Ultrasound Assisted Endovascular Thrombolysis in Adolescents: 2 Case Reports

Abstract

Descending iliofemoral thrombosis in children is a rare event. Anticoagulation therapy with low-molecular-weight-heparin is standard of care. However, patency cannot be achieved in all cases, increasing the risk for rethrombosis and postthrombotic syndrome. To reduce the risk of venous valve failure in adults, local catheter-directed thrombolysis is used to reopen vessels. Two adolescent girls (17 and 15 years old) presented with acute descending iliofemoral thrombosis of the left common iliac, external, and common femoral veins. Anticoagulation with enoxaparin was started until insertion of an EkoSonic Mach 4e catheter for ultrasound-assisted local thrombolysis with recombinant tissue plasminogen activator and administration of unfractionated heparin. Success was monitored by increases in D-dimer levels and ultrasound findings. After 24 hours respectively 48 hours, complete recanalization was obtained. No complication occurred except minimal local bleeding. Screening for hereditary thrombophilia revealed a heterozygous antithrombin mutation in 1 girl (ie, the 15-year-old). May-Thurner syndrome was identified in both girls, necessitating stenting of the left common iliac veins and continuation of anticoagulation therapy with enoxaparin and acetylsalicylic acid. No rethrombosis or complications occurred during the follow-up period. Ultrasound-assisted catheter-directed local thrombolysis with the EkoSonic Mach 4e system was effective in achieving immediate recanalization of the occluded veins and should be considered in children experiencing descending iliofemoral thrombosis. The fast recanalization might reduce the incidence of postthrombotic syndrome. May-Thurner syndrome is regularly found in these patients, and if present, requires stenting of the common iliac vein to avoid early reocclusion. However, long-term patency of iliac vein stenting in children remains to be examined.

Endovascular mechanical thrombectomy of the inferior vena cava and iliac veins with the use of Aspirex®S device in a paediatric patient

“…Usually neonates and adolescents are affected and thrombosis is typically associated with the use of intravenous catheters or severe morbidities (sepsis, cancer, heart disease, etc.). Anatomic abnormalities, primarily aplasia of the inferior vena cava and May-Thurner syndrome, and/ or disturbances of the coagulation syndrome can also be of an importance [1][2][3][4][5][6][7]. Unprovoked thrombosis in a child, such as in our patient is extremely rare.…”

How We Manage Pediatric Deep Venous Thrombosis

“…[121][122][123] Although no RCTs have assessed the safety and efficacy of this approach in pediatric patients, published data from retrospective studies and case reports have shown that the use of conventional anticoagulation, CDT, and stent placement results in high rates of recanalization and long-term patency of the iliac vein, with significant improvement in symptoms while potentially decreasing the development of PTS. 113,124,125 Surgical approaches, including thrombectomy of the iliofemoral veins with iliac venous reconstruction or placement of a cross-femoral venous bypass graft, are not recommended as first-line management, and are typically reserved for patients with significant contraindications to CDT, as they can result in high morbidity with variable rates of successful venous recanalization. 114,116 Conclusion VTE has become an increasingly recognized problem in pediatrics that can significantly impact the health outcomes of affected children.…”