfusion Injury with Compartment Syndrome Following Systemic Thrombolysis for Cardiac Catheterization-Related Arterial Thrombosis in an Infant. J Pediatr Intensive Care 2020; 9:74-76. [PMID: 31984163 DOI: 10.1055/s-0039-1700522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 09/19/2019] [Indexed: 10/25/2022] Open
Abstract
Systemic thrombolysis is increasingly used for management of arterial thrombosis following cardiac catheterization, and complications apart from bleeding manifestations are not well reported. We report the case of an infant with lower limb ischemia secondary to femoral arterial thrombosis, which developed after cardiac catheterization. Systemic thrombolysis resulted in successful reperfusion of the lower limb. However, the infant subsequently developed compartment syndrome, requiring an emergent fasciotomy. This case highlights the importance of surveillance for the development of reperfusion injury-related compartment syndrome postsystemic thrombolysis for arterial thrombosis.
Collapse
Affiliation(s)
- Dyan Zhewei Zhang
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Teng Hong Tan
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kenneth Pak Leung Wong
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Sreekanthan Sundaraghavan
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jonathan Tze Liang Choo
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
16
|
Samuel R, Dixon A, Kretschmar P, Fletcher M, Warrier R. Is This Working "Well" for Pediatrics? The Diagnosis and Treatment of Thromboembolic Disease in a Patient With Protein C Deficiency. Clin Pediatr (Phila) 2020; 59:95-98. [PMID: 31603001 DOI: 10.1177/0009922819881208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Rajasekharan Warrier
- Ochsner Children's Hospital, New Orleans, LA, USA.,Ochsner Clinical School of University of Queensland, New Orleans, LA, USA
| |
Collapse
|
17
|
da Costa ACC, Vieira NNP, Vasques CI, Ferreira EB, Guerra ENS, Dos Reis PED. Interventions for Occluded Central Venous Catheters: A Meta-analysis. Pediatrics 2019; 144:peds.2018-3789. [PMID: 31757859 DOI: 10.1542/peds.2018-3789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Thrombotic occlusion is 1 of the most frequent complications in catheters implanted in children. OBJECTIVE To identify the interventions used to treat thrombotic events in long-term central venous catheters in pediatric patients with cancer. DATA SOURCES Electronic searches were performed in the Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences Literature, LIVIVO, PubMed, Scopus, Web of Science, Google Scholar, OpenGrey, and ProQuest databases. There were no restrictions on language or publication period. STUDY SELECTION This systematic review was performed in 2 phases and included clinical trials and observational studies on drugs used to treat thrombotic catheter events in pediatric patients with cancer. The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist, and the protocol was registered at PROSPERO (identifier CRD42018083555). DATA EXTRACTION The authors evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies and Grading of Recommendations Assessment, Development and Evaluation methods. The meta-analysis was performed by using Stata software. RESULTS Ten studies were included. The drugs used to restore catheter function were alteplase, urokinase, and streptokinase. A meta-analysis of 6 studies revealed an overall restoration rate of 88% for alteplase. LIMITATIONS Reference studies were excluded when it was not possible to reliably extract data that met the inclusion criteria of this review. Sampling issues (absence of randomization, blinding, or a control group) were the main methodologic concerns for the included articles. CONCLUSIONS On the basis of the evidence obtained, thrombolysis is effective and potentially safe in this population.
Collapse
Affiliation(s)
| | | | | | | | - Eliete Neves Silva Guerra
- Laboratory of Oral Histopathology, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
| | | |
Collapse
|
18
|
Gill AE, Patel KN. The Role of Interventional Radiology in the Treatment of Acute Thrombosis and Chronic Veno-Occlusive Disease in Children and Adolescents. Semin Roentgenol 2019; 54:324-336. [PMID: 31706366 DOI: 10.1053/j.ro.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anne E Gill
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Atlanta, GA.
| | - Kavita N Patel
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA; Emory University School of Medicine, Department of Pediatrics, Atlanta, GA
| |
Collapse
|
19
|
Management of symptomatic neonatal aortic thrombosis: When is surgery indicated? JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
20
|
Mahajerin A, Betensky M, Goldenberg NA. Thrombosis in Children: Approach to Anatomic Risks, Thrombophilia, Prevention, and Treatment. Hematol Oncol Clin North Am 2019; 33:439-453. [PMID: 31030812 DOI: 10.1016/j.hoc.2019.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pediatric venous thromboembolism (VTE) is increasing in incidence but minimal data exist for best practices regarding therapy, use of thrombophilia testing, and management of long-term complications. Classification schema use anatomic location and presence of clinical or thrombophilic inciting factors. There are a small number of risk-assessment and risk-modeling systems for incident VTE, but all suffer from low numbers, single-institution design, and lack of prospective validation. Acute treatment is limited to heparin products and thrombolysis may be indicated in specific situations. In addition, chronic postthrombotic comorbidities are expected to increase in incidence and lack evidence-based treatment paradigms.
