Aortic Arch Thrombosis in a Neonate With Heterozygous Carrier Status of Factor V Leiden Mutation

Transcatheter mechanical thrombectomy of neonatal occlusive aortic thrombus using an Amplatzer Piccolo PDA occluder

Neonatal aortic thrombus is a rare and critical condition that can present mimicking severe coarctation of the aorta or interrupted aortic arch. Transcatheter thrombectomy for this lesion has not been well described. We report a premature neonate with an occlusive proximal descending aorta thrombus, who underwent transcatheter mechanical thrombectomy using an Amplatzer Piccolo PDA occluder (Abbott, North Chicago, IL, USA). The procedure was successful with no subsequent distal thromboembolic events.

Bivalirudin and thrombolytic therapy: a novel successful treatment of severe aortic arch thrombosis in a term neonate

An early-term infant with uncomplicated perinatal history was found to have a large thrombus in the aortic arch after he failed regular newborn critical congenital heart defect screen. He responded well to bivalirudin thrombolytic and tissue-plasminogen activator (tPA) combination therapy, with a significant resolution of the thrombus. The infant tolerated hospital admission well with no significant complications. He was discharged home on daily aspirin at 2 weeks of life. To our knowledge, the combination therapy approach with bivalirudin and tPA is the first one reported in the literature in the neonatal age group.

Inferior vena cava syndrome in neonates: An evidence-based systematic review of the literature

Neonatal inferior vena cava syndrome (IVCS), though uncommon, is associated with significant morbidity and mortality. Information on risk factors, diagnosis, treatment, and outcomes is limited. This review comprised 61 neonates across 33 reports. Thrombosis occurred in 98% and 42% involved a central venous catheter. Diagnosis was mainly established by ultrasound in 82%. Therapeutically, heparin was employed in 36% and thrombolysis in 18% of the cases. The overall mortality was 23%. An algorithm of clinical signs, investigation, and management is presented. Well-designed prospective studies are needed to establish a concrete investigational approach to neonatal IVCS and institute safe, evidence-based treatment.

Multimodality and multiterritory vascular imaging in a toddler with acquired, complex, and unusual aortic arch anatomy

A 20-month-old otherwise well child with no cardiac history presented for evaluation of a recent onset cardiac murmur. His initial examination revealed significant right carotid bruit along with a transthoracic echocardiogram (ECHO) concerning for severe transverse arch hypoplasia with unusual appearance and left ventricular hypertrophy with preserved function. This report demonstrates the utility of various modalities including echo, CT, and MRI to assess vascular structures in different vascular territories in a challenging patient who underwent a satisfactory arch repair with unexpected pathology findings.

In Utero Aortic Arch Thrombosis Masquerading as Interrupted Aortic Arch: A Case Report and Review of the Literature

Aortic arch thrombosis is an extremely rare but life-threatening diagnosis that is often misdiagnosed in the neonatal period. Strategies including surgical intervention, systemic anticoagulation, and thrombolysis have been previously described in the treatment of these neonates. We describe the case of a neonate who presented with concern for interrupted aortic arch and was diagnosed with an in utero aortic arch thrombosis. To our knowledge, this is the first reported case with evidence of aortic arch thrombosis in fetal life. The patient underwent successful treatment with systemic thrombolysis with tissue plasminogen activator. A brief review of the literature regarding the diagnosis, treatment, and management of neonatal aortic arch thrombosis is also presented.

Severe Acute Kidney Injury With Significant Uremia in an Infant Found to Have Inferior Vena Cava, Bilateral Renal Vein, and Bilateral Renal Artery Thromboses

Background

Common neonatal etiologies of acute kidney injury (AKI) include renal vein and inferior vena cava thromboses, maternal use of nonsteroidal antiinflammatory drugs, and congenital renal disease. The incidence of renal vein thrombosis is estimated to be 0.5 per 1,000 neonatal intensive care unit admissions, with approximately half of cases extending to the inferior vena cava and with unilateral disease being significantly more common than bilateral. Data on abdominal venous thromboembolism in pediatric patients are limited, and the clinical presentation of renal vein thrombosis can vary, although most patients have at least one of the three cardinal signs: hematuria, thrombocytopenia, or abdominal mass.

