Salvaging a Covid +ve New-born with complete Aorto-Femoral thrombosis and bilateral lower limb ischemia
Jaipur : Primary occlusion of abdominal aorta and its downstream major arterial vessels is rare catastrophe event in a new born. The causes of such thrombo -embolism phenomenon are not conclusive but many etiological causes have been implicated like congenital low levels of ant thrombin III, protein C, protein S or some virus infection, generalised sepsis, panaortisis or severe dehydration. we are describing one such case with this type of serious problem of neonatal aorta thrombosis and its consequences.
Baby Mohini ,2.8 kg ,15 days’ old arrived in Jaipur Fortis Hospital surgical ICU in very critical condition from another hospital with a diagnosis of aortic thrombosis extending into both lower limbs causing impending right foot gangrene. His both legs were cold and clammy with no femoral /distal palpable pulsations up to both feet. Legs also showed poor capillary refilling while right foot was almost greyish black proximally but toe was completely black (Fig 1). According to Dr Sunil Kaushal, Patient was very dull and feverish with almost no urine output since last 24 hours.
Dr Kaushal says, C.T angiography and color Doppler ultrasound suggested almost complete blockage of descending aorta from supra renal segment down to common iliac and upper femoral arteries on both the sides. As this dreadful aortic thrombosis was not sufficing, he was also found to be strongly Covid +ve with very high D-dimer levels. As he was already being treated conservatively at a govt hospital by anti-coagulant medicines since last 5 days. we went ahead with surgery straight way after explaining risk to the family.
Exploratory Laparotomy was done under all anti Covid precaution / and measures through mid-line full supra- and partial infra umbilical approach. Intestines were taken out in a warm sponge and descending aorta was identified, dissected, mobilised and looped up to bilateral common iliac arteries.
Transverse aortotomy was made just below the inferior mesenteric artery and multiple clots of different sizes were taken out from supra renal aorta, infra renal descending aorta, bilateral common iliac and femoral arteries as far as and as much possible by no 2Fand 3F size fogarty embolecetomy catheters (Fig 2). Flow to distal arteries got restored immediately and baby started passing urine. Intestines reposited back in abdomen. Aortotomy closed in layers.
Preoperative medical treatment in-form of infusion of heparin, NTG, verapamil was continued in addition to broad spectrum antibiotics and anti- covid measures in post-operative period as well.
Next day, his right leg become completely normal and warm while left leg also become normal in colour and temperature up to right ankle.
In next 2- 3 days his right foot also started showing improvement in colour and temperature except the blackish great toe (fig 3). Now baby is off all supports and has become Covid negative.
Dr Kaushal claimed that this is country’s youngest Covid +ve new born who not only almost recovered fully from the dreadful aortic thrombosis with bilateral limb Ischemia and sub-acute renal failure, but from Covid infection as well.
