3. Our case in NICU IN 20/10/22
اشرف ايمان بنت
حالة
14
4.
5. CASE in 2019
• of toe gangrene in preterm + septic arthritis --- Amputated --
stay in our NICU 48 days طرفة بنت
6.
7. • Arterial occlusion in the extremity of a neonate is a rare
event of obscure etiology.
• The diagnosis implies an urgent situation which may
result in extremity gangrene and ultimate loss of limb.
• In contrast, early diagnosis and appropriate management
should result in preservation of a normal limb.
• The key to successful management appears to be an
awareness of this common clinical condition in an
uncommon clinical setting.
8. • The documented incidence is higher in premature infants.
• 3%of very low and extremely low birth weight infants,
admitted to a neonatal unit, had vascular injuries
requiring a combination of medical and surgical
treatment.
• Symptoms, signs, and outcomes are dependent on whether
the disorder is primarily venous, arterial, or a
combination.
• The experience with venous occlusion in the newborn
period is increasing, and recent reports have drawn
attention to advances in management.
9. • Conversely, there is little published data on arterial
occlusion in the newborn period and consensus on
appropriate interventions and management protocols is
still evolving.
• This reflects, in part, the relative rarity of acute limb-
threatening arterial occlusions. We report a series of
newborn infants with acute arterial occlusion with a view
to highlighting the range of problems encountered,
available management strategies, and outcomes.
10. • Neonates with a clinically significant arterial
thrombosis that develops in utero or during delivery
are often born with or quickly develop gangrenous
changes, thus illustrating the importance of prompt
intervention.
• However, management guidelines for neonatal
arterial thrombosis have not been well established.
• Generally, recombinant tissue plasminogen activator
(rt-PA) has been recommended for limb or life-
threatening thrombi as initial management, but
thrombectomy has been recognized as an option in
certain situations.
11. • When an arterial thrombosis occurs perinatally, it is difficult to
determine the duration of occlusion, and limb ischemia and loss
may be imminent.
• As such, thrombectomy may be a superior option to promptly and
definitively restore flow.
12. • Neonates have the highest risk for pathologic thrombosis among
pediatric patients.
• A combination of genetic and acquired risk factors significantly
contributes to this risk, with the most important risk factor being the
use of central venous catheters. Proper imaging is critical for
confirming the diagnosis.
• Evaluation and treatment of any neonate with a clinically significant
thrombosis should occur at a tertiary referral center that has proper
support.
17. •Emergent Thrombectomy in a Neonate with an
Upper Extremity Arterial Thrombus
• Timothy J. B. Ulrich, MD,1 Marc A. Ellsworth, MD,2 and Tara R. Lang, MD2
• AJP(American Journal of Perinatology ) 2014 May; 4(1): 41–44.
18. •Case
• This case report is of a 39 4/7weeks infant who presented at the time of
birth with an immobile, cyanotic right upper extremity consistent with
ischemia but without evidence of gangrene.
• Doppler examination identified pulses in the axillary but not the
brachial or radial arteries. Extremity arterial ultrasound confirmed the
diagnosis of an arterial thrombosis extending from the right axillary
artery to the brachial artery bifurcation.
• An emergent balloon thrombectomy was performed successfully with
immediate return of blood flow.
19. • Intraoperative ultrasound demonstrated patent axillary and brachial
arteries with forward flow.
• A retroperitoneal ultrasound and limited hypercoagulable workup
failed to identify a source of the arterial thrombus. The infant had
normal return of function without residual limb effects.
• Conclusion
Emergent balloon thrombectomy should be heavily considered in
neonates with an extremity arterial thrombosis of undeterminable
duration both for limb salvage, preserve function, and to prevent
long-term growth discordance.
20. Transient Hemi-Lower Limb Ischemia in the Newborn:
Arterial Thrombosis or Persistent Sciatic Artery?
• AJP(American Journal of Perinatology ) 2017 Jan; 7(1): e13–e16.
• Case Presentations
• Patient 1: A Female Preterm Infant Presenting with Transient Ischemia of the
Left Lower Abdominal Wall and Limb Due to Arterial Thrombosis (Fig A)
• A female infant was born at 34 weeks of gestation through an induced delivery
from a multiparous mother.
• The pregnant course had been complicated with pregnancy induced hypertension,
and the family history did not reveal any thrombotic and ischemic diseases.
• The female infant was an appropriate-for-gestational age (AGA) phenotype and
the birth weight was 1,945 g.
• The umbilical cord and placenta did not demonstrate either ischemic or thrombotic
lesions.
21. • After birth, we noted the infant's left lower abdominal wall and limb to
be quite pale on the initial evaluation
Neonates complicated with circulatory disturbances of the hemi-lower limb.
