Successful thrombolysis in a preterm newborn with acute Leriche syndrome caused by spontaneous thrombotic aortoiliac occlusion: a case report and review of the literature

Introduction Neonatal aortic thromboses represent rare, yet serious conditions commonly associated with severe morbidity and a high mortality rate [1] [2]. Their management, however, issues major challenges due to limited experience and lacking treatment recommendations [2] [3]. Although systemic thrombolysis is considered first-line treatment in case of organ-threatening ischemia, a limited number of attempted thrombolytic treatment approaches, particularly in preterm neonates, have been reported to this day [2] [5] [6] [8].

Method We report a case of successful thrombolysis in a preterm newborn presenting with acute Leriche syndrome caused by spontaneous aortic thrombosis.

Results A preterm newborn of 35 weeks gestational age presented with signs of severe symmetric lower limb ischemia with cyanosis, reduced oxygen saturation and undetectable blood pressure in both lower limbs at first examination. An immediately performed echocardiogram showed no evidence of intracardiac thrombosis, congenital heart defects or aortic anomalies, while a thrombotic occlusion with absence of arterial blood flow in the aortic bifurcation and both iliac arteries was detected via Doppler ultrasound. After interdisciplinary discussion, systemic thrombolysis with tissue plasminogen activator (rtPA) at a dose of 0.05 mg/kg/h was started after application of a bolus of 0.1 mg/kg body weight, and was later on increased up to 0.075 mg/kg/h. An incremental dissolution of thrombosis and restoration of blood flow in sequentially performed ultrasound examinations could be observed. Parallel to thrombolysis, fresh frozen plasma was administered to raise plasminogen levels. Systemic thrombolysis with rtPA was ended after 48 hours with overlapping continuation of anticoagulation therapy with subcutaneously applied low molecular weight heparin (anti-Xa activity 0.6 – 1 IU/ml). No hemorrhagic complications have been observed. Laboratory screening showed no indication for acquired or hereditary thrombophilia. The patient was discharged at the twelfth day of life in good clinical condition without residual symptoms, while a follow-up examination two months after discharge showed a sufficient lower limb perfusion despite the presence of a persistent residual thrombus.

Conclusion Spontaneous neonatal aortic thromboses in absence of umbilical artery catheterization, aortic anomalies or prothrombotic disorders represent a rare and potentially life-threatening condition [2] [6] [7]. Particularly in preterm newborns, thrombolytic therapy may be complicated due to limited experience and both lacking dose recommendations and reliable laboratory monitoring options of thrombolytic activity [2] [4] [7]. Our case underlines the successful use of thrombolysis in preterm infants under careful risk-benefit consideration. Although several case reports outline the feasibility of thrombolysis in these patients, further studies are required to confirm the efficacy and safety of systemic thrombolysis in neonatal aortic thrombosis [5] [6] [7] [8].

Conflict of Interest

No potential conflict of interest was reported by the authors.

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Publication History

Article published online:
26 February 2024