Cardiac Cath-Related Arterial Thrombosis in Children
During 12 consecutive months, all children aged 0–19 years undergoing CC through the femoral arteries for diagnostic or interventional purposes at the University Children's Hospital Zurich were included in this observational study. The catheterisation laboratory at our institution is the largest in Switzerland and performs all procedures currently used to treat children with congenital or acquired CD.
Children undergoing CC are admitted to the hospital 1 day prior to the procedure. At this time, a medical history and clinical examination including vital signs, palpable pulses and Doppler blood pressure measurement of all four extremities are undertaken. CC is performed under full anaesthesia. After arterial puncture, unfractionated heparin (UFH) at a bolus dose of 100 IU/kg is administered intravenously and repeated at a dose of 50 IU/kg after 1 h. Monitoring of anticoagulation is performed every 30 min using the activated clotting time targeting 250 s (Medtronic ACT Plus, Medtronic AG, Münchenbuchsee, Switzerland). Directly after CC, children receive enoxaparin subcutaneously at a dose of 1.5 and 1.0 mg/kg every 12 h in children aged less and more than 2 months, respectively. Administration of enoxaparin is continued for 24 h in children after diagnostic procedures and 48 h in children after interventional procedures. On the evening after interventional procedures, children also receive acetylsalicylic acid at a dose of 3–5 mg/kg/day for 3 or 6 months depending on the performed procedure. To decrease the risk of bleeding from the puncture site during anticoagulation, a compression bandage at the site of the arterial puncture is used in children >1 year. In neonates and infants, a taped low pressure bandage is used for at least 24 h after sheath removal. The pressure of the dressing is chosen in an individual manner that one can still feel an arterial pulse distally to the puncture site.
During the first 6 h after CC, pedal pulses (dorsalis pedis and/or tibialis posterior artery) are palpated every hour. Thereafter, pulses are palpated every 8 h during 24 h. If pulses on the punctured leg are absent or weaker, as compared with the contralateral pulses, pulses are verified with Doppler. In this case, bilateral blood pressure measurement of the lower extremities is performed by Doppler method every hour to detect increasing blood pressure discrepancy. As soon as suspicious of decreased perfusion is detected even after removing of compression bandage, defined as cold and pale lower extremity, persistent decreased or absent palpable pedal pulses, persistent lack of signal with Doppler or Doppler blood pressure difference of the limbs of >20 mm Hg, Doppler ultrasonography is performed by a paediatric-experienced radiologist to exclude arterial thrombosis.
After diagnosis of arterial thrombosis, children are treated with low-molecular weight heparin or UFH until clinical and radiological resolution of thrombosis occurs and for a maximal duration of 3–4 weeks. In children with persistent thrombosis after 3–4 weeks therapy, heparin is changed to aspirin for 3–6 months.
Children are seen at follow-up 3 months after first diagnosis and then yearly. Follow-up visits include both clinical and ultrasound examinations. Clinical examination includes history of symptoms, such as pain, cool or pale limb, and claudication, palpation of femoral, popliteal and ankle pulses as well as Doppler-derived systolic blood pressure measurement of the upper (brachial) and lower extremities (ankle). In addition, leg circumference and length are measured.
Demographic data and information on CC for each child were collected at the time of the procedure using a predefined protocol. Data recorded included age and weight of patient at the time of procedure, haematocrit, type of CD (cyanotic, non-cyanotic) and CC (diagnostic, interventional), size of cardiac catheter sheath, number of puncture attempts, duration of CC and duration of compression bandage.
Data are presented as frequencies, mean and medians with ranges where appropriate. Significant differences between groups were assessed using Mann–Whitney and χ test as appropriate. To determine predictors of CC-related arterial thrombosis, multivariate logistic regression analyses were performed and results presented as ORs with their 95% CIs. Statistical significance was defined as p value of <0.05. Statistical analyses were performed using SPSS software (Statistical Package for the Social Sciences, V.18; SSPS, Chicago Illinois, USA).
