Management of neonatal limb ischaemia: experience from a UK tertiary children's hospital

Neonatal limb ischaemia (NLI) is a rare condition requiring urgent intervention to prevent limb loss and long-term disability. Evidence guiding optimal management is limited to small case series, and no standardized treatment algorithm exists. This study reviewed treatment strategies and outcomes in neonates with limb ischaemia to develop an evidence-based management algorithm.

A single-centre retrospective review was conducted of all neonates with suspected limb ischaemia managed at a tertiary referral centre between 2012 and 2022. Demographics, aetiology, imaging, treatments and outcomes were analysed. Primary outcomes were survival and limb salvage. Secondary outcomes included complications and thrombophilia screening results.

Nineteen neonates were included (13 male), with a median gestational age of 33 weeks and a birth weight of 2267g. Fourteen cases involved confirmed thrombosis (11 arterial, three venous) and eight were catheter-related. Heparin was the primary treatment in 13 patients, with adjunctive vasodilator therapy used selectively. One patient underwent catheter-directed thrombolysis and one required surgical brachial artery reconstruction. Overall survival was 95%, with one death unrelated to NLI. Limb salvage was achieved in 17 of 19 limbs (89%). One patient required transhumeral amputation and one foot amputation. No intracranial complications attributable to anticoagulation were observed.

Most cases of NLI can be managed successfully with prompt anticoagulation and adjunctive therapy. Neonates with occlusive arterial thrombosis and poor collateral circulation represent the highest-risk group and may require escalation to thrombolysis or surgery. Early multidisciplinary involvement is essential. An evidence-based treatment algorithm is presented to support clinical decision-making.