Natural history of deep vein thrombosis in children

Pediatric scurvy case report: a novel presentation with deep vein thrombosis secondary to large bilateral spontaneous iliac subperiosteal hematomas

BACKGROUND

Scurvy is an uncommon disease in developed countries caused by deficiency of vitamin C. We present a case of scurvy in a 14-year-old male with autism with both novel presentation and imaging findings. This case had the novel presentation of lower limb deep vein thrombosis (DVT) secondary to compression of the external iliac vein from large bilateral iliac wing subperiosteal hematomas. Subperiosteal hematoma is a well-recognised feature of scurvy but large and bilateral pelvic subperiosteal hematoma causing DVT has not previously been described.

CASE PRESENTATION

A 14 year old Caucasian male with background of autism and severe dietary restriction presented with lower limb swelling and immobility. He was diagnosed with lower limb DVT. Further investigation revealed an iron deficiency anaemia, and he was found on MRI to have large bilateral subperiosteal iliac hematomata causing compression of the iliac vessels. He improved following treatment with vitamin C replacement and follow-up imaging demonstrated resolution of the DVT and hematoma.

CONCLUSION

DVT is rare in children and when diagnosed should prompt investigation as to the underlying cause. This case demonstrates an unusual cause of DVT and as an unusual presentation of paediatric scurvy.

Diagnosis, Clinical Characteristics, and Treatment Modalities of Adolescent May-Thurner Syndrome-associated Deep Venous Thrombosis

May-Thurner syndrome (MTS) predisposes individuals to develop lower extremity deep venous thrombosis (DVT) because of compression of the left common iliac vein. Diagnosis of the anatomic obstruction is critical for effective therapy, as treatment by interventional radiology is often required in addition to anticoagulation to prevent thrombus progression and recurrence. The authors performed a retrospective review of adolescent patients who presented with MTS-associated DVT at a pediatric tertiary care center from 2009 to 2018 to assess for delays in MTS diagnosis after the presentation. Fourteen patients (median age 16.5 y, range, 13.8 to 17.9 y) were included, no DVTs were provoked by a central venous catheter. The median time from DVT to MTS diagnosis was 0.65 months (range, 0 to 21.5 mo). The initial imaging modalities used for DVT diagnosis were not able to diagnosis MTS. All patients were treated with anticoagulation and 13 underwent interventional therapy. Four patients had thrombus progression or recurrence, whereas 6 had complete thrombus resolution on follow-up imaging. Three patients who had a delayed MTS diagnosis had clinical worsening despite therapeutic anticoagulation requiring rehospitalization. Adolescent patients with "unprovoked" left lower extremity DVT should undergo appropriate imaging to diagnose MTS to allow for adequate medical and interventional therapy.

Risk factors for venous thromboembolic events in pediatric surgical patients: Defining indications for prophylaxis

BACKGROUND

Venous thromboembolism (VTE) in pediatric surgical patients is a rare event. The risk factors for VTE in pediatric general surgery patients undergoing abdominopelvic procedures are unknown.

STUDY DESIGN

The American College of Surgeon's National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database (2012-2015) was queried for patients with VTE after abdominopelvic general surgery procedures. Patient and operative variables were assessed to identify risk factors associated with VTE and develop a pediatric risk score.

RESULTS

From 2012-2015, 68 of 34,813 (0.20%) patients who underwent abdominopelvic general surgery procedures were diagnosed with VTE. On multivariate analysis, there was no increased risk of VTE based on concomitant malignancy, chemotherapy, inflammatory bowel disease, or laparoscopic surgical approach, while a higher rate of VTE was identified among female patients. The odds of experiencing VTE were increased on stepwise regression for patients older than 15 years and those with preexisting renal failure or a diagnosis of septic shock, patients with American Society of Anesthesia (ASA) classification ≥ 2, and for anesthesia time longer than 2 h. The combination of age > 15 years, ASA classification ≥ 2, anesthesia time > 2 h, renal failure, and septic shock was included in a model for predicting risk of VTE (AUC = 0.907, sensitivity 84.4%, specificity 88.2%).