Methods
Patient Population
During 12 consecutive months, all children aged 0–19 years undergoing CC through the femoral arteries for diagnostic or interventional purposes at the University Children's Hospital Zurich were included in this observational study. The catheterisation laboratory at our institution is the largest in Switzerland and performs all procedures currently used to treat children with congenital or acquired CD.
Cardiac Catheterisation
Children undergoing CC are admitted to the hospital 1 day prior to the procedure. At this time, a medical history and clinical examination including vital signs, palpable pulses and Doppler blood pressure measurement of all four extremities are undertaken. CC is performed under full anaesthesia. After arterial puncture, unfractionated heparin (UFH) at a bolus dose of 100 IU/kg is administered intravenously and repeated at a dose of 50 IU/kg after 1 h. Monitoring of anticoagulation is performed every 30 min using the activated clotting time targeting 250 s (Medtronic ACT Plus, Medtronic AG, Münchenbuchsee, Switzerland). Directly after CC, children receive enoxaparin subcutaneously at a dose of 1.5 and 1.0 mg/kg every 12 h in children aged less and more than 2 months, respectively. Administration of enoxaparin is continued for 24 h in children after diagnostic procedures and 48 h in children after interventional procedures. On the evening after interventional procedures, children also receive acetylsalicylic acid at a dose of 3–5 mg/kg/day for 3 or 6 months depending on the performed procedure. To decrease the risk of bleeding from the puncture site during anticoagulation, a compression bandage at the site of the arterial puncture is used in children >1 year. In neonates and infants, a taped low pressure bandage is used for at least 24 h after sheath removal. The pressure of the dressing is chosen in an individual manner that one can still feel an arterial pulse distally to the puncture site.
Clinical Assessment After CC
During the first 6 h after CC, pedal pulses (dorsalis pedis and/or tibialis posterior artery) are palpated every hour. Thereafter, pulses are palpated every 8 h during 24 h. If pulses on the punctured leg are absent or weaker, as compared with the contralateral pulses, pulses are verified with Doppler. In this case, bilateral blood pressure measurement of the lower extremities is performed by Doppler method every hour to detect increasing blood pressure discrepancy. As soon as suspicious of decreased perfusion is detected even after removing of compression bandage, defined as cold and pale lower extremity, persistent decreased or absent palpable pedal pulses, persistent lack of signal with Doppler or Doppler blood pressure difference of the limbs of >20 mm Hg, Doppler ultrasonography is performed by a paediatric-experienced radiologist to exclude arterial thrombosis.
After diagnosis of arterial thrombosis, children are treated with low-molecular weight heparin or UFH until clinical and radiological resolution of thrombosis occurs and for a maximal duration of 3–4 weeks. In children with persistent thrombosis after 3–4 weeks therapy, heparin is changed to aspirin for 3–6 months.
Children are seen at follow-up 3 months after first diagnosis and then yearly. Follow-up visits include both clinical and ultrasound examinations. Clinical examination includes history of symptoms, such as pain, cool or pale limb, and claudication, palpation of femoral, popliteal and ankle pulses as well as Doppler-derived systolic blood pressure measurement of the upper (brachial) and lower extremities (ankle). In addition, leg circumference and length are measured.
Data Collection
Demographic data and information on CC for each child were collected at the time of the procedure using a predefined protocol. Data recorded included age and weight of patient at the time of procedure, haematocrit, type of CD (cyanotic, non-cyanotic) and CC (diagnostic, interventional), size of cardiac catheter sheath, number of puncture attempts, duration of CC and duration of compression bandage.
Statistics
Data are presented as frequencies, mean and medians with ranges where appropriate. Significant differences between groups were assessed using Mann–Whitney and χ test as appropriate. To determine predictors of CC-related arterial thrombosis, multivariate logistic regression analyses were performed and results presented as ORs with their 95% CIs. Statistical significance was defined as p value of <0.05. Statistical analyses were performed using SPSS software (Statistical Package for the Social Sciences, V.18; SSPS, Chicago Illinois, USA).
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