Vena cava inferior thrombosis in a preterm

[kissjk]

Dear all,

I would be grateful for your advice/opinion regarding the following case.

We admitted a preterm baby 28 weeks gestation with oesophageal atresia and tracheo-oesophageal fistula in our unit in October. The baby was severely IUGR weighted only 600 g at birth. He had a fistula closure on day 1. Due to his cardiovascular and respiratory instability the full correction was delayed.  He had a difficult time following the surgery. He was stabilised, weaned of the ventilator and the correction surgery was planned when he developed sepsis. We looked for the source of the infection so among other investigations  we did an Echo. His Echo showed a mass in his right ventricle, which we thought to be a thrombosis. We started him on LMWH treatment. He deteriorated couple of days after the treatment was started and required ventilation again. The repeated Echo didn't show the thrombus in the right ventricle anymore.  Abdominal Us scan was done, which showed a mass in the inferior v. cava. The mass is about 4 cm long, seems to be attached to the wall of the vein above the renal vein, but in other places it is not connected to the wall of the vein. It didn't cause any disruption in the blood flow. (had good urine output and he was not oedematous). The most likely diagnosis was the thrombosis (as a consequence of previous umbilical/femoral catheter or longline) so I continued the LMWH.  The correction surgery was done and he came off the ventilator and reached full feeds. On the repeated scans the inferior v. cava mass didn't show any change (not even attachment to the wall), according to the Chest guideline on thrombosis we should discontinue the treatment with LMWH after 3 month. Would you recommend to stop the treatment even if the mass didn't change? Can we give aspirin to an ex-preterm as a prophylaxis? Is it necessary? Do you have experience with a thrombus which didn't show any change? Can you think of anything else as a differential?    

 

Thank you, 

 

Judit

 

[rehman_naveed]

Hi Judit

Interesting case. in your case description, you mentioned last US showed mass even not attached to wall, it means thrombus is detached, in case it may obstruct the IVC flow, can you make it clear.

Did you consult hematologist?

What about thrombocytopenia? ( Yes/No), Coagulation profile, Anti Xa level monitoring, did you follow it to guide therapy of LMWH, 

Did you consult plastic surgeons? 

Did you screen for thrombosis workup, protein C, and S, factor V leiden deficiency 

There are no set guidelines to guide treatment for thrombosis in newborn, but here in canada we do treat with LMWH, follow serial anti Xa level, to guide therapy ,involve hematology/thrombosis team, and follow serial US with doppler . 

Length of treatment varies with size of thrombosis.

Strange that in spite of thrombosis, patient went for surgery. was he on LMWH at that time?

Keep us updated.

Thanks

Naveed 

[Stefan Johansson]

Tricky question. This review paper may give some insights (into the limitations of the topic...) https://www.ncbi.nlm.nih.gov/pubmed/24477225

We would probably also get the advice from our transfusion medicine dept to give low-molecular-weight heparin (LMWH) for a limited time while performing repeated ultrasounds. If the inferior vena cava flow is not clearly obstructed when the thrombus stabilize, my (limited) experience is that the long-term outcome is good.

Although the likely explanation is a previous intra-vessel catheter, I'd follow the advice by @rehman_naveed to screen for abnormalities in the coag system.

 

[bimalc]

Interesting case.  Sorry to come late to the discussion.  Generally agree on seeking consultation (assuming it is available) from Heme/anti-coagulation on duration of LMWH and interval for imaging.  Depending on the current size and status of the baby, the amount of blood for an anti-coag workup may be large and yield is low (also difficult to interpret early in life).  In the absence of a clear family history, I would consider this a provoked thrombus and delay testing as long as possible, if not indefinitely.

[kissjk]

Dear All,

We consulted the case with a paediatric haematologist, and I also spoke with a vascular surgeon. The baby was on LMWH, and we monitored the therapy with anti-Xa levels. We took blood for a thrombophilia screen; the result came back negative. The family history was negative for thrombophilia.

 

[tarek]

the other differential is vegetations and 6 weeks course of antibiotics should be instituted

we have one case with thrombus in left atrium and after heparin started on aspirin by cardiology team