A transient ischemia of the left lower abdominal wall and limb due to arterial thrombosis (A)
and left lower limb due to a persistent sciatic artery (B)
22. • No pulsations were detected in the left femoral, popliteal, and posterior
tibial arteries. Fifteen minutes after the evaluation, the circulatory
disturbance of the affected side was spontaneously recovered.
• The initial laboratory examination revealed elevations of fibrin
degradation product (FDP; (88.8; reference range [rr]: <5 μg/mL) and
D-dimer (40.7; rr: <1.0 μg/mL).
• We therefore speculated the occurrence of arterial thrombosis as a
possible etiology of the ischemia and therefore administered AT (60
IU/kg/day) and unfractionated heparin (10 IU/kg/hour) intravenously
to the patient.
• However, we were unable to detect any thrombotic lesions in the
affected arteries on an ultrasonographic examination.
23. • The prothrombotic state thereafter gradually improved, and the
administration of both AT concentrate and heparin was
completed on the 2nd (FDP: 7.9 μg/mL; and D-dimer: 5.1 μg/mL)
and 16th day of life (FDP: <2.6 μg/mL; D-dimer: 1.1 μg/mL),
respectively. A slight decline in the platelet counts was observed
soon after the treatment (234 × 109, 221 × 109, and 543 × 109 on
the 1st, 2nd, and 16th day, respectively).
• At the time the infant was discharged from the hospital, neither an
ultrasonographic examination nor magnetic resonance imaging
(MRI) revealed any thromboembolic lesions in the cardiovascular
and central nervous system.
• No inherited deficiency of PC, PS, and AT was determined.
24. Patient 2: A Male Preterm Infant Presenting with Transient
Ischemia of the Left Lower Limb Due to a Persistent Sciatic
Artery( Fig . B)
• A male infant was born at 34 weeks' gestation through an induced
vaginal delivery from a nulliparous mother.
• The pregnant course had been complicated with a preterm–
premature rupture of the membrane.
• The family history did not reveal any history of either thrombotic
or ischemic diseases.
• The boy was an AGA phenotype and the birth weight was 1,930 g.
• The umbilical cord and placenta both demonstrated normal
findings.
25. Persistent sciatic artery (PSA)
• is a rare congenital anomaly of the circulation of the lower limb that
results from the persistence of an artery that normally regresses early
in embryonic development.
• During early embryonic development, the sciatic artery usually
disappears when the superficial femoral artery has developed
properly.
• The sciatic artery starts at the internal iliac artery and runs
through the greater sciatic foramen, from where its course is close
to the sciatic nerve
• The PSA is a rare anomaly with a high incidence of
complications including aneurysm formation and ischaemia that
may lead to amputation.
• PSA is usually an incidental finding and is exceedingly rare to find
bilaterally.
26. • After birth, we noted his left lower abdominal wall and limb to be
quite pale on the initial evaluation (Fig. 1B).
• Pulsations of the left femoral, popliteal, and posterior tibial arteries
were diminished compared with the right ones.
• However, the patient was able to move the affected extremity
spontaneously and did not appear to be in any obvious pain or
distress.
• An emergency ultrasonographic examination did not detect any
thrombotic lesions in the affected common femoral artery.
• Initial laboratory tests showed a slight elevation of FDP (12.0; rr: <5
μg/mL) and D-dimer (6.3; rr: <1.0 μg/mL).
27. • Contrast-enhanced computed tomography (CT) performed 6 hours
after birth revealed the left external iliac artery and the femoral
artery to be diminished in comparison to the right ,The superficial
and profunda femoral artery also reconstructed collateral vessels of
the internal and persistent sciatic artery .
• Based on the laboratory and image findings, the patient was
diagnosed as having transient ischemia due to external
compression of the collateral vessels, but not arterial thrombosis.
• Twelve hours after birth, the peripheral circulation of the affected
limb gradually improved.
• Thereafter, no recurrent episodes of ischemic limbs were observed.
30. What is our diagnosis for our case ( ايمان بنت
• ? Transient ischemia due to compression of the
ulnar artery
31. Conclusions
•Newborns suspected of having arterial thrombosis may
need a prompt diagnosis and proper intervention to
prevent organ ischemia and amputation of extremities.
•The possibility of PSA(Persistent Sciatic Artery) should
thus be considered in the newborn infants who present
with a circulatory disturbance of either the hemi- or
bilateral lower limb, but no evidence of
hypercoagulability assessed by the blood tests..
32. • Further accumulation of neonatal artery occlusion cases
would provide useful information for the adequate
management of symptomatic vascular anomalies