Case Report

We present the case of a 5-month-old female transferred to our pediatric intensive care unit from an outside hospital with AKI and significant uremia (creatinine 6.01 mg/dL, blood urea nitrogen >200 mg/dL) secondary to inferior vena cava, bilateral renal vein, and bilateral renal artery thromboses. The patient was started on a heparin drip and subsequently underwent mechanical thrombectomy of her inferior vena cava and right renal vein in addition to site-directed tissue plasminogen activator to her renal veins, renal arteries, and inferior vena cava. Following the procedure, she developed severe coagulopathy and became hemodynamically labile. The coagulopathy was corrected, but further anticoagulation to prevent further thrombus propagation was not sustainable in the face of ongoing bleeding and hemodynamic instability, so the decision to withdraw mechanical support was made.

Conclusion

Because of the varied presentations of renal vein thrombosis and because prompt intervention significantly improves survival and renal outcomes, a high index of suspicion is warranted when risk factors and any of the three cardinal features of renal vein thrombosis are present.

Clinical Data of Neonatal Systemic Thrombosis

OBJECTIVE

To evaluate clinical data and associated risk conditions of noncerebral systemic venous thromboembolism (VT), arterial thromboembolism (AT), and intracardiac thromboembolism (ICT) in neonates.

STUDY DESIGN

Data analysis of first systemic thromboembolism occurring in 75 live neonates (0-28 days), enrolled in the Italian Registry of Pediatric Thrombosis from neonatology centers between January 2007 and July 2013.

RESULTS

Among 75 events, 41 (55%) were VT, 22 (29%) AT, and 12 (16%) ICT; males represented 65%, and 71% were preterm. In 19 (25%), thromboembolism was diagnosed on the first day of life. In this "early onset" group, prenatal-associated risk conditions (maternal/placental disease) were reported in 70% and inherited thrombophilia in 33%. Postnatal risk factors were present in 73%; infections and central vascular catheters in 56% and 54% VT, respectively, and in 67% ICT vs 27% AT (<.05). Overall mortality rate was 15% and significant thromboembolism-related sequelae were reported in 16% of discharged patients.

CONCLUSIONS

This report from the Registro Italiano Trombosi Infantili, although limited by representing an uncontrolled case series, can be used to develop future clinical trials on appropriate management and prevention of neonatal thrombosis, focusing on obstetrical surveillance and monitoring of critically ill neonates with vascular access. A thrombosis risk prediction rule specific for the neonatal population should be developed through prospective controlled studies.

A case of neonatal arterial thrombosis mimicking interrupted aortic arch

Neonatal arterial thrombosis is a very rare entity with clinical findings resembling coarctation of aorta or interrupted aortic arch. A two day-old male newborn was admitted to a different hospital with difficulty in sucking and sleepiness. On echocardiographic examination, a diagnosis of interrupted aortic arch was made and he was treated with prostoglandin E2. When the patient presented to our center, physical examination revealed that his feet were bilaterally cold. The pulses were not palpable and there were ecchymotic regions in the lower extremities. Echocardiography ruled out interrupted aortic arch. Computerized tomographic angiography revealed a large thrombosis and total occlusion of the abdominal aorta. Since there was no response to treatment with tissue plasminogen activator, we performed thrombectomy. Homozygous Factor V Leiden and Methylenetetrahydrofolate reductase mutations were found in this patient. Neonatal aortic thrombosis which is observed very rarely and fatal should be considered in the differential diagnosis of coarctation of aorta and interrupted aortic arch.