Collapse
Affiliation(s)
- Arash Mahajerin
- Division of Hematology, 1201 West La Veta Avenue, Orange, CA 92868, USA.
| | - Marisol Betensky
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Pediatric Thrombosis Program, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins Medicine, 600 5th Street South, 4th Floor, St Petersburg, FL 33701, USA
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins Medicine, 600 5th Street South, 3rd Floor, St Petersburg, FL 33701, USA; Johns Hopkins Children's Center, Baltimore, MD, USA
| |
Collapse
|
21
|
Hanser A, Sieverding L, Hauser T, Wiegand G, Hofbeck M. Stent‐retriever thrombectomy in the treatment of infants with acute thrombosis of the superior vena cava and innominate vein. Catheter Cardiovasc Interv 2019; 93:E357-E361. [DOI: 10.1002/ccd.28142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/05/2018] [Accepted: 01/28/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Anja Hanser
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
| | - Ludger Sieverding
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
| | | | - Gesa Wiegand
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
| | - Michael Hofbeck
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
| |
Collapse
|
22
|
Hartman C, Shamir R, Simchowitz V, Lohner S, Cai W, Decsi T, Braegger C, Bronsky J, Cai W, Campoy C, Carnielli V, Darmaun D, Decsi T, Domellöf M, Embleton N, Fewtrell M, Fidler Mis N, Franz A, Goulet O, Hartman C, Hill S, Hojsak I, Iacobelli S, Jochum F, Joosten K, Kolaček S, Koletzko B, Ksiazyk J, Lapillonne A, Lohner S, Mesotten D, Mihályi K, Mihatsch WA, Mimouni F, Mølgaard C, Moltu SJ, Nomayo A, Picaud JC, Prell C, Puntis J, Riskin A, Saenz De Pipaon M, Senterre T, Shamir R, Simchowitz V, Szitanyi P, Tabbers MM, Van Den Akker CH, Van Goudoever JB, Van Kempen A, Verbruggen S, Wu J, Yan W. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Complications. Clin Nutr 2018; 37:2418-2429. [DOI: 10.1016/j.clnu.2018.06.956] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/30/2022]
|
23
|
Hauck A, Camarda J. Rare Cardiac Emergencies: Aortic Dissection, Pulmonary Hypertensive Crisis, and Pulmonary Embolism. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
24
|
Rizzi M, Albisetti M. Treatment of arterial thrombosis in children: Methods and mechanisms. Thromb Res 2018; 169:113-119. [DOI: 10.1016/j.thromres.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/05/2018] [Indexed: 12/17/2022]
|
25
|
Marchesi A, Tarissi de Jacobis I, Rigante D, Rimini A, Malorni W, Corsello G, Bossi G, Buonuomo S, Cardinale F, Cortis E, De Benedetti F, De Zorzi A, Duse M, Del Principe D, Dellepiane RM, D’Isanto L, El Hachem M, Esposito S, Falcini F, Giordano U, Maggio MC, Mannarino S, Marseglia G, Martino S, Marucci G, Massaro R, Pescosolido C, Pietraforte D, Pietrogrande MC, Salice P, Secinaro A, Straface E, Villani A. Kawasaki disease: guidelines of Italian Society of Pediatrics, part II - treatment of resistant forms and cardiovascular complications, follow-up, lifestyle and prevention of cardiovascular risks. Ital J Pediatr 2018; 44:103. [PMID: 30157893 PMCID: PMC6116479 DOI: 10.1186/s13052-018-0529-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 07/29/2018] [Indexed: 02/08/2023] Open
Abstract
This second part of practical Guidelines related to Kawasaki disease (KD) has the goal of contributing to prompt diagnosis and most appropriate treatment of KD resistant forms and cardiovascular complications, including non-pharmacologic treatments, follow-up, lifestyle and prevention of cardiovascular risks in the long-term through a set of 17 recommendations.Guidelines, however, should not be considered a norm that limits the treatment options of pediatricians and practitioners, as treatment modalities other than those recommended may be required as a result of peculiar medical circumstances, patient's condition, and disease severity or individual complications.
Collapse
Affiliation(s)
| | | | - Donato Rigante
- Università Cattolica Sacro Cuore, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | | | | | | | | | - Sabrina Buonuomo
- Bambino Gesù Children’s Hospital, Piazza S. Onofrio n. 4, 00165 Rome, Italy
| | | | | | | | - Andrea De Zorzi
- Bambino Gesù Children’s Hospital, Piazza S. Onofrio n. 4, 00165 Rome, Italy
| | - Marzia Duse
- Università degli Studi Sapienza, Rome, Italy
| | | | | | | | - Maya El Hachem
- Bambino Gesù Children’s Hospital, Piazza S. Onofrio n. 4, 00165 Rome, Italy
| | | | | | - Ugo Giordano
- Bambino Gesù Children’s Hospital, Piazza S. Onofrio n. 4, 00165 Rome, Italy
| | | | | | | | | | - Giulia Marucci
- Bambino Gesù Children’s Hospital, Piazza S. Onofrio n. 4, 00165 Rome, Italy
| | | | | | | | | | | | - Aurelio Secinaro
- Bambino Gesù Children’s Hospital, Piazza S. Onofrio n. 4, 00165 Rome, Italy
| | | | - Alberto Villani
- Bambino Gesù Children’s Hospital, Piazza S. Onofrio n. 4, 00165 Rome, Italy
| |
Collapse
|
26
|
Taha MAH, Busuttil A, Bootun R, Davies AH. A systematic review of paediatric deep venous thrombolysis. Phlebology 2018; 34:179-190. [DOI: 10.1177/0268355518778660] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The aim was to assess the effectiveness and safety of catheter-directed thrombolysis in children with deep venous thrombosis and to evaluate its long-term effect. Method and results EMBASE, Medline and Cochrane databases were searched to identify studies in which paediatric acute deep venous thrombosis patients received thrombolysis. Following title and abstract screening, seven cohort studies with a total of 183 patients were identified. Technical success was 82% and superior in regional rather than systemic thrombolysis (p < 0.00001). One cohort study identified significant difference in thrombus resolution at one year between thrombolytic and anticoagulant groups (p = 0.01). The complication rate was low, with incidence rates of major bleeding, pulmonary embolism and others at 2.8%, 1.8% and 8.4%, respectively. The overall post-thrombotic syndrome rate was 12.7%. The incidence of re-thrombosis ranged from 12.3% to 27%. Conclusion Thrombolysis for paediatric deep venous thrombosis is an effective and relatively safe therapeutic option, lowering the incidence of post-thrombotic syndrome and deep venous thrombosis recurrence.
