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Abstract
Objective Discuss the technical challenges of mechanical thrombectomy in a 2-year-old child.
Introduction A 2-year-old female with a history of hypoplastic left heart syndrome was admitted to the PICU directly from cardiology clinic for treatment of a left ventricular thrombus found on routine echocardiogram. She was initially treated with a heparin drip and transitioned to enoxaparin. One morning, the patient had an acute change in mental status and became unresponsive. On examination, the patient had bilateral extensor posturing with anisocoria and non-reactive pupils. Bedside echocardiogram revealed the known LV thrombus was no longer present. Stat CT Head demonstrated no ischemic changes. CTA Head/Neck demonstrated top of the basilar occlusion. The patient was taken emergently for mechanical thrombectomy.
Intervention The right femoral artery was accessed with a micropuncture kit. A 5F Slender radial sheath was placed into the right femoral artery. A guide catheter was not used in this case due to the small size of the patient’s arteries. A SOFIA 5F aspiration catheter was advanced directly over a 0.035’ guide wire into the left vertebral artery. Angiogram confirmed basilar artery occlusion. The SOFIA 5F aspiration catheter was then brought up into the basilar artery over a Marksman microcatheter and microwire. The system was advanced to the basilar tip. The microsystem was removed, aspiration was turned on and the catheter was pulled back under constant aspiration technique. Follow-up angiogram of the left vertebral artery showed TICI 2b revascularization. There were no complications. On 3-month clinical follow-up, the patient was progressing neurologically with no significant weakness. The patient was meeting developmental milestones.
Discussion Mechanical thrombectomy in pediatric patients has been described in the literature in case reports and reviews. It is thought to be efficacious when compared to thrombectomy in adult cases. There are very few reports of thrombectomy for basilar artery occlusions in pediatric patients less than two years of age. Furthermore, mechanical thrombectomy with the 5 Fr SOFIA catheter has been described in the literature as a viable alternative to traditional 6 Fr catheter systems. To our knowledge, this is the first case description of pediatric thrombectomy with aspiration catheter alone without guide sheath or shuttle. This case demonstrates the use of 5 Fr SOFIA intermediate catheter for mechanical thrombectomy, and the efficacy of mechanical thrombectomy in basilar tip occlusion in a 2-year-old child.
Left vertebral artery angiogram demonstating basilar artery occlusion (left). Post thrombectomy angiogram showing revascularization (right)
Disclosures S. Saripalli: None. A. Strickland: None.