Volumen: 19 # Number : 3
Publication Date : Septiembre - Diciembre Year: 2015
Diagnosis, treatment and follow-up
of venous thromboembolism (VTE) in children:
a prospective 23-year registry from a single tertiary center
Authors: Sciuccati G; Hepner M; Cervio C1; Sierre S; Pieroni G;
Annetta E; Díaz L; Pepe C; Candas A; Avalos Gomez J;
Feliu Torres A; Frontroth J; Bonduel M
Abstract: Background: There has been a significant increase
of venous thromboembolism (VTE) in children related
to medical progress in the management of critically
and chronically ill patients (pt). Risk factors,
imaging studies, thrombophilia (TB), antithrombotic
therapy (AtT) and complications have been the
subject of research in the last 25 years.
Aims: To describe diagnosis and management of a
pediatric prospective cohort with VTE registered
during 23 years at a single tertiary center.
Methods: From May 1992 to April 2015, consecutive
children <18 years of age with objectively
confirmed VTE were prospectively registered. Demographic
and clinical data, family history of VTE,
imaging studies, TB, AtT and outcomes were recorded.
Neonates and patients with cerebral or organ
specific VTE were excluded.
Results: 989 pt were recruited, 569 males (58%),
median age (range): 2y (0.1-18).
One or more risk factors were found in 983 pt
(99%) and 586 pt (59%) also had catheters. Lower/
upper/both venous systems were involved in 642 pt
(65%)/300 pt (30%)/47 pt (5%) respectively. Pulmonary
embolism was diagnosed in 19 pt (2%).
453 pt (46%) were available for TB. Prothrombotic
disorders were found in 141 pt (31%): inherited disorders
in 62 pt (14%) (FVL: 24, PT20210A: 19;
deficiency of PC: 10, PS: 7 and AT: 2) and acquired evendisorders
in 79 pt (17%) (AT deficiency:49; persistently
positive APA: 30). Seven pt (1.5%) had combined
disorders. 24 pt with hereditary PC, PS or AT
deficiency or combined disorders were compared
with 312 pt with normal TB.
A significant difference between both groups was
detected regarding the following variables: VTE extension
(92% vs 61%, p=0.003), lower venous system
localization (96% vs 74%, p=0.016), catheters
(46% vs 84, p=0.002) and family history of VTE
(50% vs 5%, p <0.001).
The AtT used was: UFH: 97 pt; enoxaparin: 871
pt, VKA: 697 pt, tPA: 29 pt, vena cava filters: 9
pt. Based on the persistence of risk factors and/or
thrombophilia 184 pt received AtT during >3 months.
Recurrence or death related to VTE occurred
in 27 pt (2,7%) and 4 pt (0.4%), respectively. Six
pt (0.6%) had major bleeding, all of them while receiving
enoxaparin. Post-thrombotic syndrome was
detected in 183/369 pt (50%) and 52 (28%) of them
were severe.
Conclusion: This is the largest prospective cohort of
pediatric VTE with long-term follow-up reported to
date. During the last ten years the incidence of VTE
in our centre was 1 case per 300 hospital admissions.
Infants younger than 1 year of age constituted the
single largest group of patients. Unprovoked VTE
was very rare. A low frequency of pulmonary embolism
was observed, probably due to a low index
of clinical suspicion. Family history of VTE, lower
venous system VTE, greater extension of VTE and
absence of central venous catheters (CVC) were the
variables most frequently associated with high risk
thrombophilia. Close management by specialized
pediatric hematologists of in-and-out patients has
allowed to achieve low rates of recurrence and major
bleeding during short- and long-term follow-up
in this pediatric cohort.
Key words: Venous Thromboembolism,
Pediatric,
Thrombophilia,
Anticoagulant therapy.
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