Successful Limb Salvage With Balloon Angioplasty and Catheter-Directed Thrombolysis (CDT) With Tenecteplase (TNK) in a Child With Brachial Arterial Thrombosis

Abstract

INTRODUCTION: Limb threatening ischemia (LTI) from brachial arterial thrombosis is rare in children. Surgical thrombectomy is associated with high recurrence rate and risk of vascular damage. There is no consensus about indications, dose, mode of delivery or duration of therapy with thrombolytics in children (1). Catheter-directed thrombolysis (CDT) using tissue plasminogen activator (tPA) has been reported (2). We present a case of a three year old child with brachial artery thrombosis treated with balloon angioplasty and CDT using tenecteplase (TNK). CASE PRESENTATION: A three year old boy presented to us with pain and discoloration of the right hand consistent with LTI. Withdrawal to pain was preserved. He was recently discharged after brief hospitalization for pneumonia. Emergent angiography revealed thrombus in distal brachial artery near the antecubital fossa (Image 1) along with filling defects in the distal branches with no significant circulation to palmar arch and digital arteries. CDT with TNK was initiated at 0.125 mg/hour with catheter tip in mid brachial artery. Repeat angiography 12 hours later revealed partial resolution of clot material from the distal brachial artery with residual clots in the radial and ulnar arteries. Brachial arterial balloon angioplasty was performed with some improvement in the flow. CDT was continued with microcatheter near the residual clot in brachial artery. TNK infusion rate was increased to 0. 25 mg/hour. Circulation improved over next 2 hours with palpable radial pulse. Angiography 24 hours later showed complete resolution of clot material (Image 2) except very distal arteries near the fingertips. TNK was discontinued. No bleeding was noted from any site. Low dose heparin drip was used concurrently with TNK and was increased to therapeutic rate after TNK was discontinued. He was later transitioned to enoxaparin. Hypercoagulability work up, echocardiography and family history were negative. Full recovery of his hand was noted at discharge. DISCUSSION: Brachial arterial thrombosis in this case was likely related to accidental brachial arterial puncture during attempted venous access. Presence of distal embolization as well as family preference led to treatment with CDT over surgical thrombectomy. We chose TNK - genetically engineered recombinant tPA due to its higher clot bound fibrin specificity, resistance to plasminogen activator inhibitor -1, and increased likelihood of preserving systemic fibrinogen levels (3). To our knowledge, this is the first report of its use for CDT in a child. Longer half life of TNK can be a disadvantage if emergent surgery is necessary CONCLUSIONS: CDT with TNK and balloon angioplasty may be an option in children presenting with arterial thrombosis if thrombolytics are not contraindicated.