Bilateral lower extremity ischemia due to a retained umbilical artery catheter in a preterm neonate

Abstract

The use of umbilical artery catheters is common in Neonatal Intensive Care Units, especially in low and very low birth weight neonates. Rarely, these can break or fracture, leading to a retained fragment, which can embolize or cause thrombosis. We pre sent a case of a very low birth weight, premature neonate, 940 grams, with a retained umbilical artery catheter that led to bilateral lower extremity ischemia. A laparotomy with aortotomy was per formed for retrieval of the catheter. Chronic occlusion of the aorta with collateralization is a long-term complication associated with this case.

Infraumbilical surgical retrieval of transected umbilical artery catheter in an 840 g newborn

“…The evidence supporting any management option for removal of retained UAC remains weak. There have been less than 15 case reports in the past 50 years outlining the removal of a UAC via either transcutaneous, trans umbilical surgical approach, exploratory laparotomy and/or aortotomy 2–13…”

“…The concern about a conservative approach was surrounding the potential complications that can occur from leaving the fragment in situ, which include its migration, abscess formation, infection, ischaemia and/or thrombosis as described in previous cases prior to removal 2–5 15. Prophylactic heparin dose was considered; however, given the lack of studies in the neonatal population and in particular in preterm newborns, it was not clear what the safest dose would be to balance the risks of bleeding (especially intraventricular haemorrhage) and thrombosis in an extreme preterm baby, who has a different physiological coagulation profile to term babies and older children 16.…”

“…Here we describe the smallest baby reported in the literature where removal of UAC was successfully achieved via surgical umbilical exploration. There have been three previous cases describing a surgical approach: two cases described an exploratory laparotomy with aortotomy,4 8 in the other case a failed attempt to umbilical exploration was followed by laparotomy 5. In the case described by Birkhold et al ,4 the patient was 940 g and the initial approach was via trans umbilical exploration at the bedside where the UAC was not visualised, exploration was further extended in the abdomen where the UAC was able to be palpated.…”

“…There have been three previous cases describing a surgical approach: two cases described an exploratory laparotomy with aortotomy,4 8 in the other case a failed attempt to umbilical exploration was followed by laparotomy 5. In the case described by Birkhold et al ,4 the patient was 940 g and the initial approach was via trans umbilical exploration at the bedside where the UAC was not visualised, exploration was further extended in the abdomen where the UAC was able to be palpated. It was at this point that the patient was noted to have severe bilateral limb ischaemia and was taken to the operating room for exploratory laparotomy, at which point the catheter was removed via infrarenal aortotomy.…”

“…Umbilical arterial catheterisation is a common practice in neonatal intensive care units (NICU) especially in the extreme preterm and very low birth weight infants. As with any procedure, it is associated with complications, including perforation of vessels at the time of insertion, thrombosis, bacterial infection, compromise of flow to distal vascular bed and in rare cases transection/fracture of the UAC itself leading to displacement/migration of the catheter internally 1–4…”