Introduction
The standard recommendation for the majority of pediatric venous
thromboses is anticoagulation alone. However, for life, limb, or
organ-threatening thromboses site directed tissue plasminogen activator
(tPA) is recommended to rapidly restore blood flow and perfusion to the
affected anatomical regions.1,2 Inadequate treatment
of deep venous thrombus (DVT) in pediatric patients may result in a
lifetime of disability and reduced quality of life secondary to
post-thrombotic syndrome (PTS), characterized by chronic leg swelling,
pain, and venous insufficiency.3-7 As pediatric
tertiary care centers are seeing an increase in the diagnosis of venous
thromboembolism (VTE) in hospitalized patients,8 it is
necessary to understand the outcomes and adverse events of the current
treatment modalities that are available for children. This is especially
important now due to the increased risk of thrombosis seen in severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
infections.9-11
Catheter-directed thrombolysis (CDT) is one treatment modality used in
pediatric tertiary care centers by interventional radiologists (IRs) and
involves placement of a specialized infusion catheter at the site of
thrombosis to infuse tPA. Additional interventional measures include
mechanical thrombectomy devices to mechanically remove thrombus burden
with (pharmacomechanical thrombectomy) or without (mechanical
thrombectomy) tPA at the time of the procedure. Large prospective
studies evaluating the long-term effects and safety of CDT have been
performed in the adult population.12-14 While the
safety and effectiveness of endovascular thrombolysis for acute DVT has
been demonstrated in children,15-18 there is limited
available data on the risks and long-term thrombosis outcomes in
pediatric patients who undergo CDT. Moreover, there is a lack of data
describing different methods of tPA administration (tPA administered via
CDT for an extended period of time or bolus “on-table” dosing of tPA
administered during a singular interventional procedure), as well as
different mechanical thrombectomy devices (including the AngioJet
ThrombectomyTM and Penumbra Indigo® Systems) in the
pediatric population.
We performed a single-center retrospective review of children at our
pediatric tertiary care center who received CDT for lower extremity (LE)
venous and/or or inferior vena cava (IVC) thrombosis to develop a
comprehensive understanding of our multi-disciplinary treatment approach
to, and outcomes in this patient population. Our outcomes focused on
thrombosis resolution and safety (bleeding events) of pediatric
thrombolysis, evaluating different methods of thrombolysis and
interventional approaches.