PB0298 - Catheter-directed Thrombolysis and Systemic Anticoagulation for IVC and Bilateral Renal Vein Thrombosis in a Septic Neonate

Sunday, June 25, 2023

18:30 – 19:30 ET

Room: Exhibition

Presenting Author(s)

Kristen Nelson McMillan, MD

Dir, Ped mechanical circulatory support; Ped cardiac critical care and heart failure
Chicagoland Children's Health Alliance
Valparaiso, Indiana, United States

Co-Author(s)

EK

Erin Kim

Pediatric nephrologist
Advocate Children's Hospital
Oak Lawn, Illinois, United States
PC

Priya Chandra

Pediatric nephrologist
Advocate Children's Hospital
Oak Lawn, Illinois, United States
SK

Sarah Kane

Pediatric DNP, Pediatric Heart Failure
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States
FY

Faeeq Yousaf

Pediatric pharmacist, Pharm D
Advocate Children's Hospital
Oak Lawn, Illinois, United States
VD

Vincent Dorsey

Pediatric pharmacist, Pharm D
Advocate Children's Hospital
Oak Lawn, Illinois, United States
JH

Joan Hoffman

Pediatric heart failure and cardiac ICU attending
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States
EC

Enrique Cifuentes

Pediatric ICU attending
Advocate Children's Hospital
Oak Lawn, Illinois, United States
CR

Carmelle Romain

Pediatric general surgery
Advocate Children's Hospital/Univ of Chicago
Oak Lawn, Illinois, United States
NH

Narutoshi Hibino

Pediatric cardiothoracic surgeon
Chicagoland Children's Health Alliance
Oak Lawn, Illinois, United States
LV

Luca Vricella

Chief, Pediatric Cardiothoracic Surgery; Co-Director of Pediatric Heart Institute
Chicagoland Children's Health Alliance
Oak Lawn, Illinois, United States
CE

Chawki ElZein

Pediatric cardiothoracic surgeon
Chicagoland Children's Health Alliance
Oak Lawn, Illinois, United States
DP

Dhaval Patel

Pediatric interventional cardiologist
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States

Background: Pediatric venous thrombosis (VT) has increased 130% over the last decade, often in association with vascular access. Acute inflammatory states such as shock may further increase risk and be associated with increased morbidity and mortality.

Aims: Rapid identification of patients at-risk for development of critical thrombosis can allow for timely implementation of life-saving therapies.

Methods: We review a pediatric patient with life-threatening thrombosis.

Results: A 3-week old presented in presumptive septic shock. He was intubated and initiated on vasoactives, but severe metabolic acidosis persisted (pH < 7 for >12 hours). Following multiple attempts at femoral venous access, he developed abdominal distention. An ultrasound revealed occlusive IVC and bilateral renal thrombi, precluding use of ECMO. A bedside exploratory laparotomy revealed viable bowel without necrosis. Catheter-directed thrombolysis via EKOS catheter was initiated with demonstration of blood flow in IVC and left renal vessels after 24 hours, but given pulmonary emboli with ventricular strain, he was transitioned to systemic tPA for an additional 24 hours. He was then maintained on systemic therapeutic bivalirudin with resolution of thrombi and required renal replacement therapy (CRRT) for renal failure for 7 days. He was extubated after 10 days. He tolerated initiation of enteral nasogastric feeds, ultimately transitioning to full feeds by mouth. MRI demonstrated no stroke and normal left renal blood flow but atrophic right kidney. One year later, he is neurologically appropriate with only mild speech and motor delay and stable solitary renal function.

Conclusion(s): Pediatric patients may require catheter-directed or systemic thrombolysis and anticoagulation with life-threatening thrombosis. Neonatal vessel size may pose significant challenges for catheter placement and may be even more difficult in vasoconstrictive states. It is imperative to not only efficiently identify patients at-risk for thrombosis and initiate preventative or therapeutic treatment but also to have a multidisciplinary team available to rapidly respond to critical thrombosis.