Neonatal aortic arch thrombosis: analysis of thrombophilic risk factors and prognosis

Arterial thrombosis in neonates and children is a rare event and is often associated with external risk factors such as asphyxia or sepsis. We report our experiences with two neonates with spontaneous aortic arch thrombosis mimicking aortic coarctation. Despite single case reports until now, no data exist for the underlying thrombophilic risk factors and prognosis of this rare event. Both patients were carriers of a heterozygous factor V Leiden mutation, which has been reported once before as a risk factor for aortic arch thrombosis. One of our patients was operated upon successfully and is alive. The second patient suffered a large infarction of the right medial cerebral artery and had a thrombotic occlusion of the inferior caval vein. The patient obtained palliative care and died at the age of 6 days. In the literature, we identified 19 patients with neonatal aortic arch thrombosis. Of the 19 patients, 11 (58%) died. Including the two reported patients, the mortality rate of patients with multiple thromboses was 80% (8/10) compared with 18% (2/11) for patients with isolated aortic arch thrombosis; this difference reached statistical significance (p = 0.009). The analysis of thrombophilic disorders revealed that factor V Leiden mutation and protein C deficiency seem to be the most common risk factors for aortic arch thrombosis.

CONCLUSION

Neonatal aortic arch thrombosis is a very rare but life-threatening event, with a high rate of mortality, especially if additional thrombotic complications are present. Factor V Leiden mutation seems to be one important risk factor in the pathogenesis of this fatal disease.

Intrauterine upper limb ischemia: an unusual presentation of fetal thrombophilia-a case report and review of the literature

Upper limb ischemia presenting in neonatal period is extremely rare. Moreover, presenting newborn with evidence of intrauterine upper limb vascular occlusion is even rarer. It needs prompt intervention to restore perfusion and avoid morbidity. We present a newborn with right upper limb brachial artery thrombosis causing ischemia that was noted at birth and appeared later to be homozygous for factor V Leiden and glycoprotein IIIa with no other identifiable risk factors. In this report, we present the case, its successful medical management, proper counseling, and review of the literature. We recommend investigating the neonates and their parents for thrombophilia mutations when they present with unusual vascular occlusion site as newborns.

Aortic arch thrombectomy in a 2.8 kilogram neonate--a case report and review of the literature

Aortic arch thrombus is a rare occurrence in neonates. In the few described cases, this has mainly been associated with sepsis or early postnatal interventions, such as insertion of umbilical arterial line. We describe a case of occlusive aortic arch thrombus in a neonate who presented with signs of critical coarctation and successfully underwent surgical thrombectomy on deep hypothermic circulatory arrest. We also present a review of the most recently published cases of aortic arch thrombus in neonates and the treatment options employed.

Aortic Arch Thrombosis Mimicking Interrupted Aortic Arch

We report a case of a 32-week-gestation male who presented initially with symptoms suggestive of an interrupted aortic arch. The absence of a VSD prompted further investigations, including a CT angiogram, which revealed that he had an extensive thrombus in his aorta. He underwent a successful aortic thrombectomy with arch repair on cardiopulmonary bypass support. In view of the extensive thrombus, the patient was referred to the haematology team. There was no family history of prothrombotic tendencies.

Life-threatening aortic thrombosis in a trauma patient homozygous for factor V Leiden mutation: Case report

We report a case of near fatal aortic thrombosis in a trauma patient homozygous for mutation of Factor V Leiden. He responded well to vascular surgery and intensive care unit management and was discharged successfully from the hospital one month later.

Management of neonatal aortic arch thrombosis with low-molecular weight heparin: a case series

Aortic arch thrombosis (AAT) is a potentially life threatening condition in neonates. We report 3 neonates with AAT and complete occlusion of a unilateral internal carotid artery with multiple cerebral infarcts. Multidisciplinary input led to deferral of thrombolytic therapy and surgical thrombectomy owing to the potential risk of hemorrhage within the infarcts. All the neonates were treated with low-molecular weight heparin treatment alone without any complications. Thrombus resolution was complete in 2 neonates, whereas it was near complete in one neonate. All the infants showed normal growth and development during follow-up. The rewarding outcome in these cases suggests that treatment with low-molecular weight heparin could be considered an option to treat AAT in selected patients.