Abstract 485: Percutaneous Catheter-directed Local Thrombolysis of Arterial, Venous and Shunt Thrombus Using Tissue Plasminogen Activator in Critically-ill Children - A Single Center Experience

Abstract

OBJECTIVE To retrospectively determine the success and complication of local catheter directed thrombolysis using recombinant tissue plasminogen activator (rTPA) in critically ill children with acute arterial, venous or shunt thrombus. BACKGROUND Local catheter directed thrombolysis is a well-described treatment modality for thrombotic events in adults, with maximal thrombolytic effect and minimal systemic sequelae. However, this treatment option in life threatening thrombosis is not well defined in pediatrics. METHOD We report an observational study in a retrospective cohort (2008-2013) of 14 cases presenting with sudden life threatening thrombosis, necessitating immediate intervention. All patients had >95% vascular/shunt occlusion which was treated with percutaneous catheter-based procedure, and rTPA administration directly at site of thrombus. The efficacy, dosage, duration, additional endovascular intervention and complications of this approach are reported. RESULTS The median age was 1.7 months (range, 10 days - 29 years) and median weight was 4.4 kilograms (range, 2.2 - 101 kg). Nine (64%) patients presented with shunt (Sano or aorto-pulmonary) thrombosis, three (22%) with arterial thrombosis and two (14%) with venous thromboembolism. All patients received a local bolus of rTPA [median dose 0.24 mg/kg (range, 0.01 - 1.0 mg/kg)]. Eight (57%) received an additional infusion of rTPA [median dose 0.17 mg/kg/hr (range, 0.02 - 1.0 mg/kg/hr)] of varying duration [median 1.3 hours (range, 0.3 - 18 hours)]; one patient received a prior systemic bolus of rTPA. Anticoagulation was administered in 12 (86%) and supplementary endovascular intervention (balloon angioplasty and/or stenting) was done in 4 (28%) patients. Thrombolytic success (defined as >95% return of antegrade flow) was achieved in 13 (93%). No major bleeding or other serious complication directly related to this approach occurred. CONCLUSION Catheter-directed local thrombolysis with rTPA can be accomplished rapidly in critical thrombosis, as a pragmatic alternative to surgery. This approach can offer satisfactory short term palliation without significant complications and improve outcome in children with life threatening thrombosis.