Seeking Suggestions for Son

Our son was born by C-section on Sept. 27, 2001 in the 31+2 week because of gestosis (970g and 37.5 cm long). He was quite healthy then. He could not perform defacation until 4 days after his birth. Colon surgery was performed on the 5th day after birth (Oct. 2, 2001) and a stoma was built up which will be reconstructed later. The situation with the bowel works well and everything is here o.K. During surgery he had an artherial catheter in his lower right leg.

On the second day after surgery this right leg started to behave in a strange manner. The femoral began to swell and the lower leg including the foot turned blue and became edematous at certain parts. The medical doctors said that this is a strange behaviour and could not find out the actual reason behind it because nothing did fit. A doubler ultrasonography showed that there was still blood flow in the right leg. For days, the whole leg was held by my wife higher than the body and the swelling in the femoral decreased. The blue color in the calf decreased until the middle of his feet. After about 1 week the front part of his feet started to get black and started die. The whole residual part of the leg became normal until about two weeks ago the foot became blue again until the heel and there was a sort of a blue line extended up to his knee. This coincided with the death of the front part of his foot. This situation was approximately stable for about the last two weeks.

The color of the foot depended very much on the position of the foot. He was heparinized the whole time. Now he gets a heparin derivative by Rhone Poulenc Rorer which can be kept in the therapeutical range.

As the situation did not improve over the last two weeks, they tried this Friday (Nov. 8, 2001) a sort of an experiment to perform a digital subtraction angiography which has at least never been performed in this hospital. They were reluctant at first to perform an angiography at all because of the risks and because he is quite small. As of Nov. 11 he has 1460g and is 40.5cm long. They laid a catheter into the heart, led the contrast agent in and performed the angiography.

The result was that it turned out that he probably had a thrombosis in the iliac artery in the pelvis. The artery cannot be seen over a long stretch. The femoral artery starts to make connections to the iliac artery in the femoral to provide blood to the leg. Two of the three arteries in the calf cannot be seen. One gives at least some blood to the lower leg which is already smaller than the left one. No blood flow can be seen in the foot which will certainly die. He might lose the whole leg. Are conservative measures to build up the blood flow to let most parts of the leg survive? What about microsurgery? Lysis by rtPA might too late and too risky? Or could anything else be done?

Thank you...

Dr. A.B.

[Forum-M.D.-DT]

Dear Dr. A.B.
Thrombosis of the iliac artery in the pelvis makes sense given the symptoms you describe. It appears as though angiography has demonstrated that there is an extensive region of the iliac artery which is not visible, therefore, meaning there is little or no blood flow through this vessel. I suspect that there are collateral vessels which may be helping the flow to the limb, however, it sounds like this collateral blood flow is not sufficient to provide adequate oxygenation to the tissue of the foot and leg and you are seeing results of inadequate blood flow and the resultant anoxia (lack of oxygen) to this limb.

About tPA: tPA is typically administered within a given time frame of a vasulo-occlusive event. For instance, it is indicated for use in stroke and heart attack if given within the first 3 hours of the onset of the occlusion. I suspect that based on this initial "criteria" for use of tPA that in this situation tPA would not be indicated.

However, I have another thought for you to consider, preferably you would discuss this option with a pediatric vascular surgeon. That is, the possible use of a "stent" with this artery. I know that this is being used in vessels such as the coronary areteries and is now being used to prevent strokes in patients who have significant narrowing of the carotid arteries (in the neck). In the situation you describe, we are talking about a much smaller diameter vessel (iliac artery ... in a neonate). Iliac artery stenting is used, quite successfully, in patients with narrowing of the iliac arteries and has resulted in significant reduction of the symptoms of claudication in adults (leg pain with walking due to narrowing of the arteries, including the iliac artery).

I would agree that heparin is most certainly indicated in this situation, however, if there is evidence that the limb still has a significantly compromised blood flow, you really need to speak to a pediatric/neonatal vascular surgeon regarding possible help with stenting.

[asking]

Hi Dr. A.B.!

I am not a doctor; I had a DVT in my left leg, from my knee to my vena cava. They did try to do lysis on me, but the older the clot gets, the less likely it is that is will work. After 1 month, the chances are only 19%, vs. 95 % if done right away... They did implant stents in my iliac vein, and I don't have any more problems now. Obviously I am an adult, not an infant; so I don't know how this would work with a baby, since its veins are growing as he grows, and mine are fully developed. Stents become part of the vein, so I don't know what they would do in your son's case...
Good luck!

Always asking ;)

[pikamom]

I'm interested to know what's been happening with this baby. Any updates? I hope things have stabilized by now.