CONCLUSION

VTE is rare in pediatric patients, but prediction modeling may help identify those patients at heightened risk. Additional studies are needed to validate the factors identified in this study in a risk assessment model as well as to assess the efficacy and cost-effectiveness of prophylaxis methods.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Catheter-directed thrombolysis through anterior tibial vein for treating acute extensive deep venous thrombosis

OBJECTIVE

The objective of this study was to evaluate the feasibility, efficacy, and safety of catheter-directed thrombolysis (CDT) through an anterior tibial vein approach for acute extensive lower extremity deep venous thrombosis (DVT).

METHODS

There were 125 consecutive patients with acute extensive lower extremity DVT who received CDT through an anterior tibial vein approach between October 2014 and June 2017. The patients with iliac vein compression syndrome were treated with balloon dilation and stent implantation after CDT. The thrombus score differences, limb circumference differences, venous patency, and complications were retrospectively analyzed.

RESULTS

The anterior tibial vein approach was successfully achieved in 118 patients (94.40% [118/125]). The mean thrombolysis time was 5.28 ± 1.10 days, and the average dose of urokinase was 3,903,400 ± 766,900 IU. Metal stents were placed in 50 patients (42.37% [50/118]). There were 109 patients (92.37% [109/118]) who had successful lysis (grade II and grade III lysis); 31 patients (91.18% [31/34]) achieved grade III lysis (no residual thrombus) within 3 days of symptom onset. In contrast, only 33.96% (18/53) of those treated within 4 to 7 days and 9.68% (3/31) of those treated after 7 days achieved grade III lysis. Compared with findings before CDT, the limb circumference above and below the knee was significantly reduced (7.22 ± 2.54 cm vs 1.58 ± 0.75 cm and 5.14 ± 1.41 cm vs 1.19 ± 0.49 cm, respectively). The incidence of bleeding was 10.17% (12/118). Six patients had puncture site bleeding, and three patients suffered major bleeding. One puncture site infection and two catheter-directed infections were observed during treatment. Two patients had accidental anterior tibial artery injury and recovered without complications, and no nerve injury occurred. During a follow-up of 19.39 ± 7.47 months (6-32 months), femoral venous insufficiency and popliteal venous insufficiency were present in 21.65% (21/97) and 30.93% (30/97) of the patients. The overall patency and post-thrombotic syndrome rates were 83.51% (81/97) and 21.65% (21/97).

CONCLUSIONS

CDT through an anterior tibial vein approach is a feasible, effective, and safe method for acute extensive lower extremity DVT patients. In addition, the anterior tibial vein approach can be an alternative to the traditional CDT approach.

Postthrombotic syndrome and other outcomes of lower extremity deep vein thrombosis in children

The frequency of PTS, PE, and DVT recurrence was higher in children with Non-LR DVT than in children with LR DVT. Thrombus resolution, DVT triggering event, and sex were predictors of LE PTS in children.

Patterns of pediatric venous disease

BACKGROUND

The spectrum of chronic venous disease (CVD) is well documented in adults; clinical guidelines standardize diagnosis and treatment. There is a paucity of data published commenting on pediatric CVD exclusive of Klippel-Trénaunay syndrome (KTS) and post-thrombotic syndrome.

METHODS

This study aimed to define patterns of pediatric venous disease. All venous reflux studies performed on patients <18 years of age between January 2012 and June 2014 were reviewed. Study indication, patient history, clinical examination, and duplex ultrasound results were queried and described. Venous reflux parameters were compared using one-way analysis of variance.