Collapse
Affiliation(s)
- Mohamed AH Taha
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Andrew Busuttil
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Roshan Bootun
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
| |
Collapse
|
27
|
Abstract
Pulmonary embolism (PE) in children is a rare condition with potential for high mortality. PE incidence is increasing owing to increased survival of children with predisposing conditions, increased use of central venous catheters, and improved awareness and recognition. Although pediatric PE is distinct from adult PE, management guidelines in children are extrapolated from the adult data. Treatment includes thrombolysis or thrombectomy, and pharmacologic anticoagulation. Ongoing clinical trials are evaluating the use of direct oral anticoagulants in children. Further research is required to develop pediatric-specific evidence-based guidelines for diagnosis and management of PE.
Collapse
Affiliation(s)
- Sarah Ramiz
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA
| | - Madhvi Rajpurkar
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA.
| |
Collapse
|
28
|
Thrombolysis Using Tissue Plasminogen Activator: Experience from a Critical Care Setting. Indian J Hematol Blood Transfus 2018; 34:723-726. [PMID: 30369748 DOI: 10.1007/s12288-018-0952-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022] Open
Abstract
To describe the experience of thrombolysis using tissue plasminogen activator (tPA) in critically ill children admitted to the pediatric intensive care unit (PICU), retrospective review of medical records of all children (1 month-16 years), who were admitted in PICU since January 2014 to December 2017 and received systemic tPA for thrombolysis was done. Data was collected on a structured proforma and included thrombus location, tPA dose and duration, outcome (resolution, survival) and complications (bleeding). Total 9 patients (7 males, 2 females) received systemic tPA therapy for thrombolysis with mean age of 74.64 ± 69.58 months. Two patients had thrombus in femoral artery, 3 in IVC and 4 had intra-cardiac thrombosis. Median number of doses was 2 with a range of 1-5 doses. Complete resolution of the clot was noted in all except one patient. A standard starting dose of 0.01 mg/kg/h was used in all patients. Only one patient developed melena after TPA therapy which self-resolved. Systemic tPA therapy was very safe in pediatric critically ill patients and was effective for thrombolysis and did not show any adverse effects in children with varying underlying diagnosis.
Collapse
|
29
|
Streif W. Myocardial infarction in a neonate. Lessons for neonatal and internal medicine. Hamostaseologie 2017; 37:219-222. [PMID: 28318007 DOI: 10.5482/hamo-16-09-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/01/2017] [Indexed: 11/05/2022] Open
Abstract
Due to the lack of evidence-based guidelines, management strategies for neonatal MI should be individualized and administered largely at the discretion of responsible treating teams. Supportive care with a focus on preserving adequate circulation and antithrombotic therapy with a view to restoring vascular patency are the mainstays of treatment. Thrombolytic therapy of neonatal MI includes a chance to completely restore myocardial function. Understanding the resilience of the neonatal heart and mechanism of cardiac cell repair in neonates may spark novel treatment strategies for severe MI in the large number of affected individuals in an aging population.
Collapse
Affiliation(s)
- Werner Streif
- Ao. Univ.-Prof. Dr. Werner Streif, Medizinische Universität Innsbruck (MUI), Dept. für Kinder- und Jugendheilkunde, Pädiatrie 1, Anichstrasse 35, A - 6020 Innsbruck, Tel: +43-512-504 23600, Fax: +43-512-504 23484, E-Mail:
| |
Collapse
|
30
|
Betensky M, Bittles MA, Colombani P, Goldenberg NA. How We Manage Pediatric Deep Venous Thrombosis. Semin Intervent Radiol 2017; 34:35-49. [PMID: 28265128 PMCID: PMC5334487 DOI: 10.1055/s-0036-1597762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Over the past two decades, the incidence and recognition of venous thromboembolism (VTE) in children has significantly increased, likely as a result of improvements in the medical care of critically ill patients and increased awareness of thrombotic complications among medical providers. Current recommendations for the management of VTE in children are largely based on data from pediatric registries and observational studies, or extrapolated from adult data. The scarcity of high-quality evidence-based recommendations has resulted in marked variations in the management of pediatric VTE among providers. The purpose of this article is to summarize our institutional approach for the management of VTE in children based on available evidence, guidelines, and clinical practice considerations. Therapeutic strategies reviewed in this article include the use of conventional anticoagulants, parenteral targeted anticoagulants, new direct oral anticoagulants, thrombolysis, and mechanical approaches for the management of pediatric VTE.
