Treatment of a Severe Arterial Thrombosis of a Healthy Premature Neonatal Infant

Objectives: Neonatal arterial thromboembolic events are rare but can have devastating effects if not treated timely. We herein present a case of a preterm newborn with acute thrombosis of the left axillary artery leading to ischemia of the left upper limb.

Methods: Delivery was performed at 34 weeks of gestational age by Caesarean section because of prelabor rupture of membranes and subsequent oligohydramnion. Birth weight was 2,000 g. The mother was a 32-year-old gravida 2 para 2 without known family history of thrombosis. THE Apgar’s scores at 1 and 5 minutes were 9 and 10, respectively. Apart from mild prematurity and mild respiratory distress, physical examination revealed an ischemic left arm. Pulses were not palpable and the forearm was cold and white. Because of the clinical picture of an acute ischemic thrombotic event, the patient was transferred to the cath laboratory 2 hours after birth.

Result: Arterial access was perforemed via the right femoral artery with a 4-F sheath. An angiogram of the left axillary artery revealed an occlusion of the brachial artery. The occluded vessel was probed and passed with a 0.014-inch coronary wire. A subsequent balloon dilatation of the vessel with a 2 mm × 8 mm Trek balloon was performed. A postinterventional angiogram showed patency of the brachial artery with partial occlusion of the ulnar artery indicating embolization of the thrombus from the brachial artery to the periphery.0.4 mg rTPA (alteplase) was injected via the catheter in the axillary artery to perform additional local thrombolysis. After the procedure the left forearm and hand showed a fast recovery with palpable pulses and normal rosy coloring of the skin indication successful reperfusion. Anticoagulation with low-dose heparin was continued for 2 days until oral thromboaggregation inhibition with aspirin was started. The child was dismissed from the hospital 2 weeks later. The left upper limb was inconspicuous and revealed no signs for significant residual thrombosis. Examination of the parents and the child revealed no hemostatic disorders. Aspirin was terminated 6 months later.

Conclusion: Neonatal thromboembolic events are rare but can have severe clinical implications. A prompt intervention can lead to complete recovery. Optimal diagnostic and therapeutic approaches in this setting are not currently based on sound clinical evidence. Although treatment of neonatal thrombosis remains controversial, thrombolytic agents must be considered when the thrombosis is life-threatening or leads to loss of a limb.