Abstract
The incidence of pediatric venous thromboembolic disease is increasing in hospitalized children. While the mainstay of treatment of pediatric thrombosis is anticoagulation, reports on the use of systemic thrombolysis, endovascular thrombolysis, and mechanical thrombectomy have steadily been increasing in this population. Thrombolysis is indicated in the setting of life- or limb-threatening thrombosis. Thrombolysis can rapidly improve venous patency thereby quickly ameliorating acute signs and symptoms of thrombosis and may improve long-term outcomes such as postthrombotic syndrome. Systemic and endovascular thrombolysis can result in an increase in minor bleeding in pediatric patients, compared with anticoagulation alone, and major bleeding events are a continued concern. Also, endovascular treatment is invasive and requires technical expertise by interventional radiology or vascular surgery, and such expertise may be lacking at many pediatric centers. The goal of this mini-review is to summarize the current state of knowledge of thrombolysis/thrombectomy techniques, benefits, and challenges in pediatric thrombosis.
Highlights
The incidence of pediatric venous thromboembolism (VTE) is estimated to be 0.07–0.14/10,000 children [1, 2], and data suggest that the incidence of thrombosis in children is dramatically increasing [3]
The zymogen plasminogen is activated by two main serine proteases, tissue-type plasminogen activator and urokinase-type plasminogen activator. tPA binds to fibrin at lysine binding sites and converts plasminogen into plasmin. uPA has no fibrin specificity and can activate both fibrin-bound and circulating plasminogen [14]
Low levels of plasminogen have been shown to impact the actions of pharmacologic thrombolytics [21], but there are insufficient data to demonstrate what effect, if any, high levels of PAI-1 or other fibrinolysis inhibitors may have on the activity of thrombolytic therapy throughout childhood
Summary
The incidence of pediatric venous thromboembolism (VTE) is estimated to be 0.07–0.14/10,000 children [1, 2], and data suggest that the incidence of thrombosis in children is dramatically increasing [3]. Anticoagulation alone does not rapidly restore the patency of occluded vessels, and in patients at high risk for acute venous insufficiency, VTE recurrence, or postthrombotic syndrome (PTS), anticoagulation may not be enough to achieve optimal outcomes. The second group consists of children with complex congenital heart disease or chronic conditions who develop venous insufficiency related to abnormal hemodynamics, surgical interventions, and lifedependence on CVCs [16, 17]. We have limited data on the risks and outcomes of thrombolysis With this in mind, we will review current data on thrombolysis and offer guidance on its use in pediatric thrombosis outside of the central nervous system
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