Collapse
Affiliation(s)
- Marisol Betensky
- Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A. Bittles
- Department of Radiology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Paul Colombani
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A. Goldenberg
- Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
31
|
Tarango C, Manco-Johnson MJ. Pediatric Thrombolysis: A Practical Approach. Front Pediatr 2017; 5:260. [PMID: 29270396 PMCID: PMC5723643 DOI: 10.3389/fped.2017.00260] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/20/2017] [Indexed: 01/07/2023] Open
Abstract
The incidence of pediatric venous thromboembolic disease is increasing in hospitalized children. While the mainstay of treatment of pediatric thrombosis is anticoagulation, reports on the use of systemic thrombolysis, endovascular thrombolysis, and mechanical thrombectomy have steadily been increasing in this population. Thrombolysis is indicated in the setting of life- or limb-threatening thrombosis. Thrombolysis can rapidly improve venous patency thereby quickly ameliorating acute signs and symptoms of thrombosis and may improve long-term outcomes such as postthrombotic syndrome. Systemic and endovascular thrombolysis can result in an increase in minor bleeding in pediatric patients, compared with anticoagulation alone, and major bleeding events are a continued concern. Also, endovascular treatment is invasive and requires technical expertise by interventional radiology or vascular surgery, and such expertise may be lacking at many pediatric centers. The goal of this mini-review is to summarize the current state of knowledge of thrombolysis/thrombectomy techniques, benefits, and challenges in pediatric thrombosis.
Collapse
Affiliation(s)
- Cristina Tarango
- Division of Hematology, Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center Cincinnati, University of Cincinnati, Cincinnati, OH, United States
| | - Marilyn J Manco-Johnson
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplantation, University of Colorado Anschutz Medical Campus, Children's Hospital, Aurora, CO, United States
| |
Collapse
|
32
|
A Previously Healthy Premature Infant Treated With Thrombolytic Therapy for Life-threatening Pulmonary Artery Thrombosis. J Pediatr Hematol Oncol 2016; 38:e319-e321. [PMID: 27258032 DOI: 10.1097/mph.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary artery thrombosis is rarely reported in preterm neonates. Although treatment of neonatal thrombosis remains controversial, thrombolytic agents must be considered when the thrombosis is life threatening. We herein present a case of a preterm newborn with pulmonary artery thrombosis accompanied by acute-onset respiratory failure and cyanotic congenital heart disease. The thrombosis was successfully treated using tissue plasminogen activator. In conclusion, the thrombolytic therapy should be considered in treatment of patients in whom the thrombosis completely occludes the pulmonary arteries.
Collapse
|
33
|
Endovascular thrombolysis to salvage central venous access in children with catheter-associated upper extremity deep vein thrombosis: technique and initial results. J Thromb Thrombolysis 2016; 40:274-9. [PMID: 25894473 DOI: 10.1007/s11239-015-1209-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Nine patients (average age 8.3 years, range 20 days to 17 years; average weight 31 kg, range 2.7-79 kg) with catheter-associated UE-DVT underwent upper extremity venous thrombolysis with the goal of access salvage. Catheter directed therapy with alteplase (tPA), balloon angioplasty, and mechanical thrombectomy was used in all cases. The mean total dose of TPA was 15 mg (range 1-40 mg). Venous access was ultimately preserved in all patients. No stents or superior vena cava filters were used. There was one episode of symptomatic clinically suspected pulmonary embolism managed by systemic tPA and heparin without long term sequaele. Mean imaging and clinical follow-up was 351 ± 208 and 613 ± 498 days respectively. Endovenous thrombolysis for catheter-associated upper-extremity DVT in children may be safe and effective and could be considered particularly in patients in whom long-term venous access is needed.
Collapse
|
34
|
Crystal MA. Thrombolytic Use in Children: Breaking Down Barriers. J Pediatr 2016; 171:12-3. [PMID: 26778259 DOI: 10.1016/j.jpeds.2015.12.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/23/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Matthew A Crystal
- Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-New York Presbyterian Hospital, New York, New York.
| |
Collapse
|
35
|
Tissue Plasminogen Activator Use in Children: Bleeding Complications and Thrombus Resolution. J Pediatr 2016; 171:67-72.e1-2. [PMID: 26707578 DOI: 10.1016/j.jpeds.2015.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/02/2015] [Accepted: 11/06/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review our institutional experience with tissue plasminogen activator (tPA) to determine outcomes related to bleeding complications and thrombus resolution. STUDY DESIGN We performed a retrospective review of all patients who received systemic tPA for thrombolysis. Data points included location of thrombus, initial and maximum tPA dose, and duration of tPA. The primary endpoint was bleeding complication. RESULTS Between 2005 and 2014, 46 patients received systemic tPA for thrombolysis: 17 (37%) were patients with a primary cardiac diagnosis, there were 17 (37%) hematology/oncology patients, and 12 (26%) patients with noncardiac, nonhematology/oncology diagnoses. The indication for tPA was central venous thrombus (n = 23), pulmonary artery thrombus (n = 9), and cardiac or aortic thrombus (n = 14). Bleeding complications occurred in 15 patients (33%). Median initial tPA dose in the bleeding complication group was 0.10 mg/kg/h vs 0.03 mg/kg/h in the group without bleeding complication group (P = .01). Cardiac patients experienced more bleeding complications (P = .01). Multivariate analysis indicated that dose of tPA (P = .01) and diagnostic category (P < .01) were associated with bleeding complication. Complete thrombus resolution occurred in 21 patients, partial in 10 patients, and no resolution in 15 patients. Complete resolution of thrombus was not associated with diagnosis, thrombus location, tPA dose, or duration. CONCLUSIONS Cardiac patients appear to be at highest risk of bleeding complication; bleeding complications were associated with higher doses of tPA, and cardiac patients were the cohort who received the highest doses of tPA. Higher tPA doses are associated with increased risk of bleeding complication but are not associated with successful thrombus resolution.
