ARTERIAL THROMBOSIS

Background:

Arterial thrombosis is the most frequent major complication of cardiac catheterization.

Incidence estimated between 3 to 8%.

n %
UCSF 25/1037 2.4% (1)
HSC 165/4952 3.3%, 8.6% (2,3)
Indiana 7% if < 7 kg (4)

Increased frequency in: infants <10 kg

interventional procedures (large French-size catheters), intimal damage
traumatic arterial cannulation
(increased total time of arterial cannulation)

Mechanism: vessel spasm with stasis

intimal injury +/- subintimal dissection and flap formation

Æ leading to thrombus formation

Morbidity: tissue loss

claudication
leg length discrepancy

Management Algorithm:

1. Prevention Minimal traumatic percutaneous entry into vessel to minimize intimal injury
Heparination (bolus 50-150 units/kg, maintain ACT > 100) during cardiac
catheterization

2. Treatment Prompt diagnosis Doppler pulse ≠ palpable pulse.

Treat non-palpable pulse, weak pulse or cool extremity.

Early rx Remove pressure bandage

Re-start heparin early (within 2 hours post cath).
Re-bolus 50 U/kg/hr with maintenance 28 U/kg/hr (≤ 1
year old), 20 U/kg/hr (> 1 year old) with monitoring for
therapeutic levels.
May switch over to low molecular weight heparin.

Persistent/severe Thrombolytic therapy (see below)

Surgical thrombectomy

Investigations: U/S of vessels if persistent non-palpable pulse after 24 hours of heparin.

If patient requires longer-term anticoagulation, contact Thrombosis Team who will monitor levels as
an outpatient.

Heparin:

Heparin is prophylactic NOT thrombolytic. It prevents propagation of existing thrombus.

Prevention: Effectiveness of systemic heparinsation in preventing thrombosis during cardiac

catheterization reduced incidence to 0.8 % (4). Note, this data pre-dates the subsequent increased
volume of interventional procedures.

Management: 71% (32/45) improved with heparin therapy alone. (ref 2)

Thrombolysis: Tissue Plasminogen Activator (at HSC)

Notify responsible HSC cardiologist prior to starting.

Consult Thrombosis Team.
Dosage: See “Anticoagulation & Anti-thrombotic Medications” in manual

Reference: Ino T, Benson LN, Freedom RM, Barker GA, Aipursky A, Rowe RD. Thrombolytic
therapy for femoral artery thrombosis after pediatric cardiac catheterization. Am Heart J
1988;115:633-639.

45 of 526 (8.6%) patient with decreased or absent femoral pulses

33% < 10 kg

71% (32/45) improved with heparin therapy alone.

84% (11/13) were successful treated with streptokinase
2.4% of total patients received streptokinase
No episodes of serious systemic bleeding.

REFERENCES:

1. Cassidy SC, Schmidt KG, Van Hare GF, Stanger P, Teitel DF. Complications of pediatric
cardiac catheterization: a 3-year study. J Am Coll Cardiol 1992;19:1285-93.
2. Vitiello R, McCrindle BW, Nykanen D, Freedom RM, Benson LN. Complications associated
with pediatric cardiac catheterization. J Am Coll Cardiol 1998;32:1433-40.
3. Ino T, Benson LN, Freedom RM, Barker GA, Aipursky A, Rowe RD. Thrombolytic therapy
for femoral artery thrombosis after pediatric cardiac catheterization. Am Heart J 1988;115:633-
639.
4. Girod DA, Hurwitz RA, Caldwell RL. Heparinization for prevention of thrombosis following
pediatric percutaneous arterial catheterization. Ped Card 1982;3(2):175-180.
5. Mansfield PB, Gazzaniga AB, Litwin SB. Management of arterial injuries related to cardiac
catheterization in children and young adults. Circulation 1970; Vol XLII, Sept:501-507.
6. Mortensson W, Hallbook T, Lundstrom NR. Percutaneous catheterization of the femoral
vessels in children. II. Thrombotic occlusion of the catheterized artery: frequency and causes.
Pediat Radiol 1975;4:1-9.