2023 Scientific Sessions

Title

AngioJet Mechanical Thrombectomy and Thrombolysis in a Neonate with Life-threatening Thrombotic Occlusion of the Abdominal Aorta

Introduction

Neonatal aortic thrombosis is a serious and rare condition with estimated incidence is ~1.1 per 100,000 newborns. Its etiology is multifactorial but the presence of an UAC is a recognized risk factor.

Medical therapy and thrombolysis are the treatment of choice. Blood loss and hypotension are known adverse events of mechanical thrombectomy, which is used relatively infrequently in neonates. We describe a case in which mechanical thrombectomy was used to treat a life threatening aortic thrombus.

Clinical Case

Our patient was a full-term infant who was admitted to the NICU due to respiratory distress secondary to meconium aspiration syndrome. She developed cyanosis in the lower extremities and weak femoral pulses. Abdominal ultrasound revealed a thrombosis adjacent to the UAC and Doppler interrogation revealed blunted systolic upstroke in the abdominal aorta. Her symptoms continue to worsen despite catheter removal.

Echocardiogram showed patent thoracic aorta with normal proximal abdominal aortic Doppler in the setting of closed ductus arteriosus. An abdomen CTA showed occlusion of the infrarenal abdominal aorta to the bilateral iliac arteries. The neonate did not improved with systemic heparinization. Due to the potential for propagation of the thrombus into major arteries, she was referred to the catheterization laboratory for intervention.

The patient was on therapeutic heparin infusion throughout the procedure. The left axillary artery was accessed and a 4 French Prelude Ideal^TM Hydrophilic sheath was placed. Angiograms demonstrated complete thrombotic occlusion of the abdominal aorta below the renal artery takeoffs.

We were able to pass the thrombus with an interventional wire. A 4Fr/145 cm Solent Dista AngioJet catheter was used to deliver a pulse lytic therapy with tPA into the thrombus. Several passes of AngioJet thrombectomy were performed along the distal aorta and proximal iliac arteries for total of 35-43 seconds. The AngioJet activations were tolerated well by the patient. Due to significant mobilization of the thrombus on repeat angiograms, multiple pulses of tPA thrombolytic therapy and balloon angioplasties were performed.

A final abdominal aorta angiogram demonstrated patency of the entire abdominal aorta and bilateral common, external iliac arteries and proximal internal iliac arteries but had complete thrombotic occlusion further down.

The patient’s coagulopathy work-up was negative. She was placed on both enoxaparin and clopidogrel post procedure. A follow up abdominal CTA nine months later demonstrated complete resolution of the thrombi, including the internal iliac arteries.

Discussion

The AngioJet Solten Dista catheter is a peripheral thrombectomy system that is available in small sizes and tracks easy over guidewires, which allows their use in pediatric patients.

Adverse events during mechanical thrombectomy are common but activation for 5-10 seconds can limit the hypotension and bradycardia. Additionally, the closer the device is to the heart, the higher the incidence of bradyarrhythmias and asystole.

In our experience, thrombectomy alone did not result in sufficient vascular patency. Therefore, catheter-administered local tPA, balloon angioplasty, and manual aspiration were used to decrease the thrombus burden. Published data support similar combination approach.