Collapse
|
36
|
Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Antihypertensives. Pediatr Crit Care Med 2016; 17:S101-8. [PMID: 26945324 DOI: 10.1097/pcc.0000000000000621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hypertension remains a common condition in pediatric cardiac intensive care. The physiologic effects of hypertension in this population are complex and are impacted by patient age, comorbidities, and primary cardiac disease. The objective of this study is to review current pharmacotherapies for the management of systemic hypertension in the pediatric cardiac ICU. DATA SOURCES Relevant literature to the treatment of systemic hypertension in children was included. Specific focus was given to literature studying the use of therapies in critically ill children and those with heart disease. Reference textbooks and drug packaging inserts were used for drug-specific pediatric guidelines. STUDY SELECTION A search of MEDLINE, PubMed, and the Cochrane Database was performed to find literature about the management of hypertension in children. Metaanalyses and pediatric-specific studies were primarily considered and cross-referenced. Pertinent adult studies were included. DATA EXTRACTION Once the studies for inclusion were finalized, priority for data extraction was given to pediatric-specific studies that focused on children with heart disease and critical illness. CONCLUSIONS Systemic hypertension is common, and there is significant heterogeneity in the patient population with critical heart disease. There are limited large, prospective analyses of safety and efficacy for pediatric drug antihypertensive agents. Despite patient heterogeneity, most pharmacotherapies are safe and efficacious.
Collapse
|
37
|
Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis. Pediatr Crit Care Med 2016; 17:S77-88. [PMID: 26945332 DOI: 10.1097/pcc.0000000000000623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Thrombotic complications are increasingly being recognized as a significant cause of morbidity and mortality in pediatric and congenital heart disease. The objective of this article is to review the medications currently available to prevent and treat such complications. DATA SOURCES Online searches were conducted using PubMed. STUDY SELECTION Studies were selected for inclusion based on their scientific merit and applicability to the pediatric cardiac population. DATA EXTRACTION Pertinent information from each selected study or scientific review was extracted for inclusion. DATA SYNTHESIS Four classes of medications were identified as potentially beneficial in this patient group: anticoagulants, antiplatelet agents, thrombolytic agents, and novel oral anticoagulants. Data on each class of medication were synthesized into the follow sections: mechanism of action, pharmacokinetics, dosing, monitoring, reversal, considerations for use, and evidence to support. CONCLUSIONS Anticoagulants, antiplatelet agents, and thrombolytic agents are routinely used successfully in the pediatric patient with heart disease for the prevention and treatment of a wide range of thrombotic complications. Although the novel oral anticoagulants have been approved for a limited number of indications in adults, studies on the safety and efficacy of these agents in children are pending.
Collapse
|
38
|
Manlhiot C, Brandão LR, Schwartz SM, Sivarajan VB, Williams S, Collins TH, McCrindle BW. Management and Outcomes of Patients with Occlusive Thrombosis after Pediatric Cardiac Surgery. J Pediatr 2016; 169:146-53. [PMID: 26589345 DOI: 10.1016/j.jpeds.2015.10.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/24/2015] [Accepted: 10/13/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate management and outcomes of thrombosis after pediatric cardiac surgery and stratify thrombi according to risk of short- and long-term complications to better guide therapeutic choices. STUDY DESIGN Retrospective review was performed of 513 thrombi (400 occlusive) diagnosed after 213 pediatric cardiac operations. Long-term outcomes over time were assessed with the use of parametric hazard regression models. RESULTS Serious complications and/or high-intensity treatment occurred with 17%-24% of thrombi depending on location, most commonly in thrombi affecting the cardiac and cerebral circulation. Bleeding complications affected 13% of patients; associated factors included thrombolytics (OR 8.7, P < .001), greater daily dose of unfractionated heparin (OR 1.25 per 5 U/kg/day, P = .03), and extracorporeal support (OR 4.5, P = .007). Radiologic thrombus persistence was identified in 30% ± 3% at 12 months; associated factors included extracorporeal support (hazard ratio [HR] 1.9, P = .003), venous (HR 1.7, P = .003), and occlusive thrombi at presentation (HR 1.8, P = .001); greater oxygen saturation before surgery (HR 1.13/10%, P = .05) and thrombi in femoral veins (HR 1.9, P = .001) were associated with increased hazard of resolution. Freedom from postthrombotic syndrome was 83% ± 4% at 6 years, greater number of persistent vessel segment occlusions (HR 1.8/vessel, P = .001) and greater fibrinogen at diagnosis (HR 1.1 per g/L, P = .02) were associated with increased hazard. CONCLUSIONS Thrombosis outcomes after pediatric cardiac surgery remain suboptimal. Given that more intensive treatment would likely increase the risk of bleeding, the focus should be on both thrombosis-prevention strategies, as well as in tailoring therapy according to a thrombosis outcome risk stratification approach.
