Original article
Acute neonatal arterial occlusion: is thrombolysis safe and effective?

https://doi.org/10.1016/j.jpedsurg.2008.04.025Get rights and content

Abstract

Purpose

We report our experience of the management of arterial occlusion in the newborn.

Methods

A case note review was carried out after ethical approval. Doppler ultrasonography confirmed the occlusion. Thrombolysis was the primary intervention. Surgery was used selectively. A good outcome was one without tissue loss or functional impairment or minimal tissue loss without functional impairment. Data are presented as medians with ranges.

Results

Ten patients (9 male; median gestational age, 35.5 weeks [range, 28-39 weeks]) presented on day 1 (range, 1-8 days). Initial management included systemic tissue plasminogen activator (8 patients) and surgery (2 infants in whom thrombolysis was contraindicated). Improvement was noted in 7 of 8 infants treated medically and in both who underwent surgery. Three infants had significant tissue loss. Outcome at 29 months (range, 1.3-95.4 months) was good in the remaining 7.

Conclusions

A multidisciplinary approach, thrombolysis and selective surgery achieved tissue preservation and function in the majority while minimizing complications. Early referral to centers with multidisciplinary teams is recommended.

Section snippets

Materials and methods

All infants admitted under the care of a general pediatric surgeon with acute, limb-threatening, arterial ischemia in the 9-year period up to July 2003 were identified. Infants with a corrected gestational age greater than 44 weeks at presentation were excluded. A retrospective case note review of the remainder was undertaken. Evaluation included demographic details, mode of presentation, and clinical and radiologic assessment of extent of ischemia. The time to start treatment (TT) was defined

Results

Ten patients (9 male) were identified. The median gestational age was 35.5 weeks (range, 28-39 weeks), and the median age at presentation was 1 day (range, 1-8 days). Six infants had undergone intraarterial cannulation; 5 umbilical artery catheters in the 5 newborns who presented with lower limb ischemia and 1 left brachial artery catheter in 1 infant with ischemia of the left forearm and hand. Three of the 10 infants were born to diabetic mothers and 7 were born by emergency cesarean delivery.

Discussion

Acute limb-threatening arterial occlusion is a rare neonatal event [4], [5]. There is a lack of consensus regarding etiology and management [4], [6]. In this series, putative risk factors included an intraarterial catheter (6 infants), sex (9 male), emergency cesarean delivery (7 infants), and maternal diabetes, or very high body mass index (4 mothers). Although iatrogenic vascular injuries have long been recognized as a risk factor for limb ischemia in infants and young children [7], the

Acknowledgments

The authors wish to thank Dr Kate Head and Dr Miguel Guelfand for help with data collection.

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