Mechanical thrombectomy for treatment of postoperative venous obstruction in pediatric patients

Four critically ill neonates and two small children have undergone a total of nine postoperative cardiac catheterizations involving mechanical thrombolysis and early post-procedure abciximab for significant venous thrombus obstruction. Bacterial infection was associated in five patients and suspected in a sixth. These procedures achieved near normal venous flow pattern and subsequent long-term seemingly normal central veins in the three survivors (by ultrasound in two patients and by autopsy in the other who subsequently died of sepsis). Three of the six patients died; one from sepsis, one from intracranial bleeding at the site of prior unknown bleeding, and one with renal failure. Mechanical thrombolysis is a feasible additional treatment for critically ill infants and children who either fail to respond to medical treatment or need a prompt intervention, such as reopening of an intracardiac fenestration in the early postoperative period. Such treatment may be particularly valuable in patients who are bacteremic and are losing considerable fluids and proteins in the setting of apparent acute thoracic duct occlusion with thrombus in the superior vena caval system and the innominate vein in particular. Mechanical thrombolysis and supplemental support with agents such as abciximab may help keep these vessels open and decrease the thrombus and bacteria load in critically ill infected patients, such that continued standard medical support can result in full recovery.