Endovascular treatment of near-fatal neonatal superior vena cava syndrome

Exploratory Use of Glycoprotein IIb/IIIa Inhibition in Prevention of Blalock-Taussig Shunt Thrombosis

OBJECTIVES

Morbidity and mortality related to modified Blalock-Taussig shunt (mBTTS) thrombosis remain a significant risk. Platelet inhibition following mBTTS may reduce this risk. However, oral antiplatelet agents have variable absorption following surgery. We determine risk factors for mBTTS thrombosis and hypothesize that IV glycoprotein IIb/IIIa inhibitor (tirofiban) as a bridge to oral aspirin reduces the rate of shunt thrombosis in the immediate postoperative period. End points within the 14-day follow-up period include mBTTS thrombosis, overall thrombosis, bleeding, length of stay, and mortality.

DESIGN

Retrospective, Institutional Review Board-approved cohort study.

SETTING

Single-center cardiac ICU.

PATIENTS

Patients under the age of 18 who had an mBTTS placed within the study period of January 2008 to December 2018 were included.

INTERVENTIONS

Patients were divided into two groups: standard of care (SOC) anticoagulation alone and SOC with tirofiban as a bridge to oral aspirin.

MEASUREMENTS AND MAIN RESULTS

Freedom from mBTTS thrombosis was estimated using the Kaplan-Meier method. A multivariable predictive model using the four most significant risk factors was developed using logistic regression. A total of 272 patients were included: 36 subjects in the SOC/tirofiban group and 236 in the SOC group. Shunt thrombosis occurred in 26 (11%) SOC group with zero in SOC/tirofiban group ( p = 0.03). The median time to thrombosis was 0 days (range, 0-12 d). The area under the curve for the predictive model (anticoagulation group, history of coagulopathy, intraoperative shunt clipping, and shunt size/weight ratio) is 0.790 ( p < 0.001). Prevalence of bleeding and mortality was not significantly different between the groups.

CONCLUSIONS

Highest risk for shunt thrombosis following mBTTS occurs within the first few days after surgical procedure. Tirofiban is a safe addition to SOC and may be an effective strategy to prevent early mBTTS thrombosis.

Acute intraprocedural thrombosis during an arterial ductal stenting successfully managed by eptifibatide

Acute stent thrombosis may complicate neonatal arterial duct stenting for reduced pulmonary blood flow. Thrombolytic agents recanalise the clot but may cause bleeding around the vascular sheaths and other sites. Since early thrombus is platelet mediated, intravenous platelet glycoprotein inhibitor like eptifibatide is likely to be effective, but rarely utilised in neonates. Ductal stent thrombosis treated with eptifibatide is reported.

Superior vena cava syndrome causing chylothoraces in a preterm neonate: a case report and literature review

A preterm neonate developed catheter-related central venous and dural sinus thrombosis. Superior vena cava (SVC) obstruction caused significant bilateral chylothoraces and SVC thrombotic obstruction led to generalized anasarca and multiple organ failure. Six weeks after the diagnosis of SVC and sagittal sinus occlusion and chylothoraces, the infant expired. We report a rare case of a chylothoraces secondary to SVC obstruction, and superior sagittal sinus thrombosis in a preterm neonate, and review the literature.

Neonatal and infant pulmonary thromboembolism: a literature review

Pulmonary thromboembolism (PTE) is rare in neonates and infants; however evidence suggests it is underdiagnosed. The primary objective is to conduct a scientific review to determine if the presentation, diagnosis, treatment and outcomes of neonates and infants with PTE are consistent across studies. Secondly, to develop an algorithm to establish the diagnosis and management of the condition based on current information. Two authors searched the literature independently using existing databases and verified that identical articles were assembled. Infants aged less than 1 year with PTE were included and further categorized into neonates 28 days or less and infants 29 days to 1 year or less. Forty-five articles with 157 cases (121 neonates; 36 infants) were identified with PTE. All of the reports were descriptive and neither randomized controlled trials nor prospective or case-control studies were identified. The reports are sub-classified into cases of pulmonary air embolism (PAE) with a higher mortality rate and patients with PTE. Diagnostic and treatment strategies varied widely and were individually case-based, dependent on clinical findings, which influenced patient outcomes. Scientific data to guide an evidence-based, diagnostic and treatment approach to PTE is limited because of the absence of rigorous clinical trials. Large scale, multicenter collaborative studies are required to firmly establish the management of PTE in this population.