RESULTS

Twenty patients were evaluated. All presented through the vascular surgery or multidisciplinary venous clinic at a tertiary academic medical center. Indications for referral included swelling (n = 10), varicose veins (n = 9), and rubor/acrocyanosis (n = 3); two patients carried a diagnosis of KTS. Mean age at study was 13 years (range, 5-17 years). Clinical examination revealed the following: dependent rubor (n = 3); edema (n = 9); and varicose veins or venous abnormality concerning for venous malformation (n = 9). There were no stigmata of chronic inflammation, hyperpigmentation, or ulceration; 90% of patients (n = 18) demonstrated venous reflux by duplex ultrasound interrogation. Mean right great saphenous vein (GSV) diameter was 0.49 cm (range, 0.31-0.66 cm); mean left GSV diameter was 0.55 cm (range, 0.24-0.93 cm). Adjunctive studies were often used (including magnetic resonance venography and lymphoscintigraphy). Despite the presence of venous reflux on imaging, an alternate diagnosis was made in 8 of 18 children (44%), including postural orthostatic hypotension syndrome (n = 2), vascular malformation (n = 2), lymphedema (n = 2), complex regional pain syndrome (n = 1), and acrocyanosis of disuse (n = 1). An additional case of KTS was identified. Three cases referred for varicose veins were diagnosed with venous malformation. Maximum GSV diameter and venous reflux time were compared across patients with isolated CVD, KTS, or an alternate diagnosis (as before). Whereas there was no significant difference in maximum GSV diameter, superficial venous reflux time was significantly increased in the patients with primary CVD and KTS (P = .0394).

CONCLUSIONS

The differential diagnosis for pediatric lower extremity edema and varicosities is broad; workup often requires adjunctive studies to secure the appropriate diagnosis. Often there is venous reflux present despite an alternative clinical diagnosis. Superficial venous reflux time may aid in the diagnosis of primary CVD. Whereas the clinical significance of pediatric venous reflux remains unclear, ongoing work to expand on venous parameters in healthy pediatric controls is warranted, as is additional follow-up to assess the natural history of pediatric venous disease.

Rare complication of pediatric inguinal hernia repair: case report of transection of the femoral vein

INTRODUCTION

The incidence of pediatric inguinal hernias ranges up to 13 %. Currently, many different techniques are being used to successfully perform herniotomy and risks of complications are minor.

CASE REPORT

This case report describes a 4-year-old male patient who underwent routine herniotomy during which the femoral vein was mistaken for hernial sac and thereby the femoral vein was transected. Postoperative vascular duplex ultrasonography revealed a complete transection of the right common femoral vein. Multiple treatment options such as venous reconstruction and interposition were considered, but a conservative treatment was chosen. At 6 months postoperative, the patient only shows minor complaints. Long-term results remain uncertain, especially since no similar case has previously been described in the current literature.

Management and Outcomes of Patients with Occlusive Thrombosis after Pediatric Cardiac Surgery

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.

Short-Term Anticoagulant Therapy and Thrombus Location Are Independent Risk Factors for Delayed Recanalization of Deep Vein Thrombosis

Background

Prompt recanalization of the vein containing the thrombus is an important goal during the initial treatment of DVT, and risk factors for delayed recanalization in patients with deep vein thrombosis (DVT) in the lower extremities need to be determined.

Material/Methods

A total of 174 patients with DVT in lower extremities were recruited from June 2014 to March 2015 at our hospital. Duplex ultrasound scanning was conducted for all patients at 1 and 6 months after baseline evaluation. We divided the patients into recanalization and non-recanalization groups and analyzed risk factors for delayed recanalization.

Results

The univariate analysis revealed that an oral anticoagulant time of less than 3 months and venous thrombus location were risk factors for delayed recanalization (P<0.01). However, age, gender, hypertension, diabetes, pulmonary embolism, incidence factors, the use of catheter-directed thrombolytic (CDT) drugs, and inferior vena cava filter (IVCF) implantation had no influence on the incidence of delayed recanalization in patients with DVT (P>0.05). The multivariate analysis showed that patients with an anticoagulant time of less than 3 months had a lower incidence of recanalization than those with an anticoagulant time of more than 3 months (OR=2.358, P<0.05). The risk of delayed recanalization in patients with proximal DVT was 7 times higher than that in patients with distal DVT.

Conclusions

Duration of anticoagulant treatment of less than 3 months and venous thrombus location are independent risk factors for delayed recanalization of DVT in the lower extremities.