Collapse
Affiliation(s)
- Cedric Manlhiot
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Steven M Schwartz
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - V Ben Sivarajan
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Tanveer H Collins
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| |
Collapse
|
39
|
Stächele J, Dinger J, Brenner S, Hofmann SR, Ifflaender S, Knöfler R. Successful thrombolytic treatment of neonatal arterial thromboses. Hamostaseologie 2015; 34 Suppl 1:S57-9. [PMID: 25382773 DOI: 10.5482/hamo-14-02-0014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 07/07/2014] [Indexed: 11/05/2022] Open
Abstract
Compared to children of other age groups neonates show an increased thrombotic risk. The acute therapy depends on thrombus age, the localisation of vascular occlusion and the severity of the underlying disease. The treatment of choice is represented by the administration of unfractionated (UFH) or low molecular weight heparin (LMWH). If loss of limbs or organs is imminent, the application of thrombolytic treatment with recombinant tissue-type plasminogen activator (rt-PA) should be considered whilst taking into account the associated bleeding risk. We report on two patients in which thrombolytic therapy has been conducted successfully.
Collapse
Affiliation(s)
- J Stächele
- Julia Stächele, Klinik und Poliklinik für Kinder- und Jugendmedizin, Fachbereich Hämostaseologie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany, E-Mail:
| | | | | | | | | | | |
Collapse
|
40
|
Álvarez Z P, Verdugo L P, Carvajal K L, Múhlhausen M G, Ríos A P, Rodríguez V D. [Recombinant tissue plasminogen activator for the management of intracardiac thrombi in newborns]. ACTA ACUST UNITED AC 2015; 86:194-9. [PMID: 26235268 DOI: 10.1016/j.rchipe.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/30/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The incidence of cardiac thrombi in newborns has increased with the use of central venous catheters. Thrombolysis with recombinant tissue plasminogen activator (rTPA) has been used as an alternative to heparin in life threatening giant thrombus and embolization. The aim of this study is to describe the response and complications related to the use of rTPA in the management of life- threatening cardiac thrombi in newborns. PATIENTS AND METHOD The medical records of 8 newborn were reviewed in a retrospective study, of whom 7 were preterm with cardiac thrombi, and rTPA was used in all of them. RESULTS The patients included 4 males with a mean weight of 1580 gr. The principal pathology was sepsis (7/8), all of them used venous central catheter. The superior vena cava was the most frequent location, with a mean time of installation before the diagnosis of 12 days. RN 7/8 thrombi were located in the right atrium with a size between 7 to 20 mm. Three patients received low molecular weight heparin prior to using rTPA. They received between 1 to 5 cycles with rTPA. In 4 patients complete resolution of the thrombus was achieved in a mean of 3.5 days. Four patients had intracranial haemorrhage grade I, without sequelae at follow-up. There were no deaths or embolism. CONCLUSION This study is the first series of infants treated with rTPA in Chile, and where its use has quickly achieved complete resolution of the thrombus in 50% of cases, and partially in the others, thus reducing the secondary life-threatening risk of this disease.
Collapse
Affiliation(s)
- Patricia Álvarez Z
- Hospital Roberto del Río, Santiago, Chile; Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Clínica Alemana de Santiago, Santiago, Chile.
| | - Patricia Verdugo L
- Hospital Roberto del Río, Santiago, Chile; Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Clínica Santa María, Santiago, Chile
| | | | - Germán Múhlhausen M
- Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Servicio de Neonatología, Hospital San José, Santiago, Chile
| | | | | |
Collapse
|
41
|
Radulescu VC. Management of venous thrombosis in the pediatric patient. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2015; 6:111-119. [PMID: 29388593 PMCID: PMC5683259 DOI: 10.2147/phmt.s65697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The incidence of venous thromboembolism in children has increased significantly over the past decade. The evaluation and management of the child with venous thromboembolism, while based on the adult experience, has its own particularities dictated by the differences in the hemostatic system of the newborn and child. The current review addresses the evaluation of pediatric patient with thrombosis as well as the established and emerging treatment interventions.
Collapse
Affiliation(s)
- Vlad C Radulescu
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
42
|
Toledo del Castillo B, Santiago Lozano M, López-Herce Cid J, Mencía Bartolomé S. Taponamiento cardiaco secundario a fibrinólisis con dosis bajas de rt-PA. An Pediatr (Barc) 2015; 82:e264-5. [DOI: 10.1016/j.anpedi.2013.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 10/22/2013] [Accepted: 10/23/2013] [Indexed: 11/26/2022] Open
|
43
|
Outcomes in children with deep vein thrombosis managed with percutaneous endovascular thrombolysis. Pediatr Radiol 2015; 45:719-26. [PMID: 25378210 DOI: 10.1007/s00247-014-3209-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 09/16/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Our center has developed a multidisciplinary approach to percutaneous endovascular thrombolysis with the goal of improving outcomes in children with thrombosis. There is little data describing the safety and efficacy of endovascular thrombolysis and the frequency of post-thrombotic syndrome after thrombolysis in children. OBJECTIVE Retrospective analysis of children undergoing percutaneous endovascular thrombolysis to determine (1) the safety and efficacy of this procedure and (2) the frequency of the diagnosis of post-thrombotic syndrome after thrombolysis. MATERIALS AND METHODS We reviewed the medical and imaging databases for children who underwent percutaneous endovascular thrombolysis for deep venous thrombosis (DVT) between November 2008 and June 2013 at our institution. Demographic data were reviewed for the technical success and complications of thrombolysis and the last assigned post-thrombotic syndrome score using standardized scoring tools. RESULTS Forty-one children ages 3 months to 21 years (median age: 15 years; 44% male) underwent percutaneous endovascular thrombolysis between November 2008 and June 2013. Upper extremity DVT occurred in 13 patients (32%); lower extremity DVT occurred in 28 patients (68%). All 41 patients received thrombolysis grading; 90% of those patients achieved greater than 50% thrombus lysis. Twenty-eight patients received formal post-thrombotic syndrome scoring and 4 (14%) met diagnostic criteria for post-thrombotic syndrome. One major bleeding episode and one pulmonary embolism occurred with no long-term sequelae. CONCLUSION Endovascular thrombolysis for DVT in children is safe, effective at thrombus removal and may reduce the incidence of post-thrombotic syndrome. Randomized or larger clinical trials would be needed to determine the long-term benefits of endovascular thrombolysis.
Collapse
|
44
|
Abstract
Two detailed reviews of the management of neonatal thrombosis were published in 2012; one was an up-dated version of guidance first issued in 2004 and the other was a comprehensive review. Both of these publications gave very similar advice regarding the practical aspects of the indications, dosage and management of antithrombotic therapy. The authors stated that the evidence supporting most of their recommendations for anti-thrombotic therapy in neonates remained weak and so the therapy for a neonate with a thrombosis has to be based on an individualized assessment of estimated risk versus potential benefit. The aim of this present review is to give the treating physician an outline of the unique physiology of neonatal coagulation and how this affects the monitoring, dosing and even the choice of therapeutic strategy for the management of thrombosis in the neonate.
Collapse
Affiliation(s)
- Andrew Will
- Department of Paediatric Haematology, Royal Manchester Children's Hospital, Manchester, UK
| |
Collapse
|
45
|
Kukreja KU, Lungren MP, Patel MN, Johnson ND, Racadio JM, Dandoy C, Tarango C. Endovascular venous thrombolysis in children younger than 24 months. J Vasc Interv Radiol 2014; 25:1158-64. [PMID: 24909354 DOI: 10.1016/j.jvir.2014.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 04/03/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To evaluate the technical feasibility and safety of percutaneous endovascular thrombolysis for extremity deep venous thrombosis (DVT) in children < 24 months old. MATERIALS AND METHODS A retrospective chart review of a clinical and imaging database was performed for pediatric patients who underwent endovascular therapy for DVT between January 2010 and July 2013. Indications, techniques, technical and clinical success, and complications were reviewed. Techniques for thrombolysis included catheter-directed therapy (CDT) using alteplase infusion via a multi-side hole catheter, mechanical thrombectomy, and angioplasty. Short-term outcomes were assessed using surgical and imaging follow-up examinations for patency of the targeted vessel. Patients included 11 children (mean age, 9 mo; range, 3 wk-23 mo) who consecutively underwent endovascular thrombolysis for upper extremity (n = 6) or lower extremity (n = 5) DVT. The most common indication was preservation of venous access for future cardiac surgery or medical therapy. RESULTS The most common risk factor was the presence of a central venous catheter (10 of 11 patients). All patients with upper extremity DVT had congenital heart disease. CDT and angioplasty were performed in all patients. Venous patency was established in all patients. A grade III (95%-100%) thrombolysis response was achieved in seven patients, and a grade II (50%-95%) thrombolysis response was achieved in four patients. A major complication of pulmonary embolism occurred in one patient with upper extremity thrombolysis and was managed by intravenous systemic alteplase and heparin. No recurrence of thrombosis was found on average follow-up of 11.8 months (range, 1-41 mo). CONCLUSIONS Percutaneous endovascular thrombolysis for extremity DVT is safe and technically feasible in children < 24 months old.
Collapse
Affiliation(s)
- Kamlesh U Kukreja
- Department of Radiology, Baylor College of Medicine & Texas Children's Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030.
| | - Matthew P Lungren
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Manish N Patel
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Neil D Johnson
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John M Racadio
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher Dandoy
- Department of Radiology and Hematology & Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cristina Tarango
- Department of Radiology and Hematology & Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
46
|
de Lorenzo-Pinto A, Sánchez-Galindo AC, Manrique-Rodríguez S, Fernández-Llamazares CM, Fernández-Lafever SN, San-Prudencio MG, Cortejoso L, Sanjurjo-Sáez M. Prevention and treatment of intraluminal catheter thrombosis in children hospitalised in a paediatric intensive care unit. J Paediatr Child Health 2014; 50:40-6. [PMID: 24134335 DOI: 10.1111/jpc.12404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM The aim of the study was to develop and implement a protocol for the prevention and treatment of catheter related intraluminal thrombosis in a paediatric intensive care unit METHODS A computerised search was carried out on MEDLINE, through PubMed, using the medical subject heading 'central venous catheter', 'central venous access device', 'central venous line' associated with 'occlusion', 'obstruction', 'catheter-related thrombosis', 'critically ill patients' and 'thrombolytic therapy'. References of reviewed articles were also searched for relevant titles as well as non-randomised controlled trials and series of cases when no information of higher level of evidence was available. RESULTS With the information gathered, a protocol for the prevention and treatment of catheter related intraluminal thrombosis was elaborated and those recommendations that best suit our environment were included. They were agreed upon by a broad panel of professionals working in the Pediatric Intensive Care Unit and the Pharmacy Department. CONCLUSIONS Due to the variety of options available for the pharmacotherapeutic management of intraluminal catheter thrombosis, one measure to improve the quality of the therapy and to diminish the variability in the prescription could be the implementation of a protocol as described in this paper.
Collapse
Affiliation(s)
- Ana de Lorenzo-Pinto
- Pharmacy Department, Gregorio Marañón University General Hospital, Madrid, Spain
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
Pediatric deep vein thrombosis is an increasingly recognized phenomenon, especially with advances in treatment and supportive care of critically ill children and with better diagnostic capabilities. High-quality evidence and uniform management guidelines for antithrombotic treatment, particularly thrombolytic therapy, remain limited. Optimal dosing, intensity and duration strategies for anticoagulation as well as thrombolytic regimens that maximize efficacy and safety need to be determined through well-designed clinical trials using use of a risk-stratified approach.
Collapse
|
48
|
Su T, Wu W, Yan T, Zhang C, Zhu Q, Bao B. Pharmacokinetics and tissue distribution of a novel marine fibrinolytic compound in Wistar rat following intravenous administrations. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 942-943:77-82. [PMID: 24216275 DOI: 10.1016/j.jchromb.2013.10.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/11/2013] [Accepted: 10/18/2013] [Indexed: 11/19/2022]
Abstract
We investigated a novel marine fibrinolytic compound for use in thrombolytic therapy. Pharmacokinetics and the tissue distribution of this novel marine fibrinolytic compound, FGFC1(2) (fungi fibrinolytic compound 1), were investigated in Wistar rats after intravenous (IV) bolus administration of two concentrations (10 and 20mg/kg). Plasma FGFC1 and tissue extracts were measured using HPLC with UV detection. FGFC1 was detected using a C18 column with a gradient eluted mobile phase of acetonitrile-water (0.1% trifluoroacetic acid), 1.0mL/min. Chromatograms were monitored at 265nm (column temperature: 40°C). Pharmacokinetic data indicate that FGFC1 fitted well to a two-compartment model. Elimination half-lives (t1/2) of FGFC1 were 21.51±2.17 and 23.22±2.11min for 10 and 20mg/kg, respectively. AUC0-t were 412.19±19.09, 899.09±35.86μg/mLmin, systemic clearance (CL) was 0.023±0.002, 0.022±0.002 ((mg/kg)/(μg/mL)/min) and the mean residence time (MRT) was 10.15±0.97, 9.65±1.40min at 10 and 20mg/kg, respectively. No significant differences were observed in the systemic clearance and mean residence time at the tested doses, suggesting linear pharmacokinetics in rats. Tissue distribution data reveal that FGFC1 distributed rapidly in most tissues except the brain and that the highest concentration of the drug was in the liver. In the small intestine, FGFC1 initially increased and then declined, but remained comparatively high 60min after administration, suggesting that enterohepatic circulation may exist.
Collapse
Affiliation(s)
- Tongwei Su
- College of food Science and Technology, Shanghai Ocean University, Shanghai 201306, China
| | | | | | | | | | | |
Collapse
|
49
|
Zia AN, Chitlur M. Management of thrombotic complications in acute lymphoblastic leukemia. Indian J Pediatr 2013; 80:853-62. [PMID: 23912824 DOI: 10.1007/s12098-013-1158-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 06/20/2013] [Indexed: 01/03/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common type of cancer diagnosed in children, and has been reported as the most common malignancy associated with thromboembolism in the pediatric age group. Treatment with Escherichia coli asparaginase, concomitant steroids, presence of central venous lines, and thrombophilic abnormalities are established risk factors for thromboembolism. The incidence varies with age, co-morbidities and chemotherapy regimens but the risk is highest during the induction and intensification phases. Treatment is necessary in majority of children to prevent serious sequelae. Mortality from thromboembolic events in any location is 2 to 4 % and the risk of recurrence is 7 to 10 %, further enhanced in the setting of malignancy. Randomized trials of venous thromboembolism (VTE) management in pediatric patients with ALL are lacking due to the low overall incidence, resulting in considerable variation in practice. The objective of this article is to review current knowledge on the treatment and prevention of thrombosis associated with pediatric ALL.
Collapse
Affiliation(s)
- Ayesha N Zia
- Carman and Ann Adams Department of Pediatrics, Division of Hematology/Oncology, Wayne State University School of Medicine, Detroit, MI, USA,
| | | |
Collapse
|
50
|
Abstract
Abstract
The incidence of venous thromboembolism (VTE) in the pediatric population is increasing. Technological advances in medicine and imaging techniques, improved awareness of the disease, and longer survival of life-threatening or chronic medical conditions all contribute to the increase in VTE rates. There is a paucity of data on management of VTE based on properly designed clinical trials, but there is significant advancement in the last 2 decades. This review summarizes the progress made in pediatric thrombosis, including epidemiological changes, advances in anticoagulant agents, and outcomes of VTE.